[Senate Hearing 110-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2008

                              ----------                              


                        WEDNESDAY, MARCH 7, 2007

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:10 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Daniel K. Inouye (chairman) 
presiding.
    Present: Senators Inouye, Mikulski, Murray, Stevens, Bond, 
and Shelby.

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF LIEUTENANT GENERAL KEVIN C. KILEY, SURGEON 
            GENERAL, DEPARTMENT OF THE ARMY

             OPENING STATEMENT OF SENATOR DANIEL K. INOUYE

    Senator Inouye. I would like to welcome all the witnesses 
today as we review the Department of Defense (DOD) medical 
programs. There will be two panels this morning. First we will 
hear from the service Surgeon Generals, General Roudebush, 
Admiral Arthur, and General Kiley. Next we will hear from our 
Chiefs of Nurse Corps, General Melissa A. Rank, Admiral 
Christine Bruzek-Kohler, and General Gale Pollock.
    We are all witnesses to the amazing advances in modern 
medicine which not only affect the daily lives of everyone in 
this room but also the impacts of lifesaving measures for our 
Armed Forces serving in harm's way.
    One of the true unsung heroes in this effort is the 
military medic. He or she is on the front lines every day, 
making critical decisions and delivering immediate medical care 
that determines the fate of our service members.
    So much has changed for the medic since I served in the 
military, yet the one thing that remains constant on the 
battlefields is the call for a medic from a wounded service 
member. Medics often endure the same hardships as the front 
line infantry soldier.
    When the Rangers came ashore on D-Day, their medics were 
right there, treating them on the beach. Seven of them were 
killed and another 25 wounded on that day. During World War II, 
medics worked miracles with few supplies. They had bandages, 
tourniquets, sulfa powder, and morphine.
    Medics played an equally critical role in both Korea and 
Vietnam. With the arrival of the mobile army surgical 
hospitals, military medicine was able to advance many of the 
lifesaving measures applied by the medic on the battlefield, 
but the tools of the medic's trade had not changed 
substantially.
    The global war on terrorism continues to utilize the 
critical skills of the medic, but today their tools contain 
advanced therapy and bandages to stop bleeding that once was 
considered uncontrollable. They also prevent the deadly effect 
of shock with the ability to warm injured shoulders far forward 
in the theater.
    With their tools, tourniquets, techniques, and skills, our 
medics have achieved groundbreaking results. Never before in 
our history has combat mortality been so low. I believe it's 
0.25 now, whereas it used to be 2.5 in World War II. I was one 
of the lucky ones to leave after suffering serious injury, but 
today service members are surviving much worse injuries.
    However, this means many more of our service members are 
returning home with significant injuries. Not only can these 
injuries take many months to recover, but we have yet to fully 
comprehend and diagnose the long-term effects of certain 
injuries such as traumatic brain injury or post-traumatic 
stress.
    Our challenge is to respond to these new challenges and 
realities. How we handle, treat, communicate, and house our 
service members and their families should be of the utmost 
importance to all of us. After everything they have gone 
through and continue to endure, our Government must ensure we 
are doing everything possible on their behalf.
    As recently exposed in the press, there is an area we have 
not addressed adequately. It now requires our complete 
attention and scrutiny. It affects both the Department of 
Defense and the Veterans Administration (VA), and it is not 
just a matter of medical care.
    We must recognize the changing indications of our service 
members surviving life-threatening injuries and the fact that 
many of them have the utmost desire to return to active duty. 
This process must not be rushed, but handled with appropriate 
manner and timeframe, with constant communication to the 
service members and their families.
    I look forward to the findings and recommendations from the 
task force established by Secretary Gates, and working with the 
Department to ensure the necessary resources are provided for 
this effort. But as one member I express my hope that it not be 
a finger-pointing exercise, or we should not be looking just 
for sacrificial lambs. I hope it will be something meaningful.
    And so, with that, I hope that the many issues related to 
the Department of Defense medical programs will be addressed 
this day. I look forward to your statements. I would like to 
welcome you all once again, and I now call upon our first 
witness, General Kiley.
    General Kiley. Thank you, Mr. Chairman, Senator Stevens, 
and distinguished members of the subcommittee.
    Senator Inouye. Before we proceed, do you have any 
statement. Excuse me, sir.

                    STATEMENT OF SENATOR TED STEVENS

    Senator Stevens. I would just repeat your statement, sir. I 
second everything you said, and welcome the Surgeon Generals 
and the Chiefs of the Nursing Corps. I look forward to working 
with you to try and fix some of these challenges that you have 
mentioned. Thank you very much.
    Senator Inouye. Senator Shelby.

                 STATEMENT OF SENATOR RICHARD C. SHELBY

    Senator Shelby. Mr. Chairman, I'll be short. I'll be short 
here.
    Over the last 2 weeks, along with the rest of the country, 
I've been shocked to learn about the appalling and unacceptable 
conditions in which some wounded war veterans are living at 
Walter Reed Army Medical Center. I think that how well we care 
for our wounded service members when they return home from war 
in itself has profound moral implications.
    Does this instance show that we're failing to meet our most 
basic obligations to those who fight our battles? I believe 
that we all agree that our service members, in particular our 
combat veterans, deserve the best facilities and care in the 
world. Reports that our war injured are recuperating in 
substandard housing have shed light on a massive failure which 
I believe is inexcusable on every level.
    Yet what is perhaps more disturbing is, this problem is 
likely not the isolated incident I hoped it would be. The 
problem clearly goes deep, beyond the facilities at Walter 
Reed. And, Mr. Chairman, I commend you for this hearing. We're 
not looking for scapegoats, but we're looking for 
responsibility and we're looking to correction because we owe 
it to our soldiers.
    Thank you, Mr. Chairman.
    [The statement follows:]

            Prepared Statement of Senator Richard C. Shelby

    Over the last two weeks, I, along with the country, have 
been shocked to learn about the appalling and unacceptable 
conditions in which some wounded war veterans are living in at 
Walter Reed Army Medical Center.
    How well we care for our wounded servicemembers when they 
return home from war, in itself, has profound moral 
implications. Does this incident show that we are failing to 
meet our most basic obligations to those who fight our battles?
    Since 2002, we have sent hundreds of thousands of our armed 
forces into combat zones. With great medical advances in 
battlefield care, more of our servicemembers are surviving than 
in any previous war--nearly 50,000 from the conflict in Iraq 
and Afghanistan alone. The killed-in-action rate for Operation 
Enduring Freedom and Iraqi Freedom is 12.5 percent, compared to 
18.6 percent for the first Gulf War and Vietnam, and 25.3 
percent for World War II. The care a servicemember receives in 
a combat zone or immediately following should be commended. 
Yet, what the Walter Reed incident shows is that there is 
clearly a major breakdown in our military health care system 
once a servicemember returns home. And this should not be the 
case.
    I believe we all agree that our servicemembers, and in 
particular our combat veterans, deserve the best facilities and 
care in the world. Reports that our war-injured are 
recuperating in substandard housing have shed light on a 
massive failure, which is inexcusable on every level.
    Yet, what is perhaps more disturbing is that this problem 
is likely not an isolated incident. This problem clearly goes 
beyond the facilities at Walter Reed. That is why we must take 
steps to improve the quality of the facilities at Walter Reed, 
but also to ensure that these standards are maintained 
throughout the entire Department of Defense health care system.
    If these issues are not addressed now, they will only get 
worse as the system becomes further stressed with more veterans 
returning from Iraq and Afghanistan.
    Our support for our men and women who wear the uniform 
cannot end when they leave the battlefield. The cost of war 
cannot simply include funding our weapon systems. It must 
include the cost of taking care of our servicemembers who fight 
in it. To deliver anything other than the very best would be 
shameful.

    Senator Inouye. Senator Murray.

                   STATEMENT OF SENATOR PATTY MURRAY

    Senator Murray. Thank you very much, Mr. Chairman and 
Senator Stevens, and I want to thank our witnesses for being 
here today, and I want to thank those service members who care 
for their sick and injured comrades, both in theater and back 
here at home.
    I am very concerned that while we have dedicated people, 
they are working in a system that is failing our soldiers. From 
what I have been hearing, Walter Reed is just the tip of the 
iceberg. This morning the Seattle Times detailed serious 
problems at the medical holdover unit at Madigan Army Medical 
Center in my home State.
    It detailed soldiers who are left to languish in medical 
units for nearly 2 years, soldiers who are being hurried out of 
DOD care before they receive the surgery they need, being given 
low disability ratings that don't reflect their injuries and 
deny them an Army disability pension, and being pressured to 
sign their medical evaluations to get them off the DOD books. 
If these reports are true, then the Pentagon is failing our 
service members at exactly the time that they need the most 
support, and that is really shameful and unacceptable.
    The Seattle Times article quotes Pamela Lane, whose 
husband, Specialist Steve Lane, was sent home without being 
diagnosed for traumatic brain injury. His wife said, ``I want 
people to know that if their loved ones are there, they will 
have to fight for their care. If they do not, they will get 
lost in the system.''
    The article says that soldiers who push for help are 
branded as malcontents, and there are conflicting reports. One 
soldier told the Tacoma News Tribune that he received excellent 
care and generally good casework at Madigan, but he also said, 
and I quote, ``If you want your care, you really have to fight 
for it. Their strategy,'' and I'm quoting him, ``is to get you 
so disgruntled that you just say screw it and go home.''
    So we've got, Mr. Chairman, very talented medical 
professionals who are trapped in a system that doesn't let them 
do their jobs fully, and to me that is an outrage. General 
Kiley, you're in charge of this system. I hold you accountable 
for every disturbing story I'm hearing in my home State, and 
I'm here today because I want answers.
    Walter Reed exposed the problems with military medical 
care, and the latest stories out of my home State show that the 
problems are much deeper and more painful than moldy walls and 
redtape.
    General, I want you to know many soldiers are very worried 
that if they speak out publicly, they're going to be punished 
or it will end their military careers. I want your personal 
assurance today that any soldier who blows the whistle on 
substandard care will not be retaliated against.
    Senator Inouye. I thank you very much.
    Senator Mikulski.

                STATEMENT OF SENATOR BARBARA A. MIKULSKI

    Senator Mikulski. Thank you very much, Mr. Chairman and 
members of the military. First of all, I think today we all 
know we were filled with shock and awe about what we have 
learned about the dysfunctional outpatient care system, both 
with military medicine as well as VA.
    We know that within this subcommittee we've been dealing 
with some of the structural issues confronting military 
medicine, the intensity of the nursing shortage and other 
allied health people supporting our doctors. We know the ops 
tempo has literally been a high burnout rate, as well as the 
grim and ghoulish injuries that are faced in theater. We 
actually salute those men and women in military medicine that 
have been delivering acute care from the battlefield until they 
arrive back home in these hospitals.
    But, however, we have now 22,000 Purple Heart men and 
women. We owe them a debt of gratitude related to what we need 
to do in terms of the next steps, and the next steps fall into 
outpatient care, rehabilitation medicine, and long-term care 
and assisted living. We have to look at care, facilities, 
social workers, and even the dysfunctional disability system 
itself.
    Yes, we have visited Walter Reed, and yes, we have visited 
other places. Some aspects are working wonderfully. Many staff 
are performing heroically, both in danger to their own lives on 
the battlefield, but at the ops tempo, whether it's in Germany 
or back here.
    We want to get to the bottom of this, so that we not just 
have phrases and yellow ribbons and ``We're going to stand up 
for our wounded warriors.'' I believe promises made are 
promises kept. We said, ``If you will go and fight for us, we 
will fight for you when you come back home.'' That's what we're 
here to do. We're here to fight for those wounded warriors, and 
all those who were wounded that we might not yet know how they 
were wounded, Mr. Chairman.
    Senator Inouye. I thank you very much, Senator Mikulski.

          PREPARED STATEMENTS OF SENATORS BOND AND MC CONNELL

    Before you start General Kiley, I have received statements 
from Senators Christopher Bond and Mitch McConnell which I will 
place in the record at this point.
    [The statements follow:]

           Prepared Statement of Senator Christopher S. Bond

    Thank you for appearing here today. The reports detailing 
the conditions at Walter Reed Army Medical Center have gotten 
just about everyone's attention and if that means the quality 
of care for our military forces and our veterans improves then 
who can complain?
    LT GEN Kiley, your staff should have relayed to you my 
interest in revisiting an investigation I conducted along with 
my colleague Senator Leahy on the conditions for soldiers on a 
medical hold status at Fort Stewart back in October 2003. We 
issued a report on our findings, dated October 24, 2003. 
Paragraph three of the report, under the Summary, reads like a 
current recount of problems at WRAMC. ``The situation at Fort 
Stewart unfortunately was, and remains, hampered by an 
insufficient number of medical clinicians and specialists, 
which has caused excessive delays in the delivery of care. 
Exacerbating the situation, was the Army's placement of wounded 
and injured soldiers in housing totally unsuitable for their 
medical condition.''
    I call your attention to this report because the problems 
at WRAMC have been encountered before and they relate directly 
to the quality, and timeliness of care, and the administrative 
processing for injured soldiers. Furthermore, shortly after our 
staff visited Fort Stewart, they traveled to Fort Knox and 
observed that the military care system there was not optimized 
to care for, and expeditiously process, soldiers injured in 
Iraq and subsequently determined to be unqualified for further 
duty.
    Fast forward to 2007 and we find similar problems. Our 
findings do not negate the tremendous care and support so many 
of our soldiers and their families are receiving. One of the 
reasons for my visit was to meet a fellow Missourian recovering 
from a sniper's bullet that he encountered just four days prior 
to his scheduled end of tour date. This soldier and his mother 
were thankful for the care he was receiving and remain 
confident that they are receiving the finest care available--
anywhere. I also met a soldier recovering from PTSD in the 
outpatient clinic. I asked this soldier about the quality of 
care and was told that it was outstanding. I asked her how she 
would explain the recent media reports on WRAMC and she 
replied, ``I should know, I am here every day, they are not.'' 
I do not mean in any way to question the reports of others, but 
I recount a few of my conversations to share my observation 
that the best service the Army provides can be sullied in a 
moment by failing to serve just one soldier properly. I am sure 
you realize the gravity of the situation we are in. Perceptions 
are hard nuts to crack and we in government now must work 
overtime to regain the public's confidence.
                                ------                                


             Prepared Statement of Senator Mitch McConnell

    I am deeply concerned about the recent details that have 
come to light regarding the Walter Reed Army Medical Center. 
Our brave soldiers deserve the best possible care and the 
situation at Walter Reed is unacceptable.
    I commend both Secretary Gates and the President for their 
responsive action to this urgent problem. I am pleased they 
have acted quickly to address the long-term needs of our active 
duty warriors and veterans--not only at Walter Reed--but at 
military health service facilities across the country.
    My home state of Kentucky is home to Ireland Army Community 
Hospital at Fort Knox and Blanchfield Army Community Hospital 
at Fort Campbell. Kentucky is home to 360,000 veterans. The 
Kentucky National Guard has sent more than 3,200 men and women 
into combat operations in Iraq and Afghanistan. For 
Kentuckians, the situation involving the health care of our 
brave men and women in the military and veterans is not an 
abstract issue. It is a very real and immediate one.

    Senator Inouye. May I now recognize General Kiley.
    General Kiley. Thank you again, Mr. Chairman and Senator 
Stevens and distinguished members. Thank you for the 
opportunity to discuss the current posture of the Army Medical 
Department and any of the subjects that you have raised. I'll 
be happy to talk to the best of my knowledge on that.
    On any given day more than 12,000 Army medics, physicians, 
dentists, veterinarians, nurses, and other allied health 
professionals, administrators, and combat medics are deployed 
around the world, supporting our Army in combat, participating 
in humanitarian assistance missions and training throughout the 
world.
    The modern battlefield is incredibly complex, and Army 
medicine is engaged in every phase of deployment. Every soldier 
who deploys must meet our individual medical readiness 
standards, and once deployed our health professionals not only 
care for the wounded but sustain medical readiness to ensure 
combat effectiveness of deployed units.
    More than 50 percent of the Army Medical Department has 
deployed at least once to care for soldiers, sailors, airmen, 
and marines during the global war on terrorism, and their 
superb performance during this war cannot be understated. They 
are involved in more than caring for combat casualties.
    Last year Army medics supported our Nation's national 
military strategy, not only in Iraq and Afghanistan but through 
nation-building and humanitarian assistance in other countries. 
Our medical logistics system has moved more than 17,000 short 
tons of medical supplies into Iraq and Afghanistan, and more 
than 70 percent of the patient care in Iraq is for Iraqi forces 
and Iraqi civilians injured in fighting.
    The toll has been high in terms of cost and human 
sacrifice. Army medics have earned over 220 awards for valor 
and more than 400 Purple Hearts. One hundred and one Army 
medical personnel have given their lives in Iraq and 
Afghanistan.
    These heroes represent all our corps. They are truly the 
best our Nation has to offer and will make any sacrifice in 
defense of their Nation and, most importantly, for the care of 
their patients.
    Despite these sacrifices, the morale of our healthcare 
professionals does remain strong, but I do have concerns about 
the long-term morale of our serving Army medical force, as well 
as the ability to recruit into the future. For the second 
consecutive year the Army fell short of its goal for awarding 
health profession scholarships in both Medical and Dental 
Corps.
    To help make up for these scholarships and make it more 
attractive, the Congress authorized an increase in the monthly 
stipend paid to these recipients, and I thank you for taking 
this important step to improve this critically important 
program. We are working hard to ensure every available 
scholarship is awarded this year, and I would be happy to 
discuss initiatives during the question period.
    The Army Medical Department is quickly integrating lessons 
learned from the battlefield into our training and doctrine, 
not only in military medicine but throughout the United States. 
Army medicine continues to lead the Nation in adopting new 
trauma casualty management techniques. Since 2003 we have 
provided rapid fielding of tourniquets, pressure dressings, 
hemostatic bandages, and the use of factor VII, teaching these 
new lessons at the Army Medical School and Center and in 18 new 
medical simulation training centers where we train our medics 
on the latest tactics, techniques, and procedure in combat 
medicine, to include operations in the tactical environment and 
evacuation. Today more than 17,000 combat medics have been 
trained in these training centers.
    As you have already recognized, post-traumatic stress 
syndrome and traumatic brain injury present long-term 
challenges to our soldiers, our healthcare system and our 
disability evaluation system. We know at least from some 
surveys that 10 to 15 percent of soldiers will be diagnosed 
with post-traumatic stress disorders (PTSD) within the first 
year after combat, and we know as many as one-third will 
exhibit some symptoms of PTSD, depression, or anxiety over 
time.
    Our screening also suggests that as much as 12 to 20 
percent of our soldiers have reported experiencing a traumatic 
brain injury (TBI) event, which is a significant number, at 
some point during their deployment. But we know very little 
about the most effective treatment strategies to apply in the 
first year after combat for TBI, and I'd be happy to talk some 
more about that also.
    During the last several months I've had the privilege of 
co-chairing the Department of Defense Mental Health Task Force 
with Dr. Shelley MacDermid from Purdue University. This task 
force, comprised of military, civilian, Department of Veterans 
Affairs, and Department of Health and Human Services 
representatives, have conducted site visits around the world to 
evaluate our mental health systems, identify trends and 
problems, and recommend changes to our mental health services. 
We are now drafting our report and will anticipate submitting 
it to Congress on time in May.
    In December 2006 I chartered an Army task force on 
traumatic brain injury, to review our policies, resources, 
research, therapeutics, and the way ahead for traumatic brain 
injury support to our soldiers and their families. This task 
force, led by Brigadier General Don Bradshaw, will include 
subject matter experts from across the Army. He has also 
included representatives from the Wounded Warrior Program, the 
Navy, Marine Corps, Air Force, and the Department of Veterans 
Affairs, and I expect General Bradshaw to provide me a report 
and recommendations in late spring of this year. I'll come back 
and report those findings to you if you're interested.
    America and Congress have known the long, rich legacy of 
excellence at Walter Reed Army Medical Center, and it is a very 
highly regarded facility. Over the last 3 weeks you have 
learned that we are not living up to that legacy, and for that 
I am personally and professionally sorry, and I apologize to 
the soldiers and their families, the Department of Defense, to 
the Members of Congress and to the Nation, for this. I am the 
commander and I share in these failures.
    I also accept the responsibility and the challenge for 
rapid corrective action. Secretary Gates expects decisive 
action now, and he and our soldiers will get it. We're taking 
immediate actions to improve the living conditions at Walter 
Reed. The last soldier in that building, it was reported to me 
this morning, will be leaving to go home today. All the other 
soldiers that were in that building are on the campus in our 
Abrams Hall.
    We're taking steps to improve responsiveness of our leaders 
in our medical system and to enhance support services for 
families of our wounded warriors. We're taking action to put 
into place longer-term solutions for the very complex and 
bureaucratic medical evaluation process that, in fact, does 
impact on our soldiers.
    America's soldiers go to war with the confidence that if 
they are injured, the finest military medical system in the 
world will take care of them, evacuate them, sustain them, and 
ultimately save them. As I have said several times, no soldier 
will charge an objective out of sight of a combat medic or 
corpsman, and by extension, all the way back through the 
evacuation system, Walter Reed is part of that confidence.
    I am committed to regaining confidence not just in Walter 
Reed but across our entire military system. My entire 
professional life is dedicated to the sustainment of that 
confidence. I am worried that these soldiers, at Walter Reed 
and across the world, will lose that confidence if we do not 
act decisively, and I will.
    In closing, let me emphasize that the service and sacrifice 
of our soldiers and their families cannot be measured with 
dollars and cents. The truth is, we owe far more than we can 
ever pay to those who have been wounded and to those who have 
suffered. Thanks to your support, we have been very successful 
in developing and sustaining healthcare delivery systems that 
honor that commitment of our soldiers, retirees, and their 
families to our Nation. I know with your continued support we 
can overcome the present challenges and make this superb 
military healthcare system even better.

                           PREPARED STATEMENT

    Thank you for inviting me today to participate in this 
presentation, and I look forward to answering your questions.
    Thank you, Mr. Chairman.
    Senator Inouye. Thank you very much, General Kiley.
    [The statement follows:]
        Prepared Statement of Lieutenant General Kevin C. Kiley
    Mr. Chairman, Senator Stevens, and distinguished members of the 
subcommittee, thank you for the opportunity to discuss the current 
posture of the Army Medical Department (AMEDD). During the past 5 
years, military medicine has constantly exceeded any measure of success 
we could establish. By now America is well aware of many of the 
successes of our medical capability and the challenges we face as our 
Army remains engaged in combat operations in Afghanistan and Iraq. 
During these operations we have recorded the highest casualty 
survivability rate in modern history. More than 90 percent of those 
wounded survive and many return to the Army fully fit for continued 
service. Our investments in medical training, equipment, facilities, 
and research, which you have strongly supported, have paid tremendous 
dividends in terms of safeguarding soldiers from the medical threats of 
the modern battlefield, restoring their health and functionality to the 
maximum extent possible, and reassuring them that the health of their 
families is also secure.
    Army medicine is an integral part of Army readiness and, like the 
Army, is fully engaged in combat operations around the world. On any 
given day more than 12,000 Army medics--physicians, dentists, 
veterinarians, nurses, allied health professionals, administrators, and 
combat medics--are deployed around the world supporting our Army in 
combat, participating in humanitarian assistance missions, and training 
throughout the world. These medics are recruited, trained, and retained 
through a integrated healthcare training and delivery system that 
includes the AMEDD Center and School at Fort Sam Houston, Texas; 36 
medical centers, community hospitals, and clinics around the world; 
and, combat training centers and 18 Medical Simulation Training Centers 
wherever our combat formations are located. It is the synergistic 
effect of this system that enables us to place in our combat formations 
the Nation's best trained medical professionals while always ensuring 
the soldier is medically and dentally ready to withstand the rigors of 
the modern battlefield.
    The modern battlefield is an incredibly complex environment and 
Army medicine is engaged in every phase of deployment. Every soldier 
who deploys must meet individual medical readiness standards. These 
standards are designed to ensure soldiers are medically and dentally 
prepared to withstand the rigors of modern combat. Army medicine 
ensures each soldier is medically fit, has appropriate immunizations, 
and has no active dental disease before they leave the United States or 
Europe.
    Once deployed, our healthcare professionals not only care for those 
wounded but sustain medical readiness to ensure the combat 
effectiveness of deployed units. More than 50 percent of the Army 
Medical Department has deployed to the Central Command area of 
responsibility in support of combat operations. Twenty-six combat 
support hospitals have deployed (4 more than once); 41 forward surgical 
teams have deployed (11 more than once); 11 medical brigade/medical 
command headquarters have deployed (3 more than once); 21 aeromedical 
evacuation units have deployed (11 more than once); and 13 Combat 
Stress Control units have deployed (6 more than once). Like the rest of 
the Army, this operations tempo is beginning to take its toll on the 
equipment and people who are vital to success.
    The superb performance of our healthcare professionals during the 
global war on terror cannot be understated. What America doesn't know 
about these people is they are involved in much more than caring for 
wounded soldiers. AMEDD personnel supported nation building engagements 
not only in Iraq and Afghanistan but in 15 countries during 25 medical 
readiness training exercises during fiscal year 2006. Our medical 
logistics system has moved more than 17,000 short tons of medical 
supplies into Iraq and Afghanistan. More than 70 percent of the 
workload in our deployed combat support hospitals is emergency care 
provided to Iraqi forces and Iraqi citizens injured in fighting. Today, 
we maintain one combat support hospital split between two detainee 
facilities in Iraq--providing the same care available to American 
soldiers in Iraq and in compliance with all internationally-recognized 
laws and mores for care of detained persons.
    The toll has been high in terms of cost and human sacrifice. Army 
medics have earned 220 awards for valor and more than 400 purple 
hearts. One hundred and one AMEDD personnel have given their lives in 
Iraq and Afghanistan. These heroes represent every aspect of Army 
medicine including Combat and Special Forces medics, Army Nurse Corps, 
Army Medical Specialist Corps, Army Medical Service Corps, Army Medical 
Corps, and Army Veterinary Corps. These men and women are truly the 
best our Nation has to offer and will make any sacrifice in defense of 
their Nation and, most importantly, for the care of their patients.
    Despite these sacrifices the morale of our healthcare professionals 
remains strong. Some data indicates that a deployment leads to 
increased retention for our physicians and we are looking carefully at 
the impact of deployments on nurses and other health professionals. The 
Deputy Surgeon General recently hosted a Human Capital Strategy 
Symposium to address growing concerns within Army medicine about 
accessions/retention, including well-being issues which have a direct 
impact on morale. In an effort to maintain and improve the morale of 
the Army's medical force, my staff has been working to make 
improvements to the monetary incentives offered as accessions and 
retention tools. Most recently, we established a 180-day deployment 
policy for select specialties, established a physician's assistant 
critical skills retention bonus to increase the retention of 
physician's assistants, increased the Incentive Special Pay (ISP) 
Certified Registered Nurse Anesthetist, and expanded used of the Health 
Professions Loan Repayment Program (HPLRP). The physician's assistant 
and nurse anesthetist bonuses have been very successful in retaining 
these providers who are critically important to our mission on the 
battlefield.
    However, I do have concerns about the long-term morale of our 
serving Army medical force as well as our ability to recruit our future 
force. Fiscal year 2006 presented Army medicine with challenges in 
recruiting healthcare providers. For the second consecutive year, the 
Army fell short of its goals for awarding Health Professions 
Scholarships in both the Medical Corps (79 percent of available 
scholarships awarded) and Dental Corps (70 percent of scholarships 
awarded). These scholarships are by far the major source of accessions 
for physicians and dentists. This presents a long-term manning 
challenge beginning in fiscal year 2009. As part of the 2007 National 
Defense Authorization Act, the Congress provided important authorities 
to allow the Secretary of Defense to increase the monthly stipend paid 
to scholarship recipients. These increases will make this program more 
attractive to prospective students and ease the financial burden they 
face as students. Thank you for taking this important step to improve 
this critically important program. We are working hard to ensure every 
available scholarship is awarded this year. In conjunction with United 
States Army Recruiting Command (USAREC) we have initiated several new 
outreach programs to improve awareness of these programs and to 
increase interest in a career in Army Medicine.
    The Reserve Officer Training Corps (ROTC) is a primary source for 
our Nurse Corps Force. In recent years, ROTC has had challenges in 
meeting the required number of Nurse Corps accessions and as a 
consequence, USAREC has been asked to recruit a larger number of direct 
accession nurses to fill the gap. This has been difficult in an 
extremely competitive market. In fiscal year 2006, USAREC achieved 84 
percent of its Nurse Corps mission (goal of 430 with 362 achieved). To 
assist USAREC we have instituted an accession bonus for 3-year 
obligation and have increased the bonus amount for those who obligate 
for 4 years. Additionally, we raised the dollar amount that we offer 
individuals who enter our Army Nurse Candidate Program to $5,000 per 
year for max of 2 years with a $1,000 per month stipend. In 2005, we 
increased the multi-year bonuses we offer to Certified Registered Nurse 
Anesthetists with emphasis on incentives for multi-year agreements. A 
year's worth of experience indicates that this increased bonus, 180-day 
deployments, and a revamped Professional Filler system to improve 
deployment equity is helping to retain CRNAs.
    The Reserve Components provide over 60 percent of Army Medicine's 
force structure and we have relied heavily on these citizen soldiers 
during the last 3 years. They have performed superbly. But accessions 
and retention in the Army National Guard and Army Reserve continue to 
be a challenge. In fiscal year 2005 we expanded accessions bonuses to 
field surgeons, social workers, clinical psychologists, all company 
grade nurses and veterinarians in the Army National Guard and Army 
Reserve. We also expanded the Health Professions Loan Repayment Program 
and the Specialized Training Assistance Program for these specialties. 
In February 2006, we introduced a Baccalaureate of Science in Nursing 
(BSN) stipend program to assist non-BSN nurses complete their 4-year 
degree in nursing. This is an effective accessions and retention tool 
for Reserve Component Nurses who have only completed a 2-year 
associates degree in nursing. Working with the Chief of the Army 
Reserve and the Director of the Army National Guard, we continue to 
explore ways to improve Reserve Component accessions and retention for 
this important group.
    The high operations tempo has also placed strain on our equipment. 
The fiscal year 2007 Emergency Supplemental Appropriation request and 
the fiscal year 2008 budget request adequately funds the replacement 
and reset medical equipment in Iraq and Afghanistan as well as 
equipment organic to units deploying to and redeploying from the Middle 
East. One area that requires our focused attention is the need for an 
armored ground ambulance. Because our current ground (wheeled) 
ambulances are not armored they are not employed outside the Forward 
Operating Bases on a regular basis. When the ground ambulances have 
operated outside the FOB perimeter it has led to the death of some 
medical personnel, and it reduces a maneuver commander's ability to 
employ ground ambulances in support of combat operations. The Army's 
modernization plan addresses this issue and your continued support of 
the Future Combat System, which includes an armored ground ambulance, 
will help alleviate this problem.
    America does not know that the Army Medical Department is a 
learning organization that seeks to quickly integrate lessons learned 
from the battlefield into healthcare training and doctrine not only in 
military medicine but throughout the United States as well. Most of the 
emergency medical response doctrine in practice in the United States 
today evolved from medical experiences in the jungles of Southeast Asia 
in the late 1960's. Today, Army medicine continues to lead the Nation 
in adopting new trauma casualty management techniques. Since 2003 we 
have provided rapid fielding of improved tourniquets, new pressure 
dressings, and the use of hemostatic bandages that promote clotting. 
Training for all soldiers in initial entry training has been revised 
and we continually revise Combat Lifesaver and Combat Medic training 
based on lessons learned on the battlefield.
    These lessons learned are incorporated in our doctrine taught at 
the Army Medical Department Center and School and in 18 new Medical 
Simulation Training Centers across the Army designed to ensure all 
Combat Medics are trained on the most current combat casualty care 
techniques under fire, in a tactical environment, and during 
evacuation. To date, more than 17,800 Combat Medics have received 
training in these Medical Simulation Training Centers which use 
computerized mannequins that simulate human response to trauma. Medics 
can practice their skills in combat scenarios at their duty station. 
Live tissue training is an integral part of Brigade Combat Team Trauma 
Training, building the confidence of 68W combat medics and providers in 
extremity hemorrhage control with use of various hemostatic agents. Use 
of live tissue best simulates the challenges and stress inherent in 
stopping real bleeding.
    The Improved First Aid Kit (IFAK) is the first major improvement in 
individual soldier care in the past 50 years. Today every soldier 
carries a first aid kit that provides intervention for the leading 
causes of death on the battlefield. The vehicle Warrior Aid Litter Kit 
(WALK) has enhanced the capability of soldiers to save lives when 
vehicles are attacked in theater. This is an expanded version of the 
IFAK with the addition of a collapsible litter to facilitate ground/air 
medical evacuation.
    Hypothermia was leading to poor casualty outcomes and, as a result, 
the Army added new equipment for patient warming and fluid warming to 
medical equipment sets including the combat medic's aid bag, ground and 
air ambulances, the battalion aid station, the Forward Surgical Team, 
and the Combat Support Hospital.
    The Joint Theater Trauma Registry is proving invaluable; rapidly 
collecting the lessons learned and guiding decisions about training, 
equipment and medical supplies based on near real-time data. An 
organized, systematic method to collect information and use it to drive 
improvements will be a key component of future military medical 
operations. As knowledge of the actual experience of U.S. medical units 
in Iraq and Afghanistan has grown, Army medicine has developed a 
Theater Combat Casualty Care Initial Capabilities Document under the 
Joint Capabilities Integration and Development System that captures the 
required capabilities and capability gaps in combat casualty care to 
guide research and development efforts and effect changes in doctrine, 
organizations, training, materiel, leadership, personnel and 
facilities.
    At the same time we are rapidly introducing new medical products 
and practices on the battlefield we are transforming our deployable 
units to better support the Army in combat. Last year we completed a 
reengineering of our aero-medical evacuation units, placing them under 
the command of the Army's General Support Aviation units to improve 
maintenance and training for our Dustoff units. We reviewed the 
doctrinal employment of forward surgical teams to ensure we are making 
the best use of this light, very mobile, far forward surgical 
capability. We also redesigned our Professional Officer Filler System 
(PROFIS) to improve the equity of deployments across regions and 
medical specialties.
    But our successes are evident in other aspects of medical care as 
well. America does not know that U.S. Army Medical Command is a $7 
billion a year business that provides care for more than 3 million 
beneficiaries world-wide. Civilian healthcare executives are frequently 
surprised to find that all of our hospitals and clinics are accredited 
by the Joint Commission on Accreditation of Healthcare Organizations. 
Our civilian peers are further surprised when they learn of the quality 
of our graduate medical education programs and the superb quality of 
Army healthcare professionals as evidenced by medical board scores, 
board qualified rates, and graduate and post-graduate education rates.
    This healthcare delivery system is essential to our success on the 
battlefield. It is within this system that our healthcare professionals 
train and maintain their clinical skills in hospitals and clinics at 
Army installations around the world everyday. These facilities provide 
day-to-day healthcare for soldiers to ensure they are ready to deploy; 
allow providers to train and maintain clinical competency with a 
diverse patient population that includes soldiers, retirees, and 
families; serve as medical force projection platforms, and provide 
resuscitative and recuperative healthcare for ill or injured soldiers. 
To accomplish this ambitious mission, we constantly strive to sustain 
appropriate staffing ratios, facility workspace, workload productivity 
and patient case-mix in our direct-care facilities while maintaining 
the right balance with an appropriately sized and supportive network of 
civilian providers for healthcare services we cannot effectively or 
efficiently provide on a day to day basis. In order to remain 
successful, however, we must transform Medical Command along with our 
battlefield system of care.
    The combination of Base Realignment and Closure (BRAC) decisions, 
Army Modular Force (AMF) redesign and stationing, and the 
transformation of the Global Defense Posture (GDP) have presented us 
with a significant challenge to adapt in support of rapid change. But 
more importantly, these initiatives offer an unprecedented opportunity 
to improve the way we care for patients at affected installations. We 
are working with the Army Corps of Engineers to improve the 
historically long-lead time necessary to plan and execute military 
medical construction projects, especially given limited funding and low 
fiscal thresholds that we must work within. Although it will be a 
significant challenge, the Army Medical Department approaches this 
epoch as an opportunity to make significant strides not only to 
transform, realign and improve our vast and aging infrastructure, but 
also to integrate exciting new acquisition methodologies, cutting edge 
medical technologies, our robust information management system and 
emerging concepts of patient treatment and care, such as Evidence Based 
Design. I am confident that with the help of Congress, we will be able 
to leverage this once in a lifetime opportunity to advance healthcare 
further, by properly aligning and improving the enabling facility 
infrastructure.
    Despite our operations tempo, we have maintained and improved the 
quality of care and timely access to care for soldiers, their families, 
and our retirees. Private sector care enrollment and workload is 
increasing as we continuously evaluate and optimize our facilities' 
enrollment to ensure appropriate personnel and facilities are available 
to meet healthcare demand. We have prioritized workload to support 
casualty care and deployment medical screening, shifting a portion of 
our family member and retiree care to the private sector to ensure they 
will continue to receive continuous high quality care during ongoing 
deployment of our medical personnel. Additionally, families of 
mobilized reserve component soldiers now have TRICARE available to them 
as their health insurance in many areas where military facilities do 
not exist or do not have the capacity to absorb additional enrollees.
    Going to war affects all soldiers. The number of soldiers with Post 
Traumatic Stress Disorder (PTSD) and other stress-related symptoms has 
gradually risen. The AMEDD has been supporting our soldiers at war for 
5 years, during 9/11 at the Pentagon, in Afghanistan, in Iraq and 
around the globe. But America does not know about the extensive array 
of mental health services has long been available for soldiers and 
their families. Since 9/11, the Army has augmented behavioral health 
services and post-traumatic stress disorder (PTSD) counseling 
throughout the world, but especially at Walter Reed Army Medical Center 
and at the major Army installations where we mobilize, train, deploy, 
and demobilize Army forces. Demand for these services will not decrease 
in 2007 and we are committed to providing the long-term resources 
necessary to effectively care for soldiers and families dealing with a 
wide variety of stress-related disorders.
    Soldiers are also now receiving a global health assessment, with a 
focus on behavioral health, 90 to 180 days after redeployment. This 
assessment, the Post-Deployment Health Reassessment (PDHRA), includes 
an interview with a health care provider. The PDHRA provides soldiers 
an opportunity to identify any new physical or behavioral health 
concerns they may be experiencing that may not have been present 
immediately after their redeployment. This new program has been very 
effective in identifying soldiers who are experiencing some of the 
symptoms of stress-related disorders and getting them the care they 
need before their symptoms manifest into more serious problems.
    The AMEDD is also performing behavioral health surveillance and 
research in an unprecedented manner. There have been four Mental Health 
Advisory Teams (MHATs) performing real time surveillance in the theater 
of operations, three in Iraq and one in Afghanistan. Colonel Charles 
Hoge has led a team from the Walter Reed Army Institute of Research in 
a wide variety of behavioral health research activities. His research 
shows that generally the most seriously affected by PTSD are those most 
exposed to frequent direct combat.
    Since the beginning of Operation Iraqi Freedom (OIF) in 2003 there 
has been a robust Combat and Operational Stress Control presence in 
theater. Today, more than 170 Army behavioral health providers are 
deployed in Iraq and another 25 are deployed in Afghanistan. Air Force 
and Navy mental health teams are also deployed and supporting soldiers, 
sailors, airmen, and marines in Iraq and Kuwait. The MHAT reports 
demonstrate both the successes and some of the limitations of these 
combat stress control teams. Based on MHAT recommendations, we have 
improved the distribution of behavioral health providers and expertise 
throughout the theater. Access to care and quality of care have 
improved as a result.
    There is a perceived stigma associated with seeking mental health 
care, both in the military and civilian world and we must take action 
to address this problem. Therefore we are moving to integrate 
behavioral health care into primary care, wherever feasible. Our pilot 
program at Fort Bragg, Respect.Mil, which provides education, screening 
tools, and treatment guidelines to primary care providers, was very 
successful. We are in the process of implementing this program at 13 
other sites across the Army.
    We continue to assess the access to and quality of our services 
using both internal and external methods. I directed and funded a 
review of behavioral healthcare services available across Army 
installations. This review is just being completed and will augment the 
impressions I have been developing as the co-chair of the Department of 
Defense (DOD) Mental Health Task Force, created by the fiscal year 2006 
National Defense Authorization Act. This task force, comprised of 
military, civilian, Department of Veteran's Affairs, and Department of 
Health and Human Services representatives is conducting site visits 
around the world to evaluate mental health systems, identify trends and 
to recommend changes to our mental health services. The task force will 
complete its work and submit its report to Congress in May 2007.
    Training in behavioral health issues is ongoing in numerous forums. 
The Walter Reed Army Institute of Research has developed a training 
program called ``Battlemind''. Prior to this war there were no 
empirically validated training strategies to mitigate combat-related 
mental health problems, and we have been evaluating this post-
deployment training using scientifically rigorous methods with good 
initial results. This new risk communication strategy was developed 
based on lessons learned from Colonel Hoge's Land Combat Study and 
other efforts. It is a strengths-based approach that highlights the 
skills that helped soldiers survive in combat instead of focusing on 
the negative effects of combat. Two post-deployment training modules 
have been developed, including one version that involves video 
vignettes, that emphasizes safety and personal relationships, 
normalizing combat-related mental health symptoms, and teaching 
soldiers to look out for each other's mental health.
    The acronym ``Battlemind'' identifies 10 combat skills that if 
adapted will facilitate the transition home. An example is the concept 
of how soldiers who have high tactical and situational awareness in the 
operational environment may experience hypervigilence when they get 
home. The post-deployment Battlemind training has been incorporated 
into the Army Deployment Cycle Support Program, and is being utilized 
at Department of Veterans' Affairs Vet Centers and other settings. We 
have also been developing pre-deployment resiliency training for 
leaders and soldiers preparing to deploy to combat using the same 
Battlemind training principals, as well as training for spouses of 
soldiers involved in combat deployments.
    Traumatic Brain Injury (TBI) is emerging as a common blast-related 
injury. TBI is a broad grouping of injuries that range from mild 
concussions to penetrating head wounds. An overwhelming majority of TBI 
patients have mild and moderate concussion syndromes with symptoms not 
different from those experienced by athletes with a history of 
concussions. Many of these symptoms are similar to post-traumatic 
stress symptoms, especially the symptoms of difficulty concentrating 
and irritability. It is important for all providers to be able to 
recognize these similarities and consider the effects of blast 
exposures in their diagnoses. Through the Defense and Veterans Brain 
Injury Center (DVBIC), headquartered at Walter Reed, we understand a 
lot about moderate to severe TBI, including severe closed head trauma, 
stroke, and penetrating head wounds. What we do not fully understand is 
the long-term effects of mild concussion or multiple mild concussion on 
soldier performance. Through Congress' support of the DVBIC has been 
instrumental in providing the DOD with a firm foundation to quickly 
improve our understanding of mild TBI, but we must move quickly to fill 
this knowledge gap.
    In December 2006 I chartered an Army Task Force on TBI to review 
our policies and resources dedicated to TBI from scientific research, 
acute diagnosis and treatment, to long-term rehabilitation. This task 
force, led by Brigadier General Don Bradshaw, will include subject 
matter experts from across Army medicine. I have also invited the Navy, 
Air Force, and Department of Veterans' Affairs to have representatives 
participate in the task force. I expect General Bradshaw to provide me 
a report and recommendations by late spring 2007.
    America does not know that rapid growth in national healthcare 
costs threaten our medical system and, ultimately, Army readiness. The 
Army requires a robust military medical system to meet the medical 
readiness needs of active duty service members in both war and peace, 
and to train and sustain the skills of our uniformed physicians, 
nurses, and combat medics as they care for family members, retirees, 
and retiree family members. Therefore we share the DOD's concern that 
the explosive growth in our healthcare costs jeopardizes our resources, 
not only to the military health system but in other operational areas 
as well.
    DOD continues to explore opportunities to help control costs within 
the DHP and in many of these initiatives the Army leads the way in 
implementation and innovation. In 2006, I implemented a performance-
based budget adjustment model throughout the Army Medical Command. This 
model accounts for provider availability, workload intensity, proper 
coding of medical records, and the use of outcome measures of as 
quality indicators to adjust hospital and clinic funding levels to 
reflect the actual cost of delivering healthcare. The Southeast 
Regional Medical Command implemented an early version of this system in 
2005 where it showed great promise. This enterprise-wide model focuses 
command attention on the business of delivering quality healthcare. It 
is a data-driven methodology that enables commanders at all levels to 
receive fast feedback on their organization's performance. Finally, the 
use of clinical practice guidelines encourages efficiency by using 
nationally accepted models for disease management. These adjustments 
provide my commanders the ability to reward high-performing activities, 
encourage best-business opportunities, and exceed industry-standard 
wellness practices.
    Fiscal year 2007 and fiscal year 2008 will be challenging years for 
the Defense Health Program (DHP) and Army medicine. Our estimates for 
cost growth through 2013 are not complete, but we are still witnessing 
sizable growth in the number of TRICARE-reliant beneficiaries in our 
system, and the pressures on the defense budget grow. Military health 
care costs continue to increase substantially. The fiscal year 2008 
President's budget request includes a legislative proposal that aligns 
TRICARE premiums and co-payments for working age retirees (under age 
65-years) with general health insurance plans. The Department may 
modify or supplement this request after it considers recommendations 
from the Department of Defense Task Force on the Future of Military 
Health Care that has been recently established with distinguished 
membership from within the Department, other Federal agencies and the 
civilian sector. A key area the task force will study and on which it 
will make recommendations is ``beneficiary and government cost-sharing 
structure.'' We believe this and the other recommendations they make 
will markedly benefit the MHS in the future.
    Simply put, the Department and Congress must work together to allow 
the Department to make necessary changes to the TRICARE benefit to 
better manage the long-term cost structure of our program. Failure to 
do so will harm military healthcare and the overall capabilities of the 
Department of Defense--outcomes we cannot afford.
    The Army continues to support the development of a Unified Medical 
Command and is working closely with our sister services and the Joint 
Staff to realize the full potential of this initiative. A fully 
functional unified command represents an opportunity to reduce multiple 
management layers within DOD's medical structure, inspire collaboration 
in medical training and research, and gain true efficiencies in 
healthcare delivery. These changes need to be made in conjunction with 
BRAC implementation and other actions to sustain the benefit if we are 
to realize the full potential of a streamlined, more responsive command 
and control structure.
    The DHP is a critical element of Army medical readiness. Healthy 
soldiers capable of withstanding the rigors of modern combat; who know 
their families have access to quality, affordable healthcare, whether 
the soldier is home with them or off to combat; and who are confident 
when they retire they will have access to that same quality healthcare 
is an incredibly powerful weapon system. Every dollar invested in the 
DHP does much more than just provide health insurance to the 
Department's beneficiaries. Each dollar is truly an investment in 
military readiness. In OIF and OEF that investment has paid enormous 
dividends.
    America has long known of the rich legacy of excellence for which 
Walter Reed Army Medical Center is so highly regarded. The issues 
highlighted in the Washington Post articles are not due to a lack of 
funding or support from Congress, the administration, or the Department 
of Defense. Nor are they indicative of any lowering of standards by the 
WRAMC leadership. We are aggressively working to address the problems 
highlighted in the media, both internally and in conjunction with the 
independent review panel appointed by the Secretary of Defense. Walter 
Reed represents a legacy of excellence in patient care, medical 
research and medical education. I can assure you that the quality of 
medical care and the compassion of our staff continue to uphold Walter 
Reed's legacy. But it is also evident that we must improve our 
facilities, accountability, and administrative processes to ensure 
those systems meet the high standards of excellence that our men and 
women in uniform so richly deserve.
    In closing let me emphasize that the service and sacrifice of our 
soldiers--and their families--cannot be measured with dollars and 
cents. The truth is that we owe far more than we can ever pay to those 
who have been wounded and to those who have suffered loss. Thanks to 
your support, we have been very successful in developing and sustaining 
a healthcare delivery system that honors the commitment our soldiers, 
retirees, and their families make to our Nation by providing them with 
world-class medical care and peerless military force protection.
    Thank you again for inviting me to participate in this discussion 
today. I look forward to answering your questions.

    Senator Inouye. And may I now recognize Vice Admiral Donald 
C. Arthur, Surgeon General of the Navy. Admiral?
STATEMENT OF VICE ADMIRAL DONALD C. ARTHUR, SURGEON 
            GENERAL, DEPARTMENT OF THE NAVY
    Admiral Arthur. Good morning, Senator Inouye, Senator 
Stevens, distinguished members of the subcommittee. Thank you 
very much for recognizing the corpsmen and, by extension, the 
medics, and their contribution to the warfight.
    We have throughout history relied on our corpsmen to 
provide the first level of care, and although we have very well 
trained surgeons, nurses, and others far forward to do surgery, 
no marine, no soldier gets to a surgeon without having first 
been cared for by a corpsman or combat medic. We take our 
obligation to them seriously. Through the lessons learned 
system we have modified and improved their trauma training 
throughout their training back here at home, so that they are 
proficient at their combat skills when they get into combat.
    I also appreciate the collaboration between the three 
services, so that a soldier or a marine can get care at a Navy 
or an Army facility on the ground, be flown by the Air Force 
with their critical care air transport teams to Landstuhl and 
back to the United States in 36 to 48 hours, and be met by 
their family at one of our facilities back home. We are in 
combat today. We take that obligation very, very seriously.
    We are in combat also here in the United States, within our 
own system. We have been given efficiency wedges which have cut 
our budget. We have been given military-to-civilian conversion 
objectives. We have had our staff cut without conversions. And 
with these financial and personnel challenges, we may very well 
find it difficult to meet our combat missions in the future.
    We have been given many medical readiness review 
assumptions that minimize the number of casualties that are 
expected in the future, minimize the number of deployments that 
we will have, minimize the biological or chemical warfare agent 
threat, minimize or even eliminate the homeland security/
humanitarian assistance and homeland defense components of our 
mission, and we will find, I think, those missions to be very 
difficult to meet in the future.
    We are concentrating very heavily during this war on 
traumatic brain injury and post-traumatic stress disorders 
because we have come to have a new realization of the magnitude 
of the combat stress that each of our veterans experience. When 
I first became Surgeon General, I had a brief that said that 25 
percent of people that go into combat are significantly 
affected by the experience. I disagreed, and still do. I think 
it's 100 percent.
    Having been in combat myself with the marines in 1991, I 
can tell you that everyone who experiences combat is 
significantly affected by the experience, and they develop a 
debt that we need to repay as soon as they come back. We need 
to be sensitive to their needs to readjust. The challenge is 
great for us because we do not want to see it in their 
employers, in their families or other indicators, where we have 
failed to recognize it first and taken effective action.
    I think we are becoming even more sensitive to mild 
traumatic brain injury and its effects on cognition, on mental 
function. I am acutely aware of this. You know that last year I 
was in a motorcycle accident with significant period 
unconsciousness which followed that, and I can tell you that it 
took many months to regain my memory, calculation, and some of 
my higher executive skills after that injury. That was a mild 
traumatic brain injury. So I'm sensitive to the fact that you 
may not pick it up in the normal tests that we give to our 
casualties.
    It may come up with the casualty coming to us and saying, 
``You know, I have trouble reading a menu. I can't decide what 
to have. Even though I know what I want, I can't make a 
decision.'' And that may be a subtle sign of traumatic brain 
injury.
    We look forward to additional collaboration with the 
Veterans Administration as we become really one seamless system 
of Federal care for our veterans. We know that there are 
challenges with the medical records system, and we're dedicated 
to providing all of the medical record information that our 
veterans need to get care in the system.
    We know that the Veterans Administration has polytrauma 
centers and has the expertise in traumatic brain injury, spinal 
cord injury, and other very serious veterans' injuries, and we 
work with them in collaboration with all their centers. We use 
them not only for care of veterans who are discharged from the 
service but also for some of our veterans who will come back to 
active duty. I think the Navy's DOD/VA collaboration in Great 
Lakes, where we have truly combined the two facilities, is a 
good benchmark for how it can be done and also a test bed for 
where we can further integrate our electronic medical record 
systems.

                           PREPARED STATEMENT

    Senator Inouye, Senator Stevens, I have 2 days ago 
submitted my request for voluntary retirement after 32 years of 
naval service. It is my time to turn over to the next Surgeon 
General of the Navy, and I want to tell you how very honored I 
have been to wear this uniform for 32 years, to be in front of 
you with great pride in how we are serving our veterans. We 
have a philosophy in our system, that the honor of our care 
should be directly proportional to the courage of our veterans.
    Thank you very much, and I look forward to your questions.
    Senator Inouye. Admiral, I'm certain I speak for the 
subcommittee. I thank you very much for your service to our 
Nation.
    Admiral Arthur. It's been an honor, sir.
    [The statement follows:]
          Prepared Statement of Vice Admiral Donald C. Arthur
                              introduction
    Chairman Inouye, Senator Stevens, distinguished members of the 
subcommittee, I welcome the opportunity to share with you how Navy 
medicine is taking care of our Nation's sailors, marines, and their 
families across the globe and at home.
    Navy medicine remains steadfast in its commitment to provide care 
on the battlefield and meet the health care needs of our beneficiaries, 
active duty, reservists, military retirees, and family members, as our 
Nation continues to be engaged in combat operations fighting the Global 
War on Terror (GWOT).
    We are dedicated to maintaining a healthy and fit force that is 
ready to deploy and to deploying medical personnel to provide the best 
health care to our warriors on the battlefield. And when that is not 
enough, we are committed to restoring the health of those injured on 
the battlefield.
    At the same time, we are responsible for ensuring access to world-
class health care for all eligible beneficiaries. Meeting these 
missions are an exceptional team of military, active and reserve, and 
civilian health care professionals who perform their duties with the 
same enthusiasm in deployed settings as well as at our Medical 
Treatment Facilities (MTFs).
  defense health program and navy medicine budget for fiscal year 2008
    In recent years, Navy medicine faced many fiscal challenges and 
anticipates that some will continue throughout fiscal year 2008. The 
President's budget for fiscal year 2008 funds healthcare operations; 
authorizes 1,011 military to civilian conversions; includes funding for 
the GWOT requirement; and assumes savings and efficiencies in several 
areas.
    Fiscal year 2008 provides funding challenges in that the efficiency 
wedge increases and certain assumptions regarding savings opportunities 
may not be borne out in execution. These reductions represent 
leadership and management challenges, which we must meet. We are 
vigorously integrating our fiscal challenges, and our military to 
civilian conversion program, into an ongoing business process review 
that is designed to make Navy medicine an efficient, effective care 
provider.
    As you know, the Department of Defense faces tremendous difficulty 
with balancing the growing costs and long-term sustainability of the 
military health system. We will need to consider all options available 
to ensure a superior benefit remains available for the long term and we 
look forward to the recommendations on fiscal and other issues that 
will come from the Department of Defense Task Force on the Future of 
Military Health Care that has recently been established with 
distinguished membership from within the Department, other Federal 
agencies, and the civilian sector.
                          combat casualty care
    We have made significant advances in combat casualty care and have 
redefined trauma management for military operational medicine. Navy 
medicine is continuously assessing its medical capabilities to make 
improvements resulting in real time adjustments to ensure the right 
health care capabilities are deployed as far forward as possible. These 
improvements are based on our experience and lessons learned, and on 
the requirements mandated by the warfighter. As a result of these 
improvements, only 2-3 percent of service members who are wounded and 
who reach medical care within 60 minutes are dying from their injuries.
    One of the most important contributors to saving lives on the 
battlefield, historically and currently, is Navy corpsmen--Navy 
medicine's first responders on the battlefield. The platoon corpsmen 
are supported by a team of field surgeons, nurses, medical technicians 
and support personnel in theater, who are supported by medical 
evacuation teams and overseas MTFs working together with MTFs in the 
United States--this is the Navy medicine continuum of care.
    Combat casualty care is a ``continuum-of-care,'' which begins with 
corpsmen in the field with the marines; progresses to forward 
resuscitative care; on to theater level care; and culminates in care 
provided in route during patient evacuation to a military hospital. 
Medical care is being provided in Iraq and Afghanistan by organic 
Marine Corps health services units which include Battalion Aid Stations 
(BAS), shock trauma platoons, surgical companies, and Forward 
Resuscitative Surgical Systems. Our forward-deployed assets include 
Navy surgical capabilities located in Al Asad and Taqaddum. These units 
are the first oasis of care for many warfighters who are seriously 
wounded fighting insurgents. At Al Asad the majority of the injuries 
treated have been from improvised explosive devices (IEDs). They 
provide patient resuscitation and stabilization for helicopter medical 
evacuations to higher-capability medical facilities, something no other 
medical unit in the surrounding area can offer.
    Sailors at the medical unit in Taqaddum treat the most serious of 
patients from the entire area of operations, most arriving by 
helicopter directly from the battlefield. The platoon is staffed by 
dedicated and highly skilled uniformed medical personnel who stand in 
harm's way ready to fight for the lives of our wounded service members.
    Changes have been made in the training of the physicians, nurses 
and corpsmen who first encounter injured service members, as well as to 
the way certain types of injuries are treated. In addition, new combat 
casualty care capabilities such as one-handed tourniquets and robust 
vehicle first-aid kits for use during convoys are being deployed. Navy 
fleet hospital transformation is currently redesigning Expeditionary 
Medical Facilities (EMFs) to become lighter, modular, more mobile, and 
interoperable with other Services' facilities in theater.
    As EMFs continue to evolve, so do Navy Medicine's Forward 
Deployable Preventive Medicine Units (FDPMU). These units include 
environmental health and preventive medicine professionals who play a 
critical role in force health protection services, including 
environmental site assessments, water quality analysis, and disease 
vector surveillance and control. The Marine Corps' remain the FDPMU's 
primary customer, however, these teams also provide preventive medicine 
support to Naval Construction Battalions/Seabee Units, Army, and Air 
Force personnel. Currently, the Navy has four FDPMUs, with teams that 
have deployed for Operation Iraqi Freedom (OIF).
    Navy medicine's commitment to the warfighter is clearly seen in the 
combat casualty care provided to injured and ill marines and sailors 
engaged in Operation Enduring Freedom (OEF) and OIF since the beginning 
of the GWOT.
    Navy medicine is constantly looking at the next steps in improving 
combat casualty care. Our current efforts center on expansion of our 
health surveillance, combat and operational stress control programs, 
and improving care for certain types of injuries such as traumatic 
brain injury (TBI). Combat casualty care is not limited to the care 
received while in theater, but extends to the information and training 
we provide to service members to prevent physical and mental health 
injuries before, during and after deployment.
    Providing preventive and treatment services as early as possible is 
the best way to avoid or mitigate the long-term effects of war. Navy 
medicine is committed to monitoring the health of deployed service 
members with the use of pre- and post-deployment health assessments. 
These assessment tools are designed to identify potential issues of 
concern, both physical and mental. The program also provides service 
members information on how to access medical services for any physical 
or mental health issues that may occur after returning from deployment.
    We know that all service members who witness or are engaged in 
combat will experience some level of combat stress. To specifically 
address this challenge, Navy medicine launched the Operational Stress 
Control and Readiness (OSCAR) pilot project in January 2004, which 
embedded psychiatrists and psychologists at regimental levels in ground 
Marine Corps units. The primary goal of this program--to effectively 
manage operational stress at the tactical level--is central to the 
readiness of the Marine Corps as a fighting force. To date there are 
three OSCAR teams, one associated with each of the three active USMC 
Divisions: 1st MARDIV located at Camp Pendleton, 2nd MARDIV located at 
Camp Lejeune, and 3rd MARDIV located at Camp Butler (Okinawa). The 
personnel for the OSCAR teams are sourced from Navy MTFs or drawn from 
elsewhere within the Marine Corps structure.
    At Navy and Marine Corps bases across the country, Navy medicine is 
coordinating with line commanders and their organic medical assets to 
establish 13 Deployment Health Clinics (DHCs) to facilitate these 
health assessments. The DHCs serve as a non-stigmatizing point of entry 
for military personnel with deployment health and/or military readiness 
needs. These clinics by design will complement and augment primary care 
services that are offered at the MTFs or in garrison at the unit level 
such as BAS. Services provided will vary with patient and health 
concern, but the services will include screening, counseling and 
initial treatment for family problems, diet and exercise, substance 
abuse, sexual practices, injury prevention, stress, primary care and 
mental health concerns. The goal is to provide appropriate treatment 
for deployment-related concerns in an environment that reduces the 
stigma associated with the service member's condition. The clinics are 
staffed to support increased referrals as deploying units return from 
the theater of operations.
    In order for combat casualty care to be effective, Navy medicine 
has incorporated service members' families into the care model. We 
first launched this concept at the National Naval Medical Center 
several years ago and are now making it part of the way we treat our 
combat casualties at every Navy MTF. Recent developments in this area 
include the establishment of the Comprehensive Combat Casualty Care 
Center (C5) at Naval Medical Center San Diego.
    C5 is based on the models for amputee care developed at Walter Reed 
and Brooke Army Medical Centers, but is expanded to include other types 
of injuries such as TBI and Post-Traumatic Stress Disorder. C5 will 
monitor and coordinate the medical care of the service member in and 
outside of the MTFs. In addition, C5 will provide support to the 
families in every way possible and focus on ensuring that the service 
members and their families have a smooth transition to civilian life or 
continued military service. When completed, NMCSD will be the 
Department of Defense's comprehensive combat casualty care ``center of 
excellence'' for the west coast.
                    humanitarian and joint missions
    The role of Navy medicine has played in OEF and OIF illustrates 
only part of the increased operational tempo of our medical personnel 
across the spectrum of Navy medicine in recent years. We have new 
expanded missions which include humanitarian efforts, missions in 
support of joint military operations, and a greater role in homeland 
security.
    As demonstrated with the Pakistan earthquake in 2005 and return 
visits to areas struck by the Indonesian tsunami, America's compassion 
and generosity are a powerful force of good will. These missions have 
transformed fear into trust and animosity into handshakes--medical 
diplomacy--a recognized impact on the GWOT.
    The Navy and Marine Corps responded to the earthquake in Indonesia 
in June 2006 and the medical team treated over 2,000 patients. The 
earthquake's destruction displaced hundreds of thousands of 
Indonesians. A mobile medical unit was set up at a local soccer field 
in Sewon and provided a variety of medical services including surgeries 
and vaccinations. The vaccination efforts focused on reducing the 
significant risk of contracting tetanus, a devastating bacterial 
infection that usually originates from a contaminated laceration.
    USNS Mercy (T-AH 19), our hospital ship home-ported in San Diego, 
completed a humanitarian assistance mission to Southeast Asia last 
year. Mercy provided direct aid to more than 87,000 people in 
Indonesia, Bangladesh and the Philippines. Mercy's team included an 
unprecedented group of volunteers and professionals, civilians and 
military, men and women, dedicated to saving lives, restoring hope and 
spreading good will. The team included a dozen non-governmental 
organizations (NGOs); U.S. Army, U.S. Air Force, and Public Health 
Service medical personnel, naval construction forces and medical 
professionals from Canada, India, Malaysia, Australia and Singapore.
    Mercy's deployment was an exciting and important opportunity to 
bolster security, stability and prosperity--both at sea and ashore--in 
a region where we have important interests. Mercy's deployment was a 
model of cooperation and deliberate planning with NGOs and partnering 
nations. This international collaboration underscores the Navy's 
commitment and tradition of providing medical and humanitarian 
assistance where and when needed and added a new dimension to forward 
presence.
    The hospital ship's state of the art operating rooms, CT scan 
equipment, laboratories and her ability to electronically transfer 
medical information allowed the staff to consult with physicians in 
other locations. The international team performed over 1,000 surgeries 
and cared for over 60,000 patients. Mercy visited 10 locations in four 
countries and demonstrated the great capability and capacity the ship 
brings without requiring a significant presence ashore. Mercy's crew 
played an important role as American good will ambassadors. Their 
actions demonstrated to thousands of people the true values and ideals 
we hold as Americans.
    Later this year, the Navy plans to deploy our East coast-based 
hospital ship, the USNS Comfort (T-AH 20), in support of a humanitarian 
mission to nations in the Caribbean and Central/South America. In 
addition, a robust medical staff based out of San Diego will deploy 
aboard the USS Pelelieu to the Western Pacific to continue our 
humanitarian efforts in that region.
    Also in 2006, Joint Forces Command (JFCOM) tasked the Navy with 
providing medical staffing in support of the Army's Landstuhl Regional 
Medical Center (LRMC) Germany. Upon arriving in November, this group of 
more than 300 Navy medical reservists and 30 active duty personnel 
became part of the LRMC team and are providing superior medical, 
surgical and preventive health care to wounded warfighters returning 
home. This mission demonstrates how our active duty and reserve 
components seamlessly integrate the talents and strengths of our 
reservists to accomplish the mission. This call to meet Landstuhl 
personnel needs also demonstrates the increased operational 
requirements and tempo to which Navy medicine has been responding since 
the beginning of OEF/OIF.
    The Expeditionary Medical Facility Kuwait (EMF-K) is in its third 
year as Navy medicine detachments staff the U.S. military hospital in 
Kuwait and its nine outlying clinics. This facility averages over 
17,500 monthly patient encounters and is staffed by Navy personnel from 
26 medical activities around the world.
    U.S. Military Hospital Kuwait is a Level 3 medical facility that 
provides outpatient, as well as inpatient, care and specialty services 
such as cardiology, pulmonary, critical care, internal medicine, 
general surgery, optometry, orthopedics, gynecology, laboratory, 
pharmacy, radiology, mental health, dental and physical therapy. 
Between December 2005 and October 2007, over 75 percent of troops who 
came to the facility were able to remain in theater. EMF-K also 
provides health care to Department of Defense personnel and Coalition 
forces stationed in the U.S. Army Forces Central Command area of 
responsibility--Kuwait, Qatar, Afghanistan, and Iraq.
    Joint initiatives are underway across the full spectrum of military 
medical operations around the world. Navy medicine is committed to 
increasing the ways we jointly operate with the Army and Air Force. 
Ideally, all U.S. medical personnel on the battlefield--regardless of 
service affiliation--should have the same training, use the same 
information systems and operate the same equipment because we are all 
there for the same reason--to protect our fighting forces. It should 
not matter whether the casualty is a soldier, sailor, airman, marine, 
or coast guardsman, or what color uniform the medical provider wears. 
Injured warfighters should receive the same level of care delivered by 
personnel with the necessary training, equipment and information 
systems to maximize our efficiency and achieve the best patient 
outcomes.
                 medical personnel and quality of care
    On an average day in 2006, Navy medicine had over 3,800 medical 
personnel from the active and reserve components deployed in support of 
operations, exercises or training around the world. While continuing to 
support our missions we have been challenged to ensure that sufficient 
numbers of providers in critical specialties are available to fill both 
the wartime mission and sustain our beneficiaries at home.
    Navy medicine is continually monitoring the impact deployments of 
medical personnel have on our staff and our ability to provide quality 
health in our MTFs. We continue to pursue an economic and quality-
centered strategy focused on maintaining the right mix in our force to 
sustain the benefits of our health care system. Together with the 
network of TRICARE providers who support local MTFs, beneficiaries have 
been able to continue accessing primary and specialty care providers as 
needed. We closely monitor the access standards at our facilities using 
tools like the peer review process, to evaluate primary and specialty 
care access relative to the Department of Defense's standard.
    Providing quality medical care is Navy medicine's priority and we 
earn the trust of our beneficiaries by ensuring our health care 
providers embrace the highest standards of training, practice and 
professional conduct. Another means used to ensure quality is our 
robust quality assurance and risk management programs that promote, 
identify, and correct process or system issues and address provider and 
system competency issues in real time. Our program promotes a patient 
safety culture that complies with nationally established patient safety 
goals and we have an extensive, tiered quality assurance oversight 
process to review questions related to the standard of medical care.
    Navy medicine also promotes healthy lifestyles through a variety of 
programs. These programs include: alcohol and drug abuse prevention, 
hypertension identification and control, tobacco use prevention and 
cessation, and nutrition and weight management. Partnering with other 
community services and line leadership enhances their effectiveness and 
avoids duplication. We have established evidence-based medicine 
initiatives and currently measure diabetes, asthma and women's breast 
health. Soon, we will add dental health and obesity.
   recruitment and retention efforts of medical department personnel
    Navy medicine continues to face challenges in reaching the end-
strength targets for our medical communities. This has resulted in 
shortages in several critical wartime specialties. Unfortunately, 
medical professionals are not considering the military for employment, 
especially as civilian salaries continue to outpace the financial 
incentives available.
    We are optimistic that new initiatives authorized in the National 
Defense Authorization Act for Fiscal Year 2007 (NDAA FY07) will enable 
the medical department to address many recruiting issues. Some of the 
improvements include: increases to the Health Professions Scholarship 
Program (HPSP), increases in direct accession bonuses for critical 
wartime specialties, and expanded eligibility for special pay programs.
    Our losses have outpaced gains over the past several years and 
fiscal year 2006 was no exception, ending the year with a 93.5 percent 
manning across the Navy medical department. Our primary concern is 
attrition within critical wartime specialties. Additionally, concerns 
over excessive deployments and mobilization of certain specialties, 
especially in the Reserve Component where Reservists fear the potential 
loss of their private practice, have been a major deterrent to entering 
the Navy's medical department in recent years.
    As of December 2006, the Medical Corps remained below end-strength 
targets and continues to experience acute shortages in critical wartime 
subspecialties. Recruiting challenges continue to exist within the 
HPSP, the primary student pipeline for Medical Corps officers. The HPSP 
met only 56 percent of goal in fiscal year 2005 and 66 percent in 
fiscal year 2006 for medical students. These shortfalls will be 
realized in fiscal year 2009 and 2010 with 230 fewer accessions than 
required. Retention issues continue to be of concern for this community 
and the effect of increased medical special pay rates offered for 
fiscal year 2007 will not be known until the end of the fiscal year.
    The Dental Corps continues to remain under end-strength (at 90 
percent manned), especially in the junior officer ranks where attrition 
is high and accessions have been a challenge in recent years. The HPSP, 
also the primary student pipeline for the Dental Corps, met 76 percent 
of its goal in fiscal year 2006. However, like the Medical Corps, it is 
expected that program improvements recently approved will have a 
positive impact on our recruitment efforts. Finally, with regard to 
dentists, a Critical Skills Retention Bonus (CSRB) was recently 
approved to grant a $40,000 contract for 2 years of additional service 
to general dentists between 3 and 8 years of service. It is anticipated 
that this bonus will help mitigate the civilian/military pay gap, 
making Navy Dental Corps more competitive with civilian salaries, thus 
improving retention.
    The Medical Service Corps assesses to vacancies in subspecialties 
and success in meeting direct accession goals is largely dependent on 
the civilian market place. Last year the Medical Service Corps fell 
short of their direct accession goal by over 30 percent for the second 
year in a row, directly impacting the ability to meet current mission 
requirements. Retention of specialized professionals such as clinical 
psychologists and physician assistants remains the greatest challenge 
as deployment requirements increase for these professions. Shortages in 
these critical wartime communities are being addressed with increased 
accession goals and a CSRB for clinical psychologists. In addition, 
Navy Medicine is working within Navy to explore other incentive 
programs for this specialty. The Health Professions Loan Repayment 
Program has been a successful recruiting and retention tool for hard to 
fill specialties and is being expanded, as funding will allow, 
providing recruiting command with additional incentives.
    Navy Nurse Corps is the only medical department specialty 
projecting to meet fiscal year 2007 accession goals. The national 
nursing shortage and competition with the civilian market and other 
military services have continued to challenge recruiting efforts for 
scarce direct accession resources. To counter this, the Nurse Corps 
Accession Bonus was increased in fiscal year 2007 and the Navy Nurse 
Corps has continued to shift more emphasis onto its highly successful 
Nurse Candidate Program (NCP), requesting a permanent increase in new 
starts for this program and decreasing direct accession goals. 
Retention rates have slightly decreased, especially among clinical 
specialties with a high operational tempo.
    We met 99 percent of the active enlisted Hospital Corpsman (HM) 
goal and 94 percent of the Reserve enlisted medical corpsman goal. From 
January 2006 to January 2007, Navy medicine retained 52 percent of 
corpsmen in Zone A, 55 percent in Zone B, and 84 percent in Zone C. HM 
is slightly below overall Navy retention rates for Zone B, but is 
improving. The other two HM zones are either at or exceed overall Navy 
retention rates and exceeds goals set.
    The outlook of the medical department shows we have some 
significant challenges ahead, and Navy medicine is grateful for 
Congress' willingness to step in and help when needed. We continue to 
reach out to universities and medical and dental schools to encourage 
these students to join us and practice medicine where keeping service 
members and their families healthy, and not just treating disease, is 
our primary mission.
                    research and development efforts
    Navy medicine is actively engaged in the research, development, 
testing and evaluation of new technologies that improve the health of 
all beneficiaries, especially those technologies focused on enhancing 
performance and decreasing injury of deployed warfighters. A 
significant part of our R&D efforts are aimed at improving the tools 
available to combat support personnel, as well as disease prevention 
and mitigation of our forces at home and abroad. Our R&D efforts 
include specific areas of expertise such as undersea medicine, trauma 
and resuscitative medicine, and regenerative medicine. We have 
partnered with the other services and with world-class organizations 
like the National Institutes of Health.
    Navy medicine's researchers have recently begun phases two and 
three of Food and Drug Administration (FDA) approved trials for a 
vaccine developed to stop the adenoviral illness that can make sailors 
ill. This illness is caused by viral pathogens, or germs, that can make 
sailors sick and causes loss of valuable time in training. The results 
from this trial, which is led by the Army, could eventually reduce 
illness in as many as one-fifth of sailors in basic training. The U.S. 
Naval Health Research Center based in San Diego (NHRC) has a long 
history of successful research on respiratory infections, especially 
adenoviral infections, and NHRC houses the Navy Respiratory Disease 
Laboratory, making it the ideal partner with the Army research team.
    After years of research into malaria, the deadly mosquito-borne 
infection that kills more than 1 million people every year, Naval 
Medical Research Center (NMRC) in Silver Spring, Maryland, will begin 
human testing on an experimental malaria vaccine. Although there have 
been no malaria deaths of U.S. military personnel since 2002, when an 
Army Special Forces soldier died following a mission to Nigeria, the 
disease can have a significant negative effect on troop readiness. In 
August 2003, during a Marine Corps deployment to Liberia, a mission was 
aborted when 44 percent of the members of the Marine Expeditionary Unit 
acquired malaria after spending nights at the Monrovia airport.
    As I mentioned before, our high combat casualty survival rates are 
due to the training and commitment of our corpsmen, our willingness to 
implement lessons learned, and improvements in life-saving 
technologies. Navy Medicine R&D is evaluating the effectiveness of more 
than a dozen new hemostatic agents and devices. The outcome of this 
critical study will drive the Marine Corps selection of the component 
to be deployed as part of the Individual First Aid Kit that every 
marine and sailor is issued when entering the combat theater. NMRC 
evaluates the effectiveness of these devices, which are designed for 
application under battlefield conditions and removal in the operating 
room. In addition to the Navy and Marine Corps, we expect other 
services and civilian police departments to benefit from this 
development.
    Navy medicine is beginning the evaluation of devices that detect 
the early signs of TBI. We have seen an increased incidence of TBI 
resulting from exposure to explosive devices in theatre, particularly 
IEDs. Fielding such a device will allow earlier intervention and 
treatment that could prevent the longer term, often devastating, 
effects of TBI. Such devices are designed to detect even mild TBI and 
indicate to our corpsmen and physicians which casualties require 
further monitoring and treatment.
    Navy medicine R&D is working side by side with the Marine Corps 
finalizing development of a critical component of the En Route Care 
System. Called the MOVES (Mobile Oxygen, Ventilation, and External 
Suction), this single integrated device provides a capability for 
casualty management that reduces the weight and cube over current 
systems by nearly 75 percent. Because it does not require external 
oxygen, the device will allow our airlift assets to operate without 
dangerous high-pressure oxygen cylinders onboard. The MOVES is 
scheduled for delivery for field testing in fiscal year 2008.
          navy medicine and the department of veterans affairs
    As the number of injured service members who return in need of 
critical medical services increases, and due to the severity and 
complexity of their injuries, increased cooperation and collaboration 
with our Federal health care partners is essential to providing quality 
care. As an extension of Navy medicine's ability to care for patients, 
partnerships with the Department of Veterans Affairs' (VA) medical 
facilities continue to grow and develop into a mutually beneficial 
association. The VA's Seamless Transition Program to address the 
logistic and administrative barriers for active duty service members 
transitioning from military to VA-centered care is at most Navy MTFs 
with significant numbers of combat-wounded. This program is working 
well and continues to improve as new lessons are learned.
    Navy medicine and the VA also continue to pursue increased 
collaboration in resource sharing, new facility construction, and joint 
ventures. Using our sharing authority, we are rapidly moving toward 
functionally integrating the Naval Hospital Great Lakes and the North 
Chicago Veterans Affairs Medical Center and expect to fully complete 
the project by 2010. This facility will seamlessly meet the needs of 
both VA and Navy beneficiaries. Other locations identified for future 
physical space sharing with the VA include: Naval Hospital Charleston, 
Naval Hospital Beaufort and Naval Hospital Guam.
    Navy medicine is also exploring new relationships with the VA such 
as the Balboa Career Transition Center. NMCSD recently entered into an 
agreement with the U.S. Department of Labor, the VA and the California 
Employment Development Department to provide quality VA benefit 
information and claims intake assistance, vocational rehabilitative 
services, career guidance, and employment assistance to wounded and 
injured service members and their families. This unique program will 
successfully coordinate all of the services available to these 
individuals.
                               conclusion
    Chairman Inouye, Senator Stevens, distinguished members of the 
committee, thank you again for the opportunity to testify before you 
today about the state of Navy medicine and our plans for the upcoming 
year.
    It has been a privilege to lead Navy Medicine for the last 3 years 
as Navy medicine has risen to the challenge of providing a 
comprehensive range of services to manage the physical and mental 
health challenges of our brave sailors and marines, and their families, 
who have given so much in the service of our Nation. We have 
opportunities for continued excellence and improvement, both in the 
business of preserving health and in the mission of supporting our 
deployed forces. I thank you for your tremendous support to Navy 
medicine.

    Senator Inouye. May I now recognize the Surgeon General of 
the Air Force, Lieutenant General James Roudebush.
STATEMENT OF LIEUTENANT GENERAL JAMES G. ROUDEBUSH, 
            SURGEON GENERAL, DEPARTMENT OF THE AIR 
            FORCE
    General Roudebush. Thank you, Senator Inouye, Senator 
Stevens.
    Senator Inouye. Can you pull that mike up? I can't hear 
you.
    General Roudebush. Thank you. Senator Inouye, Senator 
Stevens, distinguished members of the subcommittee, thank you 
for the opportunity and the privilege of being here today to 
tell you about Air Force medicine on the battlefield and at 
home station.
    Up front, I would like to note that Air Force medicine is 
not simply about support and not simply about reacting to 
illness and injury. Air Force medicine is a highly adaptive 
capability, tightly integrated into Air Force expeditionary 
capability and culture.
    We build a healthy, fit force, fully prepared to execute 
the mission from each of our bases, whether deployed or here in 
the States, because every Air Force base is an operational 
platform. Whether launching bombers from Whiteman Air Force 
Base, or sitting alert in a missile control facility at Warren 
Air Force Base, or providing close air support from Balad Air 
Base in Iraq, we project airpower for our joint forces and 
provide sovereign options for our national leadership, all from 
our bases of operation.
    Air Force medicine supports that warfighting capability at 
each of our bases, and is, in fact, designed to prevent 
casualties and sustain our fighting strength. The result is the 
lowest nonbattle injury rate in the history of warfare, but 
when there are casualties, Air Force or joint, your Air Force 
medics are there with world-class care.
    In the deployed arena, our medical teams operate closer to 
the front lines than ever before, allowing us to provide 
warfighters advanced medical care within minutes. Underpinning 
this world-class healthcare for our joint warfighters is our 
system of joint enroute care. It does begin with a Navy 
corpsman or an Army medic providing lifesaving first aid at 
that point of injury.
    The casualty is then moved to the next level of care. For 
us in the Air Force that's our theater hospital at Balad Air 
Base, the hub of the joint theater trauma system, where 
lifesaving, damage control surgery is performed by Air Force 
surgeons and, on occasion, teaming with Army surgeons to 
provide that surgical care.
    The casualty is then prepared for safe and rapid movement 
in our Air Force air medical evacuation system to Landstuhl, an 
Army hospital manned by Army, Air Force, and Navy medics. 
Retriage and restabilization is then accomplished, and the 
casualty prepared for air evacuation back to definitive care at 
Walter Reed, Bethesda, Brooke Army, Wilford Hall, Navy Balboa, 
or perhaps a VA hospital.
    These capabilities combine to achieve an average patient 
movement time of 3 days from battlefield to stateside care. 
This is certainly remarkable when compared to the 10 to 14 days 
required during the Persian Gulf war and the average of 45 days 
it took in Vietnam, and it's especially remarkable when you 
consider the severity and complexity of the wounds that our 
forces are sustaining.
    In short, Air Force medicine is a key and central player in 
the most effective joint casualty care and management system in 
military history. Having just returned from Afghanistan and 
Iraq just last weekend, I personally observed this capability 
from that far forward care all the way home on the air 
evacuation to the United States, and it's truly lifesaving 
work.
    As our casualties move back to Landstuhl and on to our 
stateside military medical centers, our Air Force casualties 
are followed closely by their unit through an assigned family 
liaison officer to ensure needs of the casualty and their 
family are met. And if going through the disability evaluation 
process is the next step for our wounded airmen, the Air Force 
Palace Helping Airmen Recover Together (HART) program ensures 
the commander, we medics, and the family liaison officer 
continue eyes-on and hands-on throughout the disability 
process.
    Our Air Force medical capabilities go beyond home station 
healthcare and support of our warfighters. Our Air Force medics 
are globally engaged in training our allies, supporting 
humanitarian missions, responding to disasters, and winning 
hearts and minds in key areas around the globe.
    And as we focus on care for our warfighters, I believe it's 
vitally important to note that caring for the families of our 
airmen is also a mission-critical factor. Knowing that their 
loved ones are well cared for back home gives our airmen the 
peace of mind to do a critical job in a stressful and dangerous 
environment. The care we provide is an important factor in 
building the trust that is fundamental to attracting and 
retaining an all-volunteer force.
    This demanding operations tempo at home and deployed also 
means that we must take care of our Air Force medics. This 
requires finding a balance between these extraordinarily 
demanding duties, time for family, and time for personal 
recovery and growth.
    And it means developing the next generation of Air Force 
medics. My charge is to ensure that we recruit the best and 
brightest, prepare them to expertly execute our mission, and 
sustain and retain them to support and lead these important 
efforts in the months and years to come.
    In summary, the talent and dedication of our military 
medics ensure an incredible 97 percent of the casualties that 
we see in our deployed and joint theater hospitals will survive 
today. For our part in this extraordinary system, Air Force 
medics have treated and safely evacuated more than 40,000 
patients since the beginning of Operations Iraqi Freedom and 
Enduring Freedom.
    Globally, we have provided compassionate care to 1.5 
million people on humanitarian missions over the last 6 years, 
and at home station we continue to provide high quality health 
care for 3 million patients every year.

                           PREPARED STATEMENT

    Thank you for your support and assistance in meeting this 
incredibly demanding and critically important mission. I assure 
you we will continue to work hard with you in the months and 
years ahead to sustain and improve our medical capabilities for 
this fight and for the next. Thank you, and I look forward to 
your questions.
    Senator Inouye. Thank you very much, General Roudebush.
    [The statement follows:]
      Prepared Statement of Lieutenant General James G. Roudebush
    Mr. Chairman and esteemed members of the committee, as the Air 
Force Medical Service's (AFMS) Surgeon General, it is a pleasure and 
honor to be here today to tell you about Air Force medical successes on 
both the battlefield and home front.
    The Secretary and Chief of Staff of the Air Force set our 
priorities: Supporting the global war on terrorism, caring for airmen 
and their families, and recapitalizing our assets. The AFMS fully 
supports these priorities by: Taking care of joint warfighters and our 
Air Expeditionary Force; taking care of our Air Force family; and 
building the next generation of Air Force medics. And please note that 
when I say ``medics,'' I am referring to all our Air Force medical 
personnel-officer and enlisted.
    Upfront, I'd like to say, Air Force medicine is not simply about 
support, not simply reacting to illness and injury, and Air Force 
medicine is definitely not a commodity. Air Force medicine is a highly 
adaptive capability, a key part of Air Force expeditionary capabilities 
and culture. Our proactive and visionary work contributes heavily to a 
healthy fit force that is leveraged and designed, in fact, to prevent 
casualties. But . . . when there are casualties, we are there with 
world class care.
    We provide the same quality of care--and access to care--for all of 
our nearly 3 million beneficiaries. Our stand out health care and 
health service support worldwide ensures total force personnel are 
healthy and fit before they deploy, while deployed, and when they 
return home. This is our hallmark, and the result is the lowest 
disease, non-battle injury and died of wounds rates in the history of 
war. We are committed to providing the very best health care to our Air 
Force and joint warfighters.
      taking care of our expeditionary force and joint warfighter
    Our medical teams operate closer to the front lines than ever 
before, enabling us to provide warfighters advanced medical care within 
minutes. Without question, every day, Air Force medics save the lives 
of soldiers, sailors, marines, airmen and civilians; Coalition, Afghani 
and Iraqi; friend and foe alike. Underpinning this world-class health 
care for our joint warfighters is our system of en route care. We 
ensure joint warfighters receive seamless care through the continuum of 
care from first battle damage surgery to definitive care and recovery 
back in the United States. En route care relies on our unique 
capabilities in Expeditionary Medical Support (EMEDS) and Aeromedical 
Evacuation (AE).
Aeromedical Evacuation
    Aeromedical evacuation is distinctly Air Force, and a critical 
component of the Air Force's global reach capability. We safely care 
for and transport even the most severely injured patients to definitive 
care.
    Our expeditionary medical system and AE system combine to achieve 
an average patient movement time of 3 days from the battlefield to 
stateside care. This is remarkable when compared to the 10-14 days 
required during the 1991 Persian Gulf War or the average 45 days it 
took in Vietnam.
    Our modern AE teams--which include Active Duty, Guard and Reserve 
forces--coupled with our innovative Critical Care Air Transport Teams 
(CCATT), operate flying intensive care units in the back of virtually 
any airlift platform. This success resulted from our shift to 
designated, versus dedicated, aircraft and training universally 
qualified AE crew members able to execute their AE mission on any 
airlift aircraft. This transformation of AE has been repeatedly proven 
in the global war on terrorism, as evidenced by the safe and rapid 
transfer of more than 38,000 Operation Enduring Freedom and Operation 
Iraqi Freedom patients from overseas theaters of operation to stateside 
hospitals!
    To illustrate this capability, consider Marine Sergeant Justin 
Ping's story. As a result of a suicide bomber attack in Fallujah, Iraq, 
Sergeant Ping sustained severe burns to his face and hands, blast 
injuries to his right arm, and shrapnel embedded in his leg and right 
eye. Without immediate care, the shrapnel to his eye would have 
undoubtedly resulted in permanent loss of sight. After receiving superb 
first aid from his Navy corpsman immediately after injury, Sergeant 
Ping was flown from the battlefield to the Air Force theater hospital 
at Balad where his injuries were stabilized. It was quickly determined 
that Sergeant Ping's injuries would be best treated in the United 
States. Major (Dr.) Charles Puls, (a CCATT physician) provided full 
life support for Sergeant Ping during the 17-hour, 7,500 mile 
aeromedical evacuation flight from Balad to Brooke Army Medical Center, 
San Antonio, Texas. Major Puls said, ``The patient was stable 
throughout flight . . . we cared for him prior to and during the 
flight,'' referring to his team comprised of Captain William Wolfe, a 
nurse, and Senior Airman Bertha Rivera, a respiratory therapy 
technician. His team ensured Sergeant Ping received the best en route 
care and most expeditious transport all the way back to definitive 
care. There is no doubt that this superb en route care saved Sergeant 
Ping's eyesight. Sergeant Ping is doing quite well today thanks to all 
the medics--Navy, Army, and Air Force--who were dedicated to his care.
    Barbara Wynne, spouse of our very own Secretary of the Air Force, 
recently expressed the importance of our capability when she wrote in a 
letter to all airmen, ``We visited the hospitals in Balad, Landstuhl, 
and at Walter Reed . . . The doctors, nurses and technicians are the 
cream of the crop. Their expertise, saving so many lives, is the silver 
lining to this conflict. It truly is the ``Miracle of Iraq and 
Afghanistan.''
Commitment to Jointness
    I am proud to say that the AFMS is all about ``Joint.'' Not only do 
we run the renowned Air Force theater hospital in Balad, as well as 
smaller facilities in Kirkuk and Baghdad, 300 Air Force medics jointly 
staff Landstuhl Medical Center, Germany. Additionally, we are about to 
assume operational control of the theater hospital at Bagram Air Base 
in Afghanistan this month.
    The AFMS has been deeply involved in establishing the most 
effective joint casualty care and management system in military 
history. Whether stabilizing a casualty, preparing a casualty for 
transport, providing continual care at stops along the way, or moving 
the patient in our AE system; what matters is providing the very best 
care possible to every injured or ill warfighter at every point in the 
care continuum. Everything medical in theater is designed to support 
moving casualties from the point of injury to the right level of care, 
at the right place, in the least amount of time.
    To that end, we believe it is critically important to work closely 
with our sister Service medics in leveraging our joint capabilities. 
Working to improve our common ``enabling'' platforms--such as 
logistics, information management, information technology, and medical 
research and development--will serve to make all medics better prepared 
to support the Joint warfighter. Side by side with our Service 
counterparts, we recently concluded a 72-day humanitarian and civic 
assistance deployment with the Navy on board the USNS Mercy. Yes, we 
are all about jointness and supporting the joint warfighter.
    However, our focus is not just the war. Our Air Force medics are 
globally engaged in training our allies, supporting humanitarian 
missions or responding to disasters. To assist in this role, this year 
the Air Force built a new type of unit--the Humanitarian Operation 
Relief (HUMRO) Operational Capabilities Package (OCP)--a streamlined 
package of 91 medics and 133 base support personnel designed to support 
a humanitarian relief mission. This HUMRO OCP will provide a rapid and 
tailorable response to a disaster; and by leaving the deployable 
hospital and medical equipment, it will provide an enduring medical 
capacity for the host nation following redeployment of our U.S. Air 
Force personnel.
    Delivering this remarkable medical care across the full spectrum of 
missions takes trained, clinically current physicians, nurses and 
technicians. The AFMS concentrates on joint medical education programs 
and has developed clinical training platforms providing surgical and 
trauma care experience. Our readiness training platforms, including 
training arrangements with Baltimore Shock Trauma, Cincinnati-Center 
for Sustainment of Trauma and Readiness Skills (C-STARS), and St. 
Louis-C-STARS, ensure our Air Force medics are the best trained in 
history.
    Taking care of the expeditionary force and warfighter is job number 
one. But crucial to that mission is taking care of our Air Force 
family.
                  taking care of our air force family
    When our airmen join the Air Force, we make a commitment to them 
and their families that we will care for them throughout their period 
of service, and into retirement for career airman, whether at their 
home station Medical Treatment Facility (MTF), in a deployed MTF, or 
through private sector care Tricare contracts. To that end, we have an 
integrated delivery system throughout our Air Force community to 
support our airmen's health, including physical, mental, and dental 
needs. We work closely with the Department of Veterans Affairs and our 
Tricare networks to provide seamless care.
Warfighter Fitness and Deployment Health
    We begin by ensuring a fit and healthy force at home station. We 
maintain every warfighter's health and fitness through periodic 
assessments of their health and workplace, and support them with an 
effective physical fitness training and testing program. Before they 
deploy, we ensure they are medically ready.
    In theater, our preventive aerospace medicine teams assess the 
austere environment to which our forces deploy, and continue to provide 
surveillance of their health and environment while deployed. If our 
airmen and joint warfighters become ill or injured, we rapidly 
transport them with cutting edge en route medical care to expeditionary 
medical support and then to definitive stateside care.
    Prior to deployment and upon redeployment home, we evaluate our 
airmen's health--physical, mental, and emotional--through the use of a 
Pre- and Post-Deployment Health Assessment (PDHA). We then reevaluate 
at 3 to 6 months post deployment using the Post Deployment Health 
Reassessment (PDHRA) as the next link in the continuum of care. To 
date, 70 percent of required PDHRAs are completed. Thirty-eight percent 
of them were considered positive due to a possible physical or 
emotional condition, with 2 percent reporting a Post Traumatic Stress 
Disorder (PTSD) symptom. Less than 0.5 percent have been positively 
diagnosed as actually having PTSD. Each positive finding is assessed by 
health care providers and appropriate treatment provided if required.
    The AFMS is committed to providing our airmen the most current, 
effective, and empirically validated treatment for PTSD. To meet that 
goal, we are training our behavioral health personnel to recognize, 
assess, and treat PTSD in accordance with the VA/DOD PTSD clinical 
practice guidelines. Using nationally recognized civilian and military 
experts, we have trained 89 psychiatrists, psychologists, and social 
workers representing 45 Air Force installations. Our goal is to equip 
every behavioral health provider with the latest PTSD research, 
assessment modalities, and treatment techniques.
    Caring for the families of our airman has a mission impact. 
Assuring high quality and timely care for our family members at home 
gives our airman the peace of mind they need to do a critical job in 
stressful and dangerous environments.
Partnerships
    Our commitment to the health of our airmen and their families also 
includes partnerships with leading civilian institutions. For instance, 
the AFMS and University of Pittsburgh Medical Center have teamed in 
collaborative efforts to prevent and/or delay type II diabetes, 
including associated complications, through education, early treatment 
modalities and community outreach. Other critically important efforts 
include the development of collaborative relationships with various 
Department of Veterans Affairs facilities and a robust Tricare network. 
Throughout this continuum, we work closely with our sister Services and 
civilian counterparts to provide preventive health care, interoperable 
surveillance, research and development, outreach, and treatment. Caring 
for our Air Force team and family also means taking care of our medics. 
We ensure that they are healthy and prepared for the mission they will 
face. With that in mind, our next priority involves taking care of our 
Air Force medics.
                       taking care of each other
    The AFMS is committed to providing our Air Force medics the 
resources needed to perform the mission. To this end, we developed a 
new ``Flight Path'' to guide our organizational structure and the 
development of each of our Air Force medical personnel.
Professional Development
    We created a clear ``Flight Path'' to match Air Force needs with 
individual professional growth requirements. The overall goal of the 
``Flight Path'' is to develop a streamlined, consistent medical group 
structure, from clinic to medical center, that provides a ready and fit 
medical force in support of the Air Expeditionary Force. It assures 
military and functional medical competence; provides a power projection 
platform to deploy medics forward; and delivers high quality, cost-
effective care.
    The ``Flight Path'' fosters corps-specific force development, 
requirements-driven leadership opportunities, and balanced leadership 
teams within the MTF. It also assures compliance with military and 
civilian certification requirements, access to graduate medical 
education, and cost-effective mission support at home and when 
deployed.
    In these ways, our ``Flight Path'' is helping us develop the next 
generation of Air Force medics. The way I view it, my charge is to 
ensure we recruit the best and brightest people, prepare them to 
expertly execute our mission, and retain them to support and lead these 
important efforts. Ideally, we do this in a way satisfying for them, 
and in a fashion that enables a balance between duty and family.
Balance
    An essential part of taking care of each other is to make sure our 
medics have the right balance in their lives between their professional 
duties and their families. We create better balance through staffing, 
finding the right mix of military, civilians and contractors, and by 
focusing our recruiting and retention efforts to maintain this mix. In 
these ways and others, we are recapitalizing our greatest resource, our 
people.
Air Expeditionary Force and Constant Deployer Model
    We believe the Air Expeditionary Force (AEF) rotational construct 
is the right construct for the AFMS. It provides the predictability 
needed for planning, training, deploying and reconstituting our force 
that leads to an effective long-term strategy and, just as crucial, 
outstanding quality of life for our airmen.
    Another innovation geared toward taking care of our people is our 
Constant Deployer Model (CDM), which provides a continuous deployed 
capability with sustained access to care at home station as well as 
maintaining a balance between our people's deployed, professional and 
personal lives. This model has ensured access to care at home via 
contracted personnel and improved quality of care at deployed 
locations. We believe working in more efficient ways lends itself to 
taking care of each other.
Air Force Smart Operations for the 21st Century, AFSO21
    An important tool--implemented Air Force-wide by the Secretary of 
the Air Force, Michael W. Wynne and the Air Force Chief of Staff, 
General T. Michael Moseley--is the Air Force Smart Operations 21 
program. Using a variety of tools, including Lean and Six Sigma, AFSO21 
is being used to streamline operations through process changes to 
improve efficiency and reduce waste.
    As medics, AFSO21 will make us more effective in supporting both 
the Air Force expeditionary mission and the joint mission. The use of 
process analysis and lean thinking will be essential in making sure 
that we are both relevant and cost-effective in support of our mission 
today, and tomorrow.
Challenges Ahead
    Today we are faced with the most challenging of times. We must 
implement BRAC while we simultaneously support the global war on 
terrorism. The BRAC process has given us a tool to reposture several of 
our key MTFs. We are also creating efficiencies outside of the BRAC 
process, restructuring some MTFs to better meet today's demands.
    Attracting and retaining the very best medics builds morale and 
trust to sustain the all volunteer force. Professional development, AEF 
rotations, AFSO21, BRAC, and military construction work together to 
recapitalize our Air Force Medical Service. Air Force medicine cares 
for our most treasured national asset--America's sons and daughters.
                                summary
    The talent and dedication of military medics ensures that an 
incredible 97 percent of the casualties we see in our deployed and 
joint theater hospitals will survive today. We safely aeromedically 
evacuated and treated more than 38,000 patients from theaters of 
operations since the beginning of Operations Iraqi Freedom and Enduring 
Freedom, provided compassionate care to 1.5 million people on 
humanitarian missions over the past 6 years, and continued to care for 
3 million patients annually all over the world.
    Despite our successes, Mr. Chairman and members of the committee, 
we are far from a position where we can rest on our laurels. I assure 
you we will continue to work hard with you in the months and years 
ahead to perfect the joint continuum of care for this fight, and the 
next! Thank you for your outstanding support.

    Senator Inouye. Senator Stevens.
    Senator Stevens. Thank you very much.

              BASE REALIGNMENT AND CLOSURE RECOMMENDATION

    General Kiley and Admiral Arthur, I am told that less than 
87 percent of the medical facilities' sustained restoration and 
modernization requirement is funded in the budget through 2008, 
and we all know that base realignment and closure (BRAC) 
funding was reduced by $3.1 billion in the enactment of the 
continuing resolution. Under these extreme circumstances--I 
would like both of you to comment--do you still believe that 
the BRAC recommendation to consolidate Walter Reed and the Navy 
hospital at Bethesda should go forward?
    General Kiley. Go ahead.
    Admiral Arthur. Senator Stevens, we have already been in 
process of merging the two facilities, and General Kiley and I 
have been very active with our staffs. The plan, the vision is 
to have a state-of-the-art medical center at Bethesda, on that 
campus, that modernizes the facilities and provides the care 
that people need in the northern part of the national capital 
area, with the southern part of the national capital area being 
cared for by an enriched facility at Fort Belvoir.
    If the plans were to change, it would, of course, change 
the shape of what our plans are at Bethesda, but I think in the 
future we have a vision of a very fine facility at Bethesda 
that combines the talents of the Army and the Navy and the 
Uniformed Services University of the Health Sciences and the 
National Institutes of Health (NIH) and the Suburban Hospital 
Trauma Center that's adjacent to NIH. So the plans are for a 
very robust, modern, and state-of-the-art facility.
    But there is a lot of advantage to combining the 
facilities, combining the staffs, and having a single DOD 
mission at a joint command.
    Senator Inouye. Do you agree, General?
    General Kiley. Sir, I have said since the law was passed 
and the decision was made to move Walter Reed over to the 
National Naval Medical Center, that the challenge and the risk 
was in properly funding this. To get to the vision that the 
BRAC saw, of a unified program on the Bethesda campus and a 
large 150-bed facility at Belvoir to manage the healthcare of 
the population to the south, was going to take a lot of money, 
and I think it still remains a significant risk to do this 
thing, this process, properly.
    In addition, consistent with what we have seen in the news 
in the last 3 weeks, the combat casualty care at Walter Reed is 
not just about in-hospital operating capability, it's about 
continuing to care for soldiers and families on the campus. The 
Chief of Staff has made it clear this is a long war, so my 
concern is, are we going to have an ability to maintain for 
however long we're in combat operations around the world, this 
same capability which we'll get right here real quick at Walter 
Reed, maintain that while making the moves and the building and 
the construction to transform it?
    My comments in other hearings were that this might require 
some more national discussion, that we may need to take a look 
at this, and I'm not in a position to proffer a recommendation 
at this time, but I clearly think it needs to be looked at in 
light of our current operations and our proposed future 
operations.
    Senator Stevens. I opposed it in the beginning because I 
didn't think it was timely in view of the flow of combat 
wounded coming back at this time. I don't know why we would 
spend money on modernization and really on consolidation. I 
think that money ought to be spent to take care of these people 
that are coming back, and I really hope it's looked at again in 
terms of the time. It's a wonderful vision when the war is 
over, but right now I think our first call ought to be to put 
all the money we can find in treating these people properly and 
getting them home, and getting the post-medical treatment piece 
of this care that's so needed right now, getting it funded.

                    MILITARY-TO-CIVILIAN CONVERSION

    I am told that the medical readiness review directed you, 
Admiral Arthur, to convert an additional number of medical 
billets to civilians, and I wonder about that. General 
Roudebush, you're involved in this, too. I'm told you're 
converting 123 of the nurses to civilians. I don't know how you 
can do that with the nursing shortage that exists in civilian 
life.
    I really wonder about some of these instructions you all 
have received, particularly in view of the fact that we're 
going to increase the end strength of the Army and Marine 
Corps. How can we find enough physicians and corpsmen to 
support the additional marines if we're going through this 
conversion to civilian positions? Can you all comment on that? 
Are you going to be able to do it? General Roudebush?
    General Roudebush. Sir, in terms of the conversions that we 
currently have programmed, we have done both the analysis to 
look at whether the capabilities are available and affordable, 
and what we have programmed at the moment, we believe we can 
convert and sustain.
    Now, going beyond that, however, we think is going to be 
very problematic, and we're very concerned about going any 
further than we've gone as we have currently programmed. So 
that is a matter of great concern to us, and what we need to do 
is to examine very closely our success in both converting and 
hiring as we go forward with those that we have currently 
programmed, and I think that will dictate in many regards the 
success of whether we can sustain this or not. So that has yet 
to be told.
    Senator Stevens. Any comments, Admiral?
    Admiral Arthur. Yes, sir. We have planned to come down from 
about 36,000 active duty members to a little over 30,000. I 
think that the assumptions that were made in the medical 
readiness requirements review were overly optimistic about the 
small number of casualties, the small number of missions, and 
the extent of deployments that we'll have to do in the future.
    For example, no one is planning to deploy multiple times to 
a theater of operations. I think we're setting ourselves up to 
disappoint our line commanders in not being able to provide 
combat service support.
    The military-to-civilian conversions that we have already 
been trying to do have been successful to about the 80 percent 
level. We are not able to fill about 20 percent of those 
positions. My fear, as we get into the more critical skills, is 
that we'll not be able to find the people that we need with the 
skills that we require for the money that we're offering, and 
they will answer a contract for money. There aren't many people 
who are on active duty today, although they earn their 
paycheck, who are working primarily for the money. They work 
for other values and other principles.
    For example, we have a radiologist in the Navy. The 
programming rate for that radiologist is $124,000. The 
composite rate, with bonuses, is $168,000. And we are only able 
to hire them, we just hired one at Bethesda, for $400,000. Now, 
the difference in pay is one thing, but when you place----
    Senator Stevens. $400,000?
    Admiral Arthur. Yes, sir, and that's cheap for a 
radiologist. And when you place a $400,000 radiologist right 
next to an active duty service member who's making less than 
half of that, the morale factor for retention of those good 
active duty officers is striking. The contractor is making 
Lexus payments and our radiologists are making Toyota payments, 
not that Toyota is a bad car, but to sit side by side, there is 
an effect on retention.
    When you combine the military-to-civilian conversions with 
the various wedges that we have been given in our funding--for 
example, next year Navy medicine is predicted to have a wedge 
of $343 million out of about a $2.4 billion budget--we are not 
going to be able to maintain services at the level that we have 
now with a one-sixth cut in our funding.
    So we are facing a number of challenges that are coming 
together in a perfect storm. It's the funding, it's the people, 
and it's the increasing mission not only for combat service 
support but for those casualties who are coming back, who need 
even more services. There are places where we have physicians 
who are doing their own administrative work, filling out 
workers' compensation forms and other paperwork, because we 
don't have the support staff because they have been 
systematically cut over the last few years. It's degrading our 
efficiency, it's degrading our morale, and it's degrading our 
ability to take care of combat-wounded veterans.
    Senator Stevens. General?
    General Kiley. Senator, I echo everything my fellow Surgeon 
Generals say. The Army's numbers were in some cases smaller, 
but the Army's Medical Department has been working for several 
years now with the Army, attempting to capture spaces to build 
brigade combat teams. And so in support of the Army's effort to 
do that, the Army Medical Department, active duty, enlisted, 
and officer have been part of the pool that has been looked at.
    To date we have been able to do the military-to-civilian 
conversion, as they say. DOD and the Army have given us the 
replacement dollars. As Admiral Arthur has outlined, we have 
attempted to avoid--in fact, we have avoided--converting some 
of the more expensive specialties, as you've heard, and 
radiology is only one of them.
    But we're at the point now where my concern is along the 
lines of second and third order effects of this, and we've 
talked about recruiting and retention and morale. We've talked 
about a rotating base of active duty. More than 50 percent of 
our medical personnel have deployed at least once, and so if we 
talk to doctors about coming into the service and they know a 
lot of doctors have already deployed, we have to show them this 
is about service to the Nation.
    We got full support from the Congress as it relates to 
resources, and by that I mean money, to contract healthcare 
personnel of every level in taking care of our wounded 
soldiers. And I can talk some more about the impacts of other 
pieces of caring for wounded soldiers. Our core budget, though, 
as Admiral Arthur has alluded to, we are now facing this wedge, 
which is a notional decrease in our budget which the Department 
of Defense is----
    Senator Stevens. That was going to be my next question. 
Efficiency wedge, I think it's called, right?
    General Kiley. Yes, sir, and I don't believe I was the 
Surgeon General when these decisions were originally made, but 
the intent was to motivate, I think, the medical services 
facilities in an effort to improve their efficiencies, find 
ways to save money, and identify those dollars so that you were 
actually not spending as much as years went on, in an effort to 
control a not insignificant inflationary rise in the DHP.
    This year it's $80 million in my core budget. Next year 
it's on the order of $142 million. I can make some adjustments 
this year to an extent. Working with the Department of Defense 
in budgeting, as we show that they're doing more work, they are 
rewarding us with more resources in a more businesslike 
environment. Now, that's not just for combat soldiers. That's 
for all our family members, retirees, et cetera.
    But I absorbed it last year. We were fully funded last 
year. This year we're challenged. It remains to be seen whether 
we'll close the budget this year. I can't find $142 million in 
efficiencies, and I have asked my hospitals to transform and to 
become more businesslike, so we can document what we're doing 
and show the Congress that we are getting the most bang for the 
buck, if I may, for that.
    So I am concerned about military to civilian. We're 
watching it very carefully. As you know, the Army may be 
expanding. We may have a larger mission, and we're dealing 
almost daily with the Army on this. And our numbers appear to 
be consistent with what the MRR asked for, so at this point 
we're not in the same position as the other two services with 
MRR.

                           EFFICIENCY WEDGES

    Senator Stevens. And I can't take any more time. I'm 
appalled. I note this efficiency wedge, Army for 2008 is $142.3 
million, Navy $147 million, and Air Force $197.5 million. For 
2008, however it goes up: the Army, $227.3 million, $234 
million for the Navy, and $323.7 million for the Air Force.
    That's on top of the assumption that we're going to enact 
the increased deductibles and charge annual enrollment fees for 
TRICARE. That has not been approved by any congressional 
committee that I know of. The assumptions, I think, Mr. 
Chairman, we need to get the budgeteers in here and ask them to 
explain to us where they found all these numbers.
    It is shocking to see, at a time when military medical 
facilities need more money, that we have budget people 
directing reductions on the basis of efficiency or increased 
payments that the military people have to make, that are 
unrealistic, totally unrealistic. I'm really, really alarmed at 
that.
    As I've said, I've taken too much time. I congratulate you 
on what you're doing, but I do think that the conversion at 
Walter Reed ought to slow down. I think the movement of the 
troops from Germany to Italy ought to slow down. I think we 
ought to start spending the money where it's needed right now, 
on the people who have been wounded in these combat activities, 
and follow them through, and put on hold a lot of these things 
the Department is suggesting.
    So I'm hopeful that we'll get the Department back in here 
again, and we'll have a chance to discuss these assumptions 
that you can make these changes and still deliver the quality 
care that these guys and ladies deserve for having served our 
country so well. Thank you, Mr. Chairman.
    Senator Inouye. Senator Murray.
    Senator Murray. Thank you, Mr. Chairman.
    General Kiley, as I said in my opening statement, I was 
deeply disturbed by what I was reading in my Washington State 
papers today. As you can imagine, since we've heard about what 
happened at Walter Reed, my office and others have been hearing 
from a number of soldiers who are on medical hold in our State. 
They have been talking to us, but as I sort of indicated, they 
have been very worried to talk publicly.
    We can't get to the bottom of this and we can't do our job 
unless we know exactly what's happening out there, and I want 
your personal assurance, if you would please give that to me, 
that no soldier who blows the whistle on substandard care will 
be retaliated against.
    General Kiley. Senator, you have my word. There's a law 
that prevents that also, the whistleblower law, and I share 
your concern that soldiers either feel that they can't talk, 
certainly talk to their representatives, certainly we want them 
to talk to us, but we've never put a prohibition or a threat of 
retaliation, for example, if they talk to the press.
    And I would ask that I, at your convenience, come back and 
report to you. I spoke to the hospital commander this morning. 
She's investigating that, and I think----
    Senator Murray. The retaliation, or what's in----
    General Kiley. No, ma'am, the issues that were--and I have 
not seen the article, but she has identified issues, the 
concern about asbestos in the living facility where the 
soldiers are, as an example. And I am told that yes, there is 
asbestos, and it is sealed. It has been investigated. It is not 
a risk to the soldiers.
    So there are issues that we need to deal with across the 
Medical Department. Many of them, and I've said this in other 
testimony, really revolve around this very complex and 
inefficient and in many cases confrontational process between 
the medical boarding process and the physical evaluation 
boarding process. Soldiers don't feel like they've gotten the 
respect they deserve for their sacrifices when they're given a 
small disability from the Department of Defense.
    Senator Murray. Well, let me ask you a number of questions. 
First of all, I am hearing from soldiers who say they are 
languishing for months and even years in military holdover 
units without the care that they need. The Seattle Times 
article that I mentioned to you tells the story of a woman, 
Captain Mary Maddox, who said, ``The biggest problem with 
Madigan is that they are understaffed and overworked, and I 
ended up getting bounced from clinic to clinic.''
    Other press reports mention other soldiers who have been in 
medical hold for years. How can this be happening, 4 years into 
this war? Is it lack of staff? Is it lack of accountability? Is 
it a lack of caseworkers? A lack of leadership? What is 
happening?
    General Kiley. It's not acceptable to have soldiers 
languishing, and I'll be the first to say that, and clearly we 
are taking action to make sure we don't. But I have said before 
that there are some soldiers who feel like it has taken a long 
time for their evaluation, and other soldiers----
    Senator Murray. What do you think is a long time?
    General Kiley. Well, this is what I was getting to. It 
depends on the condition. And the problem that we face across 
our military systems is that these are not simple injuries and 
diagnoses. They are----
    Senator Murray. Is 18 months too long?
    General Kiley. It may not be too long, ma'am, if there are 
a series of operative procedures that a soldier needs, and then 
they need to fully recover from each one of those. It may not 
be too long if they have a condition like TBI and PTSD and 
they're undergoing therapy, rehabilitative therapy. It may take 
as long as 1 year for us to get to a point where the soldier 
and the physicians feel that that soldier has reached the 
maximum therapeutic benefit.
    Senator Murray. Well, you can understand what it's like for 
18 months for someone to sit there day after day, appointment 
after appointment, being told one thing or another, and feeling 
like their life is absolutely on hold.
    General Kiley. Yes, ma'am.
    Senator Murray. You can imagine what it's like for their 
families. So we----
    General Kiley. It's very difficult, I agree with you, and 
we're going to take----
    Senator Murray. It seems to me way too long. I think it's 
an issue we need to address.
    Let me focus on artificially low disability ratings--you 
mentioned that a second ago--which we all know will limit their 
military disability pension. It has a huge lifetime impact. I 
understand that lifetime pension requires a 30 percent 
disability rating?
    General Kiley. Yes, ma'am.
    Senator Murray. Well, one soldier told us that in more than 
1 year he has only seen one person receive a 30 percent rating. 
There is a woman named Sergeant Jane Sullivan. She was granted 
only a 10 percent disability rating. She's in a wheelchair. Her 
medical problems include a back injury and heart condition.
    And I have to tell you there is a suspicion that medical 
and physical boards are giving artificially low disability 
ratings simply to save money for the Army. At a hearing 
yesterday it was revealed that while other branches grant full 
disability about 20 percent of the time, for the Army it's only 
about 4 percent.
    So, General Kiley, I want to know, has anyone suggested to 
you or have you suggested to anyone that there are problems 
with giving service members high disability ratings?
    General Kiley. First of all, Senator, the medical personnel 
do not give the disability rating. The medical personnel do not 
do that. The personnel community does that, through the G-1 of 
the Army and the TAG of the Army down through the physical 
disability system. What the medical personnel do is, they treat 
and document the conditions and then present them.
    I agree that the system that we have and that we have had 
since we first developed this is clearly perceived as unfair, 
particularly when it is compared with the VA system of 
disability. And I have suggested and we have already started 
discussions to change that. Some of this is in the law, some of 
it is in Department of Defense directives, and some of it is in 
Army regulations.
    The other day General Cody used an example of an 
individual--the Department of Defense disability makes the 
determination that a soldier is unfit for a particular 
condition, as an example, if a soldier loses an eye, they are 
unfit for further service.
    Senator Murray. Yes.
    General Kiley. That's a disability of 40 percent. Now, the 
soldier may have other conditions that the VA would increase 
the disability, but the Department of Defense can't do that.
    Senator Murray. I understand that. Will you send guidance 
to all of your board members, telling them that you expect 
disability ratings to reflect accurately a service member's 
injury?
    General Kiley. I will send to all of my medical personnel 
to ensure that the medical evaluation board, which is in my 
lane, which is my responsibility, will, in fact, accurately 
reflect that. Yes, ma'am.

                         TRAUMATIC BRAIN INJURY

    Senator Murray. Okay, and let me ask you one other quick 
question, and that's regarding traumatic brain injury. Many of 
you mentioned it. You know this is the signature issue of this 
war. We have a guardsman at Madigan who was sent home for a 
different injury, and it was his wife--who kept saying, ``Well, 
he's not remembering things''--that actually got him back in.
    The Department of Veterans Affairs announced several days 
ago that they are going to start screening for this, but I want 
to know if the Army and other services are going to start 
screening service members when they come home, before they have 
to wait forever to get into the VA system to discover this.
    General Kiley. Yes, ma'am, and I agree that that's 
something that we have not done a good job at, for the simple 
reason that some of the mildest TBI can be difficult to 
diagnose, and in the face of all of these conditions----
    Senator Murray. But it seems to me that if you are asking 
soldiers if they've been in the vicinity of an explosion, you 
will have an indication----
    General Kiley. Yes, ma'am.
    Senator Murray [continuing]. Fairly soon that they should 
be watched for this, that they should have the knowledge that 
this may be happening, so if they see symptoms, or their family 
does, they can get care immediately rather than struggling for 
months not knowing what has happened to them. So I would like 
to ask a commitment from you that we start screening these 
soldiers and finding out if they have been in the vicinity of 
an explosion, so that they don't get lost for months on end.
    General Kiley. Yes, ma'am, and Secretary Winkenwerder, as I 
understand it, is in the process of changing the post-
deployment screening to specifically ask soldiers that, number 
one. Number two, my TBI task force is about to come back to me 
with recommendations of exactly how to go about doing that, 
what's the best format, and then what are the best therapeutic 
modalities. So I'm taking that on very----
    Senator Murray. And I hope that's soon, because every day 
that goes by we're losing.
    General Kiley. Yes, ma'am. I agree.
    Senator Murray. Thank you.
    Admiral Arthur. May I add that we don't wait until they 
come back? We have the military acute concussion evaluation 
that we do in theater for people who are in the vicinity of a 
blast and they have a concussive injury, and we do that 
evaluation, and if they are deemed to have an injury, then we 
take them out of----
    Senator Murray. So you ask everyone before they leave the 
theater?
    Admiral Arthur. If they are in the vicinity of a blast. We 
don't screen everyone in theater, but when we do have a blast, 
an improvised explosive device (IED), and there are casualties 
who are moved out but there are others who are in the vicinity, 
we do an evaluation on them.
    Senator Murray. Do you have any indication of the 
percentage of marines who have been impacted by that?
    Admiral Arthur. No, and it's very difficult, especially 
with mild traumatic brain injury, to assess very slight 
cognitive----
    Senator Murray. Do you have any numbers of how many marines 
have been in the area of a blast?
    Admiral Arthur. No, I don't, but we could get that.
    Senator Murray. I would like to know.
    Admiral Arthur. There are also confounding variables of 
combat stress and others that we have to tease out. It is a 
stressful environment and it's difficult to assess mild 
traumatic brain injury, in theater or even when they first come 
back, with all the confounding stress issues.
    Senator Murray. Thank you very much.
    Admiral Arthur. Yes, ma'am.
    Senator Murray. Thank you, Mr. Chairman.
    [The information follows:]

    The Navy/Marine Corps does not maintain an electronic 
database to track Sailors and Marines that have been in the 
area of a blast. Given the erratic nature of combat theater and 
the likelihood of taking indirect fire, all service members are 
at risk, both inside and outside the wire. Navy Medicine's 
approach has been to focus on effective screening, 
identification, and treatment for all service members.
    Navy medical personnel in theater utilize the Navy-Marine 
Corps Combat Trauma Registry (CTR) to assess and document 
Traumatic Brain Injury (TBI) in those service members treated 
at Level 1 and 2 medical facilities for battle injuries. The 
consistent use of the CTR to identify TBI is in an early stage 
of development and available data is being analyzed by Naval 
Health Research Center (NHRC). Preliminary analysis of data 
from CTR for 5,087 service members injured in the Iraq area of 
operations from March 2004 to January 2007 suggests that 
approximately 1,700 personnel were diagnosed with a mild to 
severe TBI (33 percent). NHRC estimates that approximately 80 
percent of TBI diagnoses were blast related, and that most 
service members were returned to duty. Currently, NHRC is 
evaluating level of risk by occupational specialty. It is 
important to note that reporting by field units has been 
inconsistent and that CTR data is limited to diagnoses in 
theater.
    The Post Deployment Health Re-Assessment (PDHRA), 
administered to service members 90 to 180 days post deployment, 
includes the question: ``Do you have any persistent major 
concerns regarding the health effects of something you believe 
you may have been exposed to or encountered while deployed 
[such as] blast or motor vehicle accidents.'' Approximately 4 
percent of Navy and Marine Corps active and reserve personnel 
responded yes to this question. It is not possible to 
differentiate between members exposed to a blast and a motor 
vehicle accident. DOD/Health Affairs has recently directed 
additional TBI-related screening questions to the PDHRA, the 
Post Deployment Health Assessment (PDHA), and the Periodic 
Health Assessment (PHA).
    Finally, the Marine Corps has issued guidance strongly 
encouraging the use of the Military Acute Concussion Evaluation 
(MACE) to screen injured personnel for possible TBI. Medical 
personnel document MACE results in the service member's field 
medical record. Currently, the data is not tracked in a 
centralized database. As a result, we are unable to provide 
Congress with an accurate number of Sailors and Marines that 
were in the area of a blast and received the MACE at this time.

    General Roudebush. Senator Murray, if I might add, since we 
do a great deal of the definitive care through our theater 
hospital, both in Bagram and at Balad, as well as our combat 
stress teams which are out working with their Army and Navy 
counterparts, one of the things in my recent trip was an 
awareness of traumatic brain injury and the fact that the 
stress teams, for example, are much more sensitive to that, 
since that can be a very much related issue. So the awareness 
is there. I cannot give you the numbers, but awareness of this 
as an issue and the effort to both identify and vector toward 
treatment I think is moving in very much the right direction.
    Senator Murray. We're 4 years into this conflict. We've had 
thousands of people impacted that have gone home and are out of 
the system. We need to really work on this, Mr. Chairman.
    Senator Inouye. Senator Shelby.
    Senator Shelby. Thank you, Mr. Chairman.
    General Kiley and panel, when we neglect our wounded 
soldiers, basically we stain the reputation of America 
regarding the support for our soldiers. Would you agree with 
that?
    General Kiley. Yes, sir.
    Senator Shelby. Okay. That's obviously, to all of us, 
shameful and unacceptable. We know that Walter Reed has been 
not just a premier hospital, it has a worldwide reputation as a 
premier hospital. A lot of us have spent time there. We know it 
has been a good hospital.
    You were the commander, is that correct, at Walter Reed?
    General Kiley. Yes, sir.
    Senator Shelby. And from what year to what year?
    General Kiley. 2002-2004.
    Senator Shelby. And during that time, did you ever go to, 
is it Building 18?
    General Kiley. No, sir, I did not.
    Senator Shelby. You didn't? Why not?
    General Kiley. For several reasons, the first of which was 
that I didn't have patients in that building when I was the 
commander there.
    Senator Shelby. What was in that building?
    General Kiley. We had transient students, student trainees.
    Senator Shelby. Students training in a medical profession?
    General Kiley. Yes, sir, but not patients. We did not have 
patients there when I was there.
    Senator Shelby. As commander, did you visit all the other 
facilities at Walter Reed?
    General Kiley. Yes, sir.
    Senator Shelby. Except Building 18?
    General Kiley. Yes, sir.
    Senator Shelby. And that's the only one you failed to----
    General Kiley. Well, I can't say I was in every office of 
every building, but it was my intent to visit the buildings 
that we had combat casualties in, Malone House, Delano Hall.
    Senator Shelby. Is Building 18 basically a dilapidated 
building? Is that a fair assessment?
    General Kiley. I don't believe that's a fair statement.
    Senator Shelby. How would you describe it?
    General Kiley. I would describe it as an old building with 
some humidity problems that requires constant maintenance and 
upkeep.
    Senator Shelby. Have you visited Building 18 in the last 
several weeks?
    General Kiley. Yes, sir.
    Senator Shelby. Who was assigned to Building 18?
    General Kiley. Until today, there were soldier patients 
assigned to 18.
    Senator Shelby. Wounded soldiers?
    General Kiley. Yes, sir, wounded and ill. Yes, sir.
    Senator Shelby. And how many would be there assigned, 
roughly?
    General Kiley. Sir, even in the last couple weeks the 
numbers fluctuated between mid-70s and mid-60s. I think it has 
54 rooms. It has a maximum capacity of about 100, 108.
    Senator Shelby. Had it ever come up through the command to 
you as the Surgeon General that there were deep problems at 
Walter Reed?
    General Kiley. Not as it relates to these articles, no, 
sir.
    Senator Shelby. Nothing? In other words, you had no 
inclination--you're the Surgeon General, a former commander of 
Walter Reed--you had no inclination, no knowledge, no 
information whatsoever that the conditions were deteriorating 
at Walter Reed?
    General Kiley. I had no information that there were issues 
of mold and other maintenance problems in Building 18. I knew 
that Walter Reed had a large number of casualties that were 
recovering, with a very active amputee center, and that we had 
some of the same issues we have at all of our facilities with 
the MEB/PEB process.
    Senator Shelby. After you became Surgeon General of the 
Army, have you been to Walter Reed?
    General Kiley. Yes, sir.
    Senator Shelby. Recently?
    General Kiley. Yes, sir.
    Senator Shelby. And how many times have you been to Walter 
Reed?
    General Kiley. Oh, pretty frequently, at least once every 
couple of months if not once a month, but not any more 
frequently than that.
    Senator Shelby. Did you ever ask questions of the commander 
who succeeded you as to the conditions at Walter Reed, were 
they understaffed, were the facilities in good shape, and so 
forth?
    General Kiley. My discussions with General Farmer, who was 
my successor there for 2 years, were along the lines that they 
were with my other commanding generals of the regions, which 
was to continue to watch the process of receiving, and whenever 
they needed resources, if they had a problem that they needed 
my help with, they could come to me. And, as I have said 
before, for the care of wounded soldiers, we have the resources 
in terms of money in our budget to help them.
    Senator Shelby. Shouldn't the care of our wounded soldiers 
be one of our highest, highest priorities?
    General Kiley. Absolutely.
    Senator Shelby. And especially the Surgeon General of the 
Army, is that your highest priority?
    General Kiley. Yes, sir, it is.
    Senator Shelby. Did you minimize these complaints when you 
read about them? Did you take them lightly, or were you 
cavalier about it?
    General Kiley. Absolutely not, Senator. And I know that 
that's been perceived.
    Senator Shelby. Yes, it has been.
    General Kiley. I apologize for that. This is very serious 
business. I was devastated, frankly, to read about some of 
these cases and to see that some of this was going on, and 
immediately began investigating.
    Senator Shelby. Did you go out there yourself, immediately, 
and see what was going on?
    General Kiley. Yes, sir.
    Senator Shelby. You did?
    General Kiley. Yes, sir.
    Senator Shelby. Did you take a team of your people with 
you?
    General Kiley. Well, when all of this broke, we sat down 
with the commander and we started analyzing what was going on. 
Yes, sir. I have a team that has gone out subsequent to that, 
visiting other facilities.
    Senator Shelby. What are you doing about it? What three 
steps have you made since the revelations have come out 
regarding the conditions at Walter Reed, of all hospitals?
    General Kiley. First, I think the command has taken on the 
infrastructure, the brick and mortar. The building was 
immediately repaired. The mold was removed. That was number 
one.
    Number two, the commander directed formal AR 15-6 
investigations, both into the chain of command and into the 
quality of care delivered in terms of medical records, 
appointments, et cetera. The Vice Chief of Staff established an 
action plan to make some other corrections, and to appoint a 
colonel to command and control the med hold. General Weightman 
was in the process of making changes and improving things. It 
was clear we needed to accelerate that.
    Senator Shelby. Sir, have you checked the record thoroughly 
to make sure that if there were any complaints bubbling up from 
the lower echelons at Walter Reed to the higher-ups that were 
never heeded, never considered?
    General Kiley. Any complaints that came directly to me, I 
certainly would ask the commanders to brief me on what was 
going on.
    Senator Shelby. What about complaints now, as you look 
back, that came to others, that maybe should have come to you? 
Have you dug into that?
    General Kiley. Not at this time, no, sir.
    Senator Shelby. Do you plan to? Don't you need to know 
everything about what was going on, or it never got to your 
desk, or your attention, perhaps, if it did, and how this could 
have been prevented?
    General Kiley. Yes, sir, and I'm looking back at that. I 
intend to talk to my commanders. It's clear I need to have much 
closer, more intense supervision of this process so that I 
don't miss this again.
    Senator Shelby. But you're the Surgeon General of the 
United States Army. What's the chain of command as far as you 
are concerned in your duties over Walter Reed? You were the 
former commander, but you're the Surgeon General.
    General Kiley. I'm the Surgeon General and the Commander of 
the U.S. Army Medical Command----
    Senator Shelby. Absolutely.
    General Kiley [continuing]. So my next subordinate 
commander is now General Schoomaker for Walter Reed, and he 
is----
    Senator Shelby. So basically, as the Surgeon General, you 
are the overall responsible person dealing with the Army 
medical centers, wherever they are. Is that correct?
    General Kiley. Yes, sir.
    Senator Shelby. Do you believe you have fulfilled your 
duty?
    General Kiley. I believe that the management of Walter Reed 
and the accountability, which I am accountable for----
    Senator Shelby. Absolutely.
    General Kiley [continuing]. Similar to my accountability 
for places like Landstuhl and Brooke, clearly it's not the only 
responsibility I have. I have many other responsibilities of a 
global nature, to include broad strategic and policy issues.
    Senator Shelby. Well, what's your number one obligation? 
It's the soldiers, isn't it?
    General Kiley. Getting soldiers off the battlefield alive, 
getting them through Landstuhl, and getting them to all of my 
medical centers.
    Senator Shelby. Absolutely. Let's talk about Walter Reed 
and the future of Walter Reed. You know, this was made by the 
base closing commission.
    General Kiley. Yes, sir.
    Senator Shelby. I think we have to think about today's 
care, that's very important, and the standard of that care at 
Walter Reed, or lack thereof. But we have to think about 
tomorrow, too, the new Walter Reed, because it seems to me to 
be very logical to build a state-of-the-art medical facility at 
Bethesda, where you have the medical school, where you have the 
NIH, where you have Bethesda. And of course you plan, I think, 
that we're going to name it Walter Reed, which is fitting. But 
we have to deal with the present, but we've got to deal with 
the future, too, and I think we can do both if we do it right. 
What do you think?
    General Kiley. I absolutely agree with you, Senator, with 
the proviso that, one, it must be fully funded and, two, we 
must recognize, in the new Walter Reed at the National Military 
Medical Center Campus, that much of the work we're doing right 
now at Walter Reed as it relates to families and family support 
and outpatient work will have to continue in that new campus. 
And I think if we recognize all that and we coordinate this 
process of transformation over to the Bethesda campus, I don't 
think we will drop a single soldier through this from our 
current operations. But it has to be fully resourced.
    Senator Shelby. Well, you're before the Defense 
Appropriations Subcommittee. We are responsible for funding the 
military, wherever they are, including our hospitals and 
everything. Do you believe that we have adequately funded our 
medical, Army medical team and so forth, including Walter Reed? 
And if not, would you speak out for it?
    General Kiley. Yes, sir.
    Senator Shelby. This is where the money comes from, right 
here in this subcommittee.
    General Kiley. Yes, Senator, I understand, and I have said 
in the previous 3 fiscal years that I have served as the 
commander that as it relates to the global war on terrorism and 
everything Army hospitals do, that everything I've asked for, 
you have given us, and I have not gone wanting there.
    Senator Shelby. Have you asked for everything you need to 
run a first-class hospital at Walter Reed and anywhere else 
that you have our wounded veterans?
    General Kiley. I have asked. Part of that is a core budget 
that endures past combat operations, that may not have global 
war on terrorism funding, and in that respect we have had to 
deal with the wedge and efficiencies and taxes, and it has made 
it more challenging. And this wedge, this notional wedge in the 
coming budget, is going to make it even more challenging for 
us.
    Senator Shelby. I believe myself, as a member of this 
subcommittee, both sides of the aisle, Democrats or 
Republicans, we will fund whatever is necessary to treat our 
veterans more than right, the best in the world medical 
treatment, if you ask for it.
    General Kiley. Yes, Senator. Thank you. Yes, Senator.
    Senator Shelby. Thank you.
    Thank you, Mr. Chairman.
    Senator Inouye. Thank you.
    Senator Mikulski.
    Senator Mikulski. Thank you very much, Mr. Chairman. I 
thank you and the ranking member, Senator Stevens, for your 
longstanding leadership and commitment on military medicine.
    I think the issues raised by the leadership and the panel 
in the BRAC situation are really very well taken. We understand 
why there was this whole desire for a joint facility, but in a 
minute I'll get into privatization, which shows that perhaps 
some assumptions are dated. I'd like to suggest to the 
subcommittee we ask the military to review that, and also that 
the Dole-Shalala Commission take a look, so that at the end of 
their report we might have a comprehensive list on that, 
because my concern--well, first of all, you know, we have 
phrases like ``wounded warrior.'' They evoke nostalgia.
    What we're talking about, we ought to start calling it the 
50-year care program. We have men and women who were injured 
and they are 19 or 20 years old. They are going to be alive for 
50 years, if it all works the way it should. So for 50 years, 
what does this mean to TRICARE? For 50 years, what does this 
mean to the VA?
    Yes, we can look at Walter Reed. Then where do they go to 
rehab? And then when they leave rehab, where do they go from 
there? Are they going to go into nursing homes? Are they going 
to go into assisted living? If they get home healthcare, who is 
going to help the families, these 19-year-old brides, with 
assistance with living for a guy who may have 40 percent of his 
brain shot off, or no arms or no legs, and the stress on the 
family?
    So we have to be thinking of this not as--I love the 
phrase, ``wounded warrior.'' It's very respectful and shows an 
emotional commitment, but I think we have to start calling it 
the 50-year commitment. And then how do we do this? Because the 
facilities here at the acute care and the outpatient care are 
only the first step to a series of steps that will last 50 
years, so let's take a look at that.

                             PRIVATIZATION

    But this question about what did you know and when did you 
know it and all that, I'd like to bring to the subcommittee's 
attention and a question to General Kiley and to the other 
Surgeon Generals about privatization. I am concerned that the 
administration's relentless pursuit of privatization has caused 
dire consequences at our facilities.
    If we go to Walter Reed, there was a relentless effort to 
privatize the 300 employees who did building maintenance. Three 
hundred employees who did building maintenance. The 
administration spent $7 million on an A-76 process and then 
another $5 million to implement it, $12 million to get rid of 
300 employees. I protested it along the way, with my former 
colleague, Senator Sarbanes, but I wasn't the only one. I 
wasn't standing up for Maryland employees, though I was. I 
thought I was standing up for Walter Reed.
    Then Colonel Garibaldi sent a letter or memo on September 
6. This is the famous Garibaldi memo that said all of the 
contracting out of building maintenance was based on criteria 
for the year 2000, a year before 9/11 hit, 3 years before we 
went to war in Iraq--well, 2 years before Afghanistan, 3 years 
before Iraq. So we were functioning on outmoded data, once 
again not planning for war, not planning for the casualties of 
the war, not planning for the care of the casualties of the 
war. We took data from the year 2000.
    Garibaldi says we've got to do this, we've got to staff and 
implement something very different here. He cries out, saying 
the Army initiated this study in 2000. The current workload in 
the hospital has grown significantly. He goes on that the A-76 
in 2000 didn't even think about what we were facing. And the 
punch line here, he says without favorable consideration of 
these requests--which means don't do this--patient care and 
services are at a risk of mission failure.
    Well, while he was writing his memo, Sarbanes and Mikulski 
were doing an amendment on the Senate floor to overturn that A-
76. We lost it, 50 to 48. We went from 300 employees very 
quickly to 50, 300 employees to 50.
    I'm going to ask that the Garibaldi memo be submitted for 
the record.
    [The information follows:]
                        Department of the Army,    
                       United States Army Garrison,
                           Walter Reed Army Medical Center,
                                         Washington, DC 20307-5001.
MEMORANDUM THRU MG George W. Weightman, Commander, NARMC and WRAMC, 
        6900 Georgia Avenue NW, Washington, DC 30207
FOR COL Daryl Spencer, Assistant Chief of Staff for Resource 
        Management, MEDCOM, 2050 Worth Road, Bldg 2792, Suite 9, MCRM, 
        Fort Sam Houston, TX 78234-6009
Subject: Challenges Concerning the Base Operations A-76 Study and 
        Resulting Reduction In Force (RIF) at Walter Reed Army Medical 
        Center (WRAMC)

    Walter Reed Army Garrison and Walter Reed Medical Center (WRAMC) 
requests approval and financial support as the Base Operations A-76 
Study proceeds toward a reduction-in-force (RIF) and the date when the 
contractor will assume duties. Specifically we are requesting the 
following to prevent possible mission failure:
  --Approval and funding of the personnel in the ``bridge 
        organization'', and fiscal year 2007 funding for VERA/VSIP.
  --Establishment of a larger than approved Continuing Garrison 
        Organization (CGO).
  --Formal implementation of the Directorate Of Logistics (DOL) and 
        Plans Analysis and Integration Office (PAIO) organizations.
    Since the Army initiated the A-76 study in 2000, the current 
workload in the hospital and garrison missions has grown significantly 
in the past six years due to our need to care for and support Wounded 
Warriors from Operation Enduring Freedom, Operation Iraqi Freedom, and 
other outcomes of the Global War on Terrorism (GWOT). As a result, the 
Army performed the competition with dated workload data and 
expectations created before the GWOT began in 2001. Now in 2006, we 
need more personnel than the study had anticipated. To rectify this 
situation, we need more government employees to remain on staff and 
need to implement a garrison DOL and PAIO.
    As a direct result of the A-76 study, its associated proposed RIF, 
and eventual Base Realignment and Closure (BRAC) of WRAMC's Main Post, 
we face the critical issues of retaining skilled clinical personnel for 
the hospital and diverse professionals for the Garrison, while 
confronted with increased difficulties in hiring. In our efforts to 
manage the RIF, we implemented a Voluntary Early Retirement Authority/
Voluntary Separation Incentive Program (VERA/VSIP) effort. As a result 
we lost 21 personnel in June and nine more in July; an additional seven 
personnel will leave at the end of September while 30 to 35 more will 
depart after due course notification of Congress. Due to the 
uncertainty associated with this issue, WRAMC continues to lose other 
highly qualified personnel. A planned Priority Placement Program (PPP) 
registration will allow other employees to be placed into Department of 
Defense jobs at other locations. So far 67 personnel have registered 
for this program, which will become effective on 26 September 2006.
    The bump and retreat process that follows a RIF will impact the 
Hospital's patient care mission as highly skilled and experienced 
personnel in the current workforce are moved in to other jobs or 
involuntarily separated. The danger of an ``under-lap'' of personnel to 
perform vital functions could decrease our ability to complete the 
garrison mission and provide world class patient care. To ensure 
WRAMC's primary mission experiences little or no disruption, we request 
you approve a personnel ``bridge organization'' (attached as Enclosure 
1) to support the transition process until the contractor performance 
period begins.
    Compounding the issue is Medical Command's (MEDCOM's) non-
concurrence with our requested residual organization, the Continuing 
Garrison Organization (CGO). Using the older workload data in 2004, 
WRAMC proposed a relatively small CGO of 25 government personnel. 
Earlier this year, with a better understanding of the greater workload 
requirements, the WRAMC Leadership submitted to MEDCOM a request for 63 
CGO positions (Enclosure 2) to be spread across the WRAMC garrison to 
provide effective oversight and monitoring of contractor activities 
proposed to implement the BASOPS support. After MEDCOM reviewed the 
request and sent a manpower analyst to discuss the revised CGO with 
each of our directors proposal they reduced the approved CGO total to 
26 slots (Enclosure 3).
    WRAMC established its garrison command in 2002 when the Army 
established the Installation Management Agency (IMA). Consequently the 
A-76 study data in 2000 did not include other areas of the garrison 
command necessary to run a full service BASOPS organization. These 
include the DOL and the PAIO; therefore, the final contractor 
submission did not include positions for them. Furthermore, MEDCOM did 
not approve any full time equivalents for the Garrison DOL or PAIO 
functions anywhere in the CGO.
    No provisions were made for a PAIO which has created additional 
problems. The PAIO is the Garrison Commander's right hand in the areas 
of planning, assessment and improvement. Working hand in hand with the 
BRAC office, the PAIO facilitates and maintains the BIG PICTURE 
Garrison planning efforts. Working with cross-functional planning teams 
we truly considered all aspects of every challenge facing the Garrison 
during the A-76, the RIF and BRAC processes, as well as the programs 
and services we provide to our customers on a daily basis. The PAIO 
consolidates all Garrison plans (Master Plan, Human Resource Plan, 
etc.) into an over arching Garrison Strategic Plan governed by an 
Installation Planning Board. This board is designed to be made up of 
the Installation Chain of Command, MEDCOM representatives, other tenant 
organization representatives and chaired by the Installation Commander. 
It is imperative that we continue ongoing measurements, analysis, 
assessment and adjustments that result in our goals and objectives 
being met at the installation level. Meeting these goals and objectives 
guarantees improvement of the Garrison BASOPS mission for the MEDCOM, 
our tenant units, our soldier's and their family members.
    Our last point has to do with section C.5.10 of the Performance 
Work Statement that was submitted for contracting, where DOL functions 
are represented. These functions relate to the ``Hospital'' DOL and do 
not consider Garrison DOL functions. The Garrison DOL is the property 
accountability and supply and services authority for the Garrison 
organization. Without these essential offices, WRAMC, MEDCOM, the Army 
and the U.S. taxpayer are vulnerable to property loss amounting to 
hundreds of thousands of dollars over the next five years. DOL's hand 
receipt system and follow on Financial Liability Investigation of 
Property Loss (FLIPL) process were implemented to hold hand receipt 
holders accountable for lost property and is a systematic and proven 
means of ensuring government property is tracked and accounted for. In 
addition, the disposition and transfer of property, equipment and 
facilities are all logistical functions and during BRAC the Vice Chief 
of Staff of the Army expects accountability from closing installations. 
Once the hospital is relocated this becomes a Logistics action and the 
hospital DOL will not be here to perform that function. After BRAC 
there could be a AAA Audit or GAO review to see that the correct steps 
were taken. The DOL also serves as a central office for supply 
acquisition and distribution thereby building a more efficient and 
effective means to procure supplies and equipment for the entire 
Garrison operation. A central supply system reduces redundancy and 
increases availability of supplies to Garrison organizations.
    Without favorable consideration of these requests, WRAMC Base 
Operations and patient care services are at risk of mission failure.
    Thank you for your interest in and support of our challenges. The 
POC is the undersigned at (202) 782-3355.
                                        Peter M. Garibaldi,
                                       COL, MS, Garrison Commander.

    Senator Mikulski. But I'm saying to General Kiley, the 
Surgeon General, could I have your word now that you're going 
to evaluate the privatization, to evaluate the privatization 
efforts that are going on at these facilities and the impact 
that this is having on patient care? I want to know, and this 
subcommittee wants to know, why did we spend $12 million to get 
rid of 300 people so we now have 50 people? Okay, so that's the 
privatization. Can I have your word to do that?
    General Kiley. Senator, I will take----
    Senator Mikulski. Were you there during this A-76?
    General Kiley. Oh, yes, Senator, I was.
    Senator Mikulski. Well, what did you do about it?
    General Kiley. Senator, the A-76 as I understood it was the 
law. It was required of us to do a privatization across--for 
MEDCOM purposes, across three----
    Senator Mikulski. But you could have challenged it. The 
assumptions were based on the year 2000.
    General Kiley. That's correct, and----
    Senator Mikulski. Did you challenge the assumptions of the 
A-76 with your higher-ups and say, ``Let's take another look 
here?'' There were 16 different appeals.
    General Kiley. Yes, ma'am, and at the time that that began, 
I was then the MEDCOM commander. And I know that General Farmer 
worked through that, to include the issue about 2000 data, and 
as I understand it, as it has been explained to me, they 
updated the data a little bit.
    But you have identified the problem. The problem was as 
much a function of the morale of the employees, and the fact 
that Garibaldi----
    Senator Mikulski. No, my identification of the problem was 
that the A-76 was based on 2000, the year 2000, data. That was 
the problem. And we spent $7 million to implement something 
that was based on it. That was what the problem was. Did it 
have an impact on you now? Yes.
    General Kiley. Yes, ma'am, it did.
    Senator Mikulski. Okay, so yes, it did. What about you, 
Admiral Arthur?

                              A-76 STUDIES

    Admiral Arthur. Yes, ma'am. We have not had similar 
incidents of A-76 studies on as grand a scale as Walter Reed 
has, but I would tell you in general whenever you promulgate an 
A-76 study, the very best people that we have start looking for 
other jobs, and we end up with a dearth of people in the 
billets that are currently filled. And very often I think it 
comes out that a government worker, someone on the General 
Schedule or one of our contractors, is at least as cost-
effective as a privatization would be.
    Senator Mikulski. I think this is something, again, that we 
need to be looking at, I mean truly looking at, and that also 
goes to Dole-Shalala.
    Admiral Arthur. Yes, ma'am.
    General Kiley. Yes, ma'am.
    Senator Mikulski. General?
    General Roudebush. Yes, ma'am. I think it's very pertinent 
to go back and look at the privatization issue, and I think 
that's an exercise that is certainly worthy and will press on 
that.
    For us in the Air Force, we have a mix across our 
facilities of privatized contracts or base support. For us it 
has worked reasonably well. However, I think the opportunity to 
go back, revisit it, take a look, is something that we will 
certainly press on.
    [The information follows:]

    Approximately 72 percent (53 of 74) of Air Force Medical 
Service medical treatment facilities (MTFs) use contractors to 
provide day to day facility maintenance. The external 
accreditation body for health care facilities (Joint Commission 
on Accreditation of Healthcare Facilities) has had high praise 
for many of the contract maintenance companies in terms of 
processes and documentation of the work performed. 
Additionally, facility satisfaction with contract Maintenance 
is very high.
    On March 9, 2007, the Air Force Surgeon General asked the 
Auditor General of the Air Force to provide audit support for 
oversight of contractors responsible for medical facility 
cleaning and maintenance.
    While the Air Force Medical Service has never previously 
had an audit to evaluate the Performance of a contract 
maintenance provider, we take several measures to ensure we 
received quality maintenance. Each site has a contracting 
officer representative to ensure compliance with the specified 
level of maintenance. The contractors are required to provide 
monthly status reports on their performance. Notably, we also 
have a central cadre of experienced technical staff that 
further reviews the performance status reports. This staff, 
comprised of military and government civilian experts, provides 
oversight and support to the local representatives. We manage 
preventive maintenance and demand maintenance needs of our MTFs 
through the Facility Management Module of the Defense Medical 
Logistics Support System allowing us to monitor the state of 
equipment and trend the performance of our contractors. We 
ensure past performance is a key evaluation factor when we 
award new contracts and decide to exercise option years. Our 
maintenance contracts are structured to place full life-cycle 
liability for covered building systems on the contractors; 
therefore, the contractors have an inherent incentive to 
accomplish appropriate maintenance. If a system fails, they are 
financially liable to make all repairs or replacements. 
Collectively, these measures ensure we are providing quality 
maintenance of our medical infrastructure.

                           CONTINUITY OF CARE

    Senator Mikulski. Yesterday in the Levin hearings, the 
Assistant Secretary for Health said one of the most important 
things to ensure continuity of care was continuity of the 
caregivers, and he talked about the need for a cadre, and I'll 
use the term, of civil servants. It goes to, should military 
people even be running these hospitals? Should there be a cadre 
of civil servants that do this? And that also goes to the 
privatization question.
    I'm not questioning that but, as you know, in the private 
sector doctors don't run hospitals anymore. But you know tours 
of duty change. Since you were at Walter Reed, General Kiley, I 
think we've even had a third or a fourth----
    General Kiley. Yes, ma'am. A fourth now, yes, ma'am.
    Senator Mikulski. And that's the military way, so they come 
and they go, they come and they go, and they come and they go. 
So there's the loss of institutional memory, the culture the 
institution needs to maintain.
    I believe that there needs to be military leadership at 
military facilities, but I think we've got to take a look at 
the role of civil service here and now. It also goes to the 
contracting out of other services, because we not only have the 
wounded warrior, we have the wounded waiting warrior. Now, that 
takes me----
    Admiral Arthur. Yes, ma'am. May I comment, ma'am, just 
briefly?
    Senator Mikulski. Yes.
    Admiral Arthur. The CNO asked me, when I first took this 
job, could we have our casualties seen at Mayo Clinic or Johns 
Hopkins? And I said they could treat their injuries and 
illnesses, but the advantage of having a military hospital with 
military commanders and people in charge is, we understand what 
our mission is and whom our population is.
    We never ask our patients how sick they can afford to be. 
And all of our people, all of our uniform people, have been to 
combat or at least have been exposed to the operational 
scenario so that they know what our patients have gone through, 
and I think there's great benefit to understanding the patient 
who has been in combat, the family needs, et cetera. So having 
someone other than military run our basic facilities runs the 
risk of not understanding who----
    Senator Mikulski. No, no. I'm not talking about contracting 
it out to Hopkins or to Mayo. I'm talking about who should be 
there all of the time, which is the chief executive officer 
(CEO) manager. No, I in no way would mean to dilute that.
    But let me go on. In TRICARE you do contract it out. There 
is TRICARE, but you reach a point where you do contract it out. 
That's one of the reasons, and one of the reasons these guys 
and gals are wild to get a 30 percent disability, so that they 
can get TRICARE for life, because they fear if they go into the 
VA they're going to wither away, exactly for the reasons you 
said.

                           DISABILITY RATINGS

    Which then takes me to this. General Kiley, of the 22,000 
Purple Hearts that we have, how many of them have achieved a 30 
percent or more disability?
    General Kiley. Senator, I can take that question for the 
record. I do know that in 2006, as I understand it, the active 
force had about a 4 percent permanent disability, so about----
    Senator Mikulski. Which goes to the Murray point. Thank 
you.
    General Kiley. Yes, ma'am.
    [The information follows:]

    The Department of the Navy has identified 362 military 
personnel (326 Marine Corps/36 Navy) who have been awarded a 
Purple Heart and a combined disability rating of 30 percent or 
greater for injuries sustained while participating in 
Operations ENDURING FREEDOM and IRAQI FREEDOM.

    Senator Mikulski. Admiral?
    Admiral Arthur. All Purple Hearts are given to active duty 
military. I'm not sure how many have received a disability. 
We'll take it for the record. But there are a lot of injuries 
which are minor, for which a Purple Heart is awarded.
    Senator Mikulski. Well, we don't know how minor is 
``minor,'' now. That's the whole point about this war, that 
``minor'' might become ``major,'' which is one of the reasons 
they're talking about, when you are discharged and you have 
been handed over to the VA, which there's a lot of flashing 
lights about, that there is no goodbye physical that's uniform 
and passed on to them.
    Admiral Arthur. Well, we do have a joint physical that 
we're piloting and we've had for several years with the VA, so 
that we----
    Senator Mikulski. Let me tell you why I asked about the 
disability. So, okay, they're at Walter Reed, and we clean it 
all up and everybody is jazzed, and we ought to be jazzed. 
Well, what I worry about is what happens after they leave 
Walter Reed.
    Admiral Arthur. Yes, ma'am.
    General Kiley. Yes, ma'am.
    Senator Mikulski. And that's why I was asking for this. 
Now, what is the plan, and have you taken the action that----
    General Kiley. The plan, to address your question, Senator, 
from my view is for the Army to get together very quickly----
    Senator Mikulski. But have they? Have they? Have you met? 
What is your plan?
    General Kiley. Well, I have not yet met, since I started 
working through this process here at Walter Reed----
    Senator Mikulski. But how long have you been Surgeon 
General?
    General Kiley. Two and one-half years.
    Senator Mikulski. And how long have we been at war in Iraq?
    General Kiley. A pretty long time. Yes, ma'am.
    Senator Mikulski. I think it's since March 2003, isn't it?
    General Kiley. Yes, ma'am.
    Senator Mikulski. We went to war, so we have been at war 
there as long as World War II.
    General Kiley. Yes.
    Senator Mikulski. And you don't have a plan for these----
    General Kiley. In terms of the issues of addressing what we 
have been talking about, which is what appears to be and to me 
is a disparity and a confrontational position, we have to take 
this on, and I----
    Senator Mikulski. Well, that's the disability of 4 percent, 
but what is your plan for even the 4 percent?
    General Kiley. In terms of taking care of those soldiers?
    Senator Mikulski. Yes. What is the long-term care plan? Do 
you have a plan for TRICARE for them? Do you have a plan for 
assisted living? Do you have a plan for long-term care? Do you 
have a plan for family assistance? Do you have a plan to pay 
for the divorce lawyers? Do you have any plan at all for any of 
this?
    General Kiley. For the 50-year plan, no, ma'am, I do not.
    Senator Mikulski. Do you have it for the next 3-year plan?
    General Kiley. Not yet. We have not addressed----
    Senator Mikulski. Well, I find this shocking. This is a war 
that we have been fighting for 5 years. One hundred and fifty 
thousand people will now be there, if the President gets his 
surge way, but even now, 128,000. Five years, longer than World 
War II, where these men fought and bear the permanent wounds of 
war. That's why they are so passionate about this. They know 
what good care and good follow-up care means.
    General Kiley. Yes, ma'am.
    Senator Mikulski. I have heard their personal stories, and 
been touched and motivated and been inspired by them. How about 
you? Now, you said, when the problem with the Post article 
occurred, that it was yellow journalism and you wanted to reset 
our thinking. What thinking now do you want to reset? You 
wanted a private meeting with me. I want a public hearing. What 
part of that do you want to reset? You said it at the press 
conference.
    General Kiley. Senator, I did not call the Post series by 
reporters Priest and----
    Senator Mikulski. No, but you said you wanted to reset our 
thinking. Here is your moment in the sun. What part of that 
Dana Priest series do you want to reset our thinking on?
    General Kiley. I don't want to reset anyone's thinking, 
Senator. I share the concern of----
    Senator Mikulski. But you did when you said it. You did in 
your first press conference, said you wanted to reset thinking.
    General Kiley. I wanted to assure the American people that, 
one, we were as concerned as the report was, that we wanted to 
work through solutions, we weren't sitting back on our heels. I 
clearly was not attempting to suppress or in any way mitigate 
the circumstances.
    Senator Mikulski. Well, let me tell you what I'm hearing. 
I'm hearing from soldiers where they wanted to appeal their 
benefits, but they told me I can't use their stories because 
they fear retaliation.
    General Kiley. Yes, ma'am, and I----
    Senator Mikulski. That people fear retaliation, you need to 
know that. They fear retaliation about speaking up at 
facilities, so you need to know that.
    General Kiley. Yes, ma'am.
    Senator Mikulski. So there is a culture here, and I think 
the culture has got to change.
    General Kiley. And I agree.
    Senator Mikulski. This is why we think it's a failure of 
leadership. But I'm going to come back to the leadership of 
this subcommittee, who have devoted their life to military 
medicine, and who I'm proud to serve with. I think we've got to 
look at this, the fact that here we are in the fifth year of 
the war in Iraq, and we don't have a plan for what happens when 
these men and women leave truly acute care, not only the 50-
year plan, but we don't have a 3-year plan.

             MILITARY MEDICINE AND VETERANS ADMINISTRATION

    Now I'm going to ask, have the Surgeon Generals of military 
medicine met with Nicholson at the VA to talk about that 
continuity handoff? Have you as a group met with him?
    Admiral Arthur. Not as a group, ma'am, but I've met with 
him individually and have met when Secretary Perlin was the 
Under Secretary for Health of the VA.
    Senator Mikulski. And do you have a plan for doing this, 
for handing off the marines?
    Admiral Arthur. Yes, ma'am.
    Senator Mikulski. And other Navy personnel?
    Admiral Arthur. The marines also have a plan for the 
marines, the Marine for Life Program and others that take care 
of marines even after they are discharged, active duty or 
reserves. The marines have been very, very forthcoming and 
forward-leaning in taking care of their own marine casualties.
    Senator Mikulski. Have you met with them?
    General Roudebush. Yes, I've met off line with Secretary 
Nicholson on at least one occasion, talking about this, as well 
as----
    Senator Mikulski. Do you feel you have a plan?
    General Roudebush. Ma'am, the plan that the Air Force uses 
is something that we call our wounded warrior plan, with the 
Palace HART, which actually follows our individuals through 
their hospitalization, through their disability processing, out 
into the civilian life, and continues to track them to assure 
that their needs are, in fact, met.
    Senator Mikulski. Have you met with them?
    General Kiley. I have not met with the Secretary on this 
subject. I have met with, had discussions over the last several 
years with Dr. Perlin and particularly with Dr. Kussman about 
the handoff from our facilities to the VA. I have put U.S. Army 
personnel into our multitrauma centers as liaisons to 
coordinate that. I have visited the polytrauma centers myself. 
I am very concerned about and think that that's the next great 
plan we need, which is to make sure the VA can continue to 
support these soldiers.
    Senator Mikulski. I find this horrifying, after 5 years, I 
just find this, the lack of a continuum. But I have confidence 
in the leadership of this subcommittee and look forward, and 
now the Dole-Shalala investigation, where we can continue this. 
Let's start with the BRAC, look at the facilities, and then the 
human infrastructure and the plan.
    Thank you, Mr. Chairman.
    Senator Inouye. Senator Stevens.
    Senator Stevens. My comment to the Surgeon Generals would 
be that both of our Senators have spoken up very strongly. I 
particularly want to go back to what Senator Murray said, 
though. We have all heard, from the families of these wounded 
members of the military, an expression of fear if they speak 
up. Somehow or other that has got to be dispelled.
    General Kiley. Yes, Senator, I agree.
    Senator Stevens. And I think it applies across the board. I 
would urge that you ask that there be just a flat statement 
that there is no retaliation. We welcome those comments. Those 
comments help us find ways to solve the problems, and I think 
many times they will help you.
    General Kiley. Yes, Senator.
    Senator Stevens. I would hope that we find some way to 
dispel this and start retaliating against the people who put 
that fear in these people. That should not be. There should not 
be any fear of speaking up about the quality of care or the 
future plans for these people. I don't think we can emphasize 
that too much. That has just got to stop.
    General Kiley. I agree completely, Senator, and I send 
surveys directly to med holdover soldiers and ask for their 
direct feedback to us, and we're getting that back. We've had 
over 1,000 surveys come back. Many of the comments are 
negative.
    It's not about going and reprising against someone. It's 
about finding out what's going on out there and letting us 
know. I can travel every camp, post, and station, and I do. I 
talk to soldiers. I was in Puerto Rico talking to med holdover 
soldiers. They have issues. We need to get on with it, and 
there will be no reprisal. It's absolutely unacceptable.
    Senator Stevens. Thank you, Mr. Chairman.
    Senator Inouye. Thank you very much.
    Like all citizens, when I began reading the articles in the 
Washington Post, I began to reflect, and I thought about a 
moment just about 1 year ago when a group of high school 
students converged into my office to interview me. And the 
first question I asked was, I suppose, a soft one: What happy 
moments have you had in your life? What were the happiest 
moments of your life?
    And my answer was a shocker for them because I said, ``The 
21 months I spent in the Army hospital after my injury.'' They 
couldn't understand that. In fact, they were my most enjoyable 
moments in my life. I had a ball in the military hospital.
    But as you think about it, you realize that there was a 
difference in culture. The President of the United States in my 
time, World War II, was very popular. The people were almost 
100 percent in favor of the war. Veterans were treated like 
gods. We would go into a restaurant and ``Anything you want, 
fella.'' Times were different.
    And then, well, I got hospitalized in the most unlikely 
place. We took over the best places in the United States. For 
my surgery it was Atlantic City. That's where it was. We took 
over Haddon Hall and Chalfont Hotels, huge hotels.
    When the Miss America program was finally restored, we got 
the front rows. And although I don't have a leg injury, I asked 
the surgeon to put a cast on because I wanted to get on a 
wheelchair to sit up in front. And I think I'm the only Member 
of Congress of the United States who was kissed by Miss America 
at that time.
    Senator Mikulski. And you well deserved it.
    Senator Inouye. These were happy moments for me. I spent 21 
months. The average GI spends 5 months in surgical, medical, 
and then he's an outpatient. I was not an outpatient. I was a 
member of the population there. We had 7 months of surgery and 
medical treatment and 14 months of what we called rehab.
    Had a group of carpenters from the carpenters group in that 
town who came out to teach us how to do carpentry. I built my 
own desk. Plumbing. To do electrical work, so that we won't be 
afraid to fiddle around with wiring, electrical wiring.
    We had to demonstrate that we can play sports. We had a 
choice. I decided not to take golf because after three rounds 
it was 92, and that's pretty high. I took up basketball and 
swimming, passed those tests.
    I took a driving course because I never drove before I got 
in the service, and they taught me how to drive, gave me a 
certificate to qualify me to drive in all States, all 
territories, all possessions, because at that time you know 
States had different driving laws.
    I had to play a musical instrument. Before the war I played 
a saxophone and a clarinet, but that was impossible, so they 
tried a trumpet and they said, ``No, your lips are too soft for 
that.'' And so they said, ``How about the piano?'' I said, 
``You must be out of your mind,'' but I passed the test. 
Someday I'll demonstrate to you.
    They even taught us how to make love. Someday I'll say so 
in public, not for the record here, but I can assure you it was 
the best lesson I ever got. I've never made a mistake since.
    They taught us self-defense. They taught us how to dine, 
how to dress, how to dance. When you ask for a dance for the 
first time since your injury, how do you hold the lady? With 
your right? With the left? These are things you think about.
    When we learned how to swim, we were all required to swim, 
it was not in the hospital pool. It was in the public lake, so 
you had to swim in the presence of normal people. You know, the 
average guy who is injured is reluctant to show his ugliness 
and scars to others. That's human nature. He has to be taught. 
I'll go out here anytime, it doesn't bother me. I walk around 
the house and the backyard with shorts on. Doesn't bother me. 
But I think it would bother some of those who are just coming 
back because they haven't been taught how to do it.
    Well, the culture is different. As far as I'm concerned, 
you people are doing the utmost you can. And when you consider 
that since 2002 Walter Reed, for example, has handled over 
6,000 war-injured veterans, that's a load that's suddenly 
thrust upon them. Outpatient load since the war has gone up 
from 100 to about 800 a day.
    At the same time, as Barbara Mikulski, Senator Mikulski, 
has pointed out, you had this BRAC. When people were moving up, 
they wanted a permanent job. They knew that 2011 was right 
around the corner, so they wanted a job with some pension plan, 
so they were leaving. And Bethesda, because of the new orders 
of opening up a good, first class hospital, began recruiting. 
And voluntarily I know that six anesthesiologists have left, 
and if you don't have an anesthesiologist, you don't have 
surgery.
    And so in the beginning I said I hope this is not a finger-
pointing exercise or fault-finding, scapegoating, sacrificial 
lamb, because all of us have dirty hands. Some got dirtier 
hands than others but we all do.
    So let's do our best. The soldiers deserve much better. I 
was horrified to see that mold and stories of rats around the 
place. These things didn't happen, I don't recall happening in 
my time.
    We had great socials. I don't know if they do have great 
dances today, but we had some good ones. And the first woman I 
ever fell in love with was a nurse. You couldn't help it. They 
were that good.
    So, with that, I'd like to thank the three gentlemen, and 
now may we call the nurses.
    General Kiley. Thank you, Senator.
    Admiral Arthur. Thank you.
    General Roudebush. Thank you, sir.
    Senator Inouye. I would like to welcome the Nurse Corps 
Chiefs: Major General Gale Pollock, Chief of the U.S. Army 
Nurse Corps; Rear Admiral Christine Bruzek-Kohler, Director of 
the Navy Nurse Corps; and Major General Melissa Rank, Assistant 
Air Force Surgeon General for Nursing Services.
    As I have indicated, as a veteran the first woman I fell in 
love with was a nurse, and I'm still in love with them. You're 
doing a great job. And with that, got any words, Ted?
    Senator Stevens. No, I don't have a similar experience to 
talk about.
    Senator Inouye. Well, well, well. May I call upon General 
Rank?
STATEMENT OF MAJOR GENERAL MELISSA A. RANK, ASSISTANT 
            SURGEON GENERAL FOR NURSING SERVICES, 
            DEPARTMENT OF THE AIR FORCE
    General Rank. Mr. Chairman and distinguished members of the 
subcommittee, I am pleased to represent nearly 8,000 men and 
women of the total nursing force. It has been my privilege to 
lead and serve alongside my senior advisors, Brigadier General 
Jan Young of the Air National Guard and Colonel Ann Hamilton of 
the Air Force Reserve.
    Air Force nursing is an operational capability, and 
strengthening clinical currency remains a priority. I have 
connected with each unit level nursing leadership for updates 
on their top initiatives. I can assure you that our clinical 
sustainment policy of 168 hours at the bedside has returned 
seasoned clinicians to inpatient settings to refresh skills and 
mentor the less experienced.
    Since September 2001, more than half of the Air Force 
service deployments have been filled by the total nursing 
force. We are in demand, serving in the air, on the ground, in 
every time zone, theater of operations, and level of care. Just 
as the global war on terrorism triggered an evolution in combat 
medicine, the unrelenting volume of complex trauma patients has 
generated an unprecedented demand for nursing resources.
    In the words of deployed Reserve officer, Lieutenant 
Colonel Dawn Smith, ``We do more than change dressings, 
maintain airways, stabilize blood pressure, and control 
bleeding. We provide the human touch. The hands I have held, 
the stories I have listened to, and the blank stares I have 
helped to find focus again, that is the essence of nursing.'' 
And that is why we are here. I couldn't describe Air Force 
nursing any better.
    This type of nursing care rivals that of any stateside 
facility. We are providing phenomenal critical trauma care and 
maximizing survivability for patients during high volume air 
evacuation missions and in theater hospitals at Balad and 
Bagram.
    To provide this operational capability, we increased 
production of critical care trauma nurses. Building upon the 
successful joint training program in San Antonio, we awarded 30 
critical care and emergency nursing fellowships, and are 
expanding our training sites to Bethesda and St. Louis 
University Hospital in Missouri.
    The Graduate School of Nursing at the Uniformed Services 
University is the primary source for training our certified 
registered nurse anesthetists (CRNAs) and perioperative nurse 
specialists. We are particularly pleased with the operational 
focus of their programs and the collaborative initiatives of 
the current leadership. We would also like to recognize the 
TriService Nursing Research Program which funds a number of 
expeditionary-focused studies conducted by Air Force nurses. 
Thank you for your continued support of both programs.
    The national nursing shortage is posing a threat to our 
recruiting and retention efforts. Overall, we accessed 92 
percent of our goal for fiscal year 2006, reflecting a 10-
percent increase from the previous year. We attribute our 
success to offering higher accession bonuses and more loan 
repayment options. We are implementing a specific Nurse 
Enlisted Commissioning Program similar to the successful Army 
and Navy programs. We have secured 12 student starts, and 
anticipate exponential growth of this program over the next 5 
to 10 years.
    Of grave concern is our current inventory, which has 
dropped to 85 percent. We are evaluating the downward trend in 
retention rates, and are now offering a $15,000 critical skills 
retention bonus to nurses completing their initial commitment. 
For the first time, we are also considering monetary incentives 
to impact retention at the 9- to 15-year point.
    On a positive note, we are encouraged by gains in master 
clinician billets. We anticipate this will allow nurses to stay 
at the bedside and remain competitive for promotion to colonel. 
Our powerful retention tool is professional development, and we 
continue to invest in advanced military and professional 
education programs. We are moving forward with plans to 
relocate enlisted medical basis and specialty training to a 
TriService Medical Education and Training Campus at Fort Sam 
Houston.
    We have fiercely maintained our ability to grant Community 
College of the Air Force degrees to Air Force students, and are 
exploring the feasibility of extending that benefit to our 
sister services. We are also investing in remarkable 
individuals like Staff Sergeant Victoria Weiger, who enlisted 
in 2001 at the age of 17. She has deployed twice to Iraq, and 
refers to helping injured U.S. and coalition forces as her most 
rewarding military experience.
    Sergeant Weiger expanded her scope of practice as an 
immunization technician and then as a critical care technician. 
She has earned an associate degree, and will be attending our 
Independent Duty Medical Technician Program early this summer. 
She aspires to commission as a Nurse Corps officer and becoming 
an Air Force CRNA.
    Last fall, I received an e-mail and photo from one of our 
deployed nurses. He was holding an Iraqi baby. This e-mail 
said: ``This child is one of our better outcomes. We see quite 
a few children here, and some very sad outcomes. We had three 
come in yesterday. One had both legs blown off near the hip, a 
very beautiful 8-year-old girl. I stopped by to see her. She 
was on continuous pain medication, and she looked like a 
sleeping angel. I didn't stay long because I couldn't keep the 
tears from welling up. No regrets about being here in Iraq. I 
love my work. Thanks for your support, and you take care.'' 
Signed, Captain Jose P. Jardin III.
    Mr. Chairman and distinguished subcommittee members, 
Lieutenant Colonel Smith, Captain Jardin, and Sergeant Weiger 
are representative of Air Force nursing. It is imperative that 
we recruit and retain quality airmen, afford them the best 
training and equipment, and safeguard clinical platforms to 
operationally prepare them and their replacements. We will look 
after their families while they are far from home, and be 
prepared to care for them when they return.
    We need to optimize the potential in our enlisted force 
with the opportunity to commission, and I must work diligently 
to improve Nurse Corps promotion opportunity and timing so that 
we can retain these airmen and capitalize on their leadership, 
clinical expertise, and operational experience. They are the 
symbol of the future of Air Force nursing.

                           PREPARED STATEMENT

    I am extremely honored to be here today. Thank you for the 
considerable support you have given us this year, and thank you 
for inviting me to tell our Air Force story.
    Senator Inouye. Thank you very much, General. Would you 
share with us the names and addresses of those three gallant 
nurses?
    General Rank. I would be proud to.
    Senator Inouye. We would like to send a note to them, a 
note of appreciation.
    General Rank. Yes, sir.
    [The statement follows:]
          Prepared Statement of Major General Melissa A. Rank
    Mr. Chairman and distinguished members of the committee, it is my 
honor to be here today representing Air Force Nursing Services. The 
Total Nursing Force encompasses officer and enlisted nursing personnel 
of Active Duty, Air National Guard, and Air Force Reserve Command 
components. It has been my privilege to lead and serve alongside 
Brigadier General Jan Young of the Air National Guard and Colonel. Anne 
Hamilton of the Air Force Reserve Command, my senior advisors for their 
respective components this past year.
    The Secretary and Chief of Staff of the Air Force have set three 
priorities: Win the global war on terrorism, develop and care for our 
airmen, and modernize and recapitalize our assets. I assure you Total 
Nursing Force objectives align with, and directly support, these 
priorities.
                         expeditionary nursing
    Air Force nursing is an operational capability, and Air Force 
Nursing Services remains in the forefront supporting the warfighter. 
Between January and December 2006, 12 percent of the Total Nursing 
Force inventory (2,187 personnel) deployed to 43 locations in 23 
countries. Within the active duty component, 13 percent of our nurses 
and 15 percent of our medical technicians were deployed in 2006. The 
average deployment length was 110 days. Since September 2001, the Total 
Nursing Force has completed 53 percent of all Total Force deployments 
within the Air Force Medical Service. Total Nursing Force nurses and 
medical technicians are providing remarkable operational support. We 
are a well-trained, highly motivated capability serving in every time 
zone, every theater of operations, and at every level of care.
    In January 2007, we activated the 455th Expeditionary Medical Group 
and assumed operational control of Craig Theater Hospital located at 
Bagram Air Field, Afghanistan. We have received impressive reports of 
life-saving care at the 455th. For one Afghani National admitted with 
multi-organ failure, classic medical-surgical nursing care saved his 
life. Over a 3-week period, Captain Cindee Wolf saw to his daily care 
and treatments. Providing frequent personal care, administering 
countless intravenous and oral medications, cajoling ``one more bite'' 
at mealtimes, and performing multiple range of motion exercises were 
just a few of the interventions nursing teams employed. Disease, 
compounded by poor nutrition and harsh living conditions, proved just 
as life threatening as an insurgent's bullet. The compassionate care of 
everyone assigned to the 455th Immediate Care Ward contributed to this 
patient's recovery and discharge home.
    The 332nd Expeditionary Medical Group remains the epicenter for 
wounded in Iraq. Located at Balad Air Base, this Air Force theater 
hospital treats more than 300 trauma patients every month and provides 
care to another 400 sick and injured patients. Of the roughly 700 
patients seen per month, about 500 (71 percent) are U.S. troops, 170 
(20 percent) are Iraqi soldiers, police and civilians, and the 
remaining 30 (10 percent) are foreign national contract employees, 
insurgents, or those of unknown status.
    Nursing teams are providing phenomenal emergency trauma care and 
maximizing favorable outcomes for patients in these high-volume theater 
hospital environments. U.S. casualties making it to Balad have an 
unprecedented survival rate of 97 percent to Landstuhl Regional Medical 
Center in Germany. Describing the response of medics to an influx of 
casualties, 332nd Chief Nurse Colone Rose Layman said, ``. . . we had 
such a smooth rhythm as we worked together . . . we were able to take 
20 patients with multiple traumatic injuries and triage, treat, and 
move them . . . without calling any additional staff. I stood in that 
empty emergency room (exactly 1 hour after the first casualty came in 
and simply thought, wow!''
    Our nursing care rivals that of any stateside facility. In the 
words of one of our experienced Air Force Reserve Command nurses, ``I 
had the best experience in my entire 20 years as a trauma nurse 
[because] I saw how trauma patients should be treated--I saw the best 
possible care done on the worst traumas I have seen in the shortest 
time imaginable. I work at one of the largest trauma centers in my 
State and just realized we could learn a lot.'' What a testimony to the 
Air Force Medical Service!
    The en route care construct has significantly decreased our 
footprint on the ground. Since October 2001, the Air Force Medical 
Service Aeromedical Evacuations System has moved nearly 40,000 
patients. To put this in terms you may appreciate, this equates to 
evacuating the entire population of Annapolis, Maryland. In an excerpt 
from the Chief of Staff of the Air Force's ``Portraits of Courage'', 
General Moseley recognized our Aeromedical Evacuation flight nursing 
teams. Although written with the 86th Aeromedical Evacuation Squadron 
(AES) in mind, his comments described the mission performed by any one 
of our 31 Total Force Aeromedical Evacuation units. ``. . . wounded 
warriors, premature babies, accident victims, retirees falling ill and 
other Department of Defense (DOD) beneficiaries needing medical care 
are routinely transported by [teams of] flight nurses and aeromedical 
evacuation technicians . . . Our Nation asks much of her military and 
she provides an unsurpassed transportation of the sick and injured 
around the world . . .''
    The challenging task of facilitating Aeromedical Evacuation 
missions rests with our four Global or Theater Patient Movement 
Requirements Centers. The Theater Patient Movement Requirements-Europe 
provided around-the-clock support during the Beirut, Lebanon Non-
combatant Evacuation Operation. Working in concert with DOD, Department 
of State, U.S. European Command, and U.S. Consulates in Nicosia, 
Cyprus, and Frankfurt, Germany, they synchronized patient movement of 
evacuees. In one case, the U.S. Consulate in Nicosia contacted Theater 
Patient Movement Requirements-E and requested assistance moving an 84-
year-old Lebanese-American. At the outbreak of hostilities, this 
gentleman was evacuated from Beirut and admitted to the American Heart 
Institute in Nicosia for treatment of his chronic cardiac and 
respiratory problems. Theater Patient Movement Requirements-E validated 
the need for en route medical care, coordinated an accepting physician 
at Landstuhl Regional Medical Center in Germany, and secured airlift 
for an Aeromedical Evacuation mission. Within 24 hours, the mission was 
complete and the patient was receiving care at Landstuhl Regional 
Medical Center.
    Members of the Total Nursing Force, like Aeromedical Evacuation 
Technician Staff Sergeant Jason St. Peter, saved lives using their 
extensive medical and combat readiness training. While on a rescue 
mission into a high threat area of anti-coalition militia activity, 
SSgt. St. Peter was informed that the casualty count had quadrupled. 
Taking decisive action, he directed reconfiguration of the aircraft to 
accommodate additional patients. Upon landing, he triaged and 
prioritized treatment under infrared illumination provided by overhead 
aircraft. SSgt. St. Peter was credited with saving eight soldiers, as 
well as eliminating the need to bring additional rescue teams into 
harm's way. He was nominated for a Distinguished Flying Cross.
    In the Pacific theater, crews from the 18th AES moved six 
critically burned sailors from Guam to Hawaii and then on to San 
Antonio. During the final leg of this 6,000 mile journey to Brooke Army 
Medical Center, the sailors received en route critical care from a team 
of burn specialists. This feat showcased Tri-Service interoperability, 
validating the joint capability of moving patients in an efficient 
manner and providing the greatest opportunity for survival and 
rehabilitative care. Notably, it was during this mission that our C-17 
fleet logged its one-millionth hour.
    For some, duties were performed along our Nation's border in 
support of Operation Jump Start. One hundred fifty-five Air National 
Guard nurses and medical technicians from four States were activated 
for 1 to 4 month rotations supporting this Homeland Security Border 
Control mission.
                     operational skills sustainment
    The global war on terrorism demand for operational, clinically-
current specialty nurses has steadily grown. In response, we have 
increased production of critical care and trauma nurses and returned 
nurses with specialty nursing experience to the deployment pool.
    Encouraged by the success of our joint training pipeline in San 
Antonio, we awarded 30 critical care and emergency fellowships this 
year and expanded our joint training platforms to include the National 
Naval Medical Center in Bethesda and St. Louis University Hospital in 
Missouri. We have not stopped there. We are revising our support 
agreement with the University of Cincinnati Medical Center in Ohio to 
accommodate critical care nursing fellows.
    We continue to rely on our Centers for Sustainment of Trauma and 
Readiness Skills (C-STARS). These advanced training platforms are 
embedded into major civilian trauma centers throughout the continental 
United States. In 2006, this invaluable clinical immersion enabled 614 
doctors, nurses, and medical technicians to refresh operational 
currency while preparing them to deploy as Critical Care Air Transport 
Team (CCATT) members or clinicians in expeditionary medical support 
(EMEDS) facilities. Many of our chief nurses consider the Centers for 
Sustainment of Trauma and Readiness Skills an essential component of 
their clinical competency programs and the majority of the graduates 
tell us it is one of the best training experiences of their military 
career.
    Strengthening operational clinical currency remains a priority. Now 
11 months old, our clinical sustainment policy continues to gain 
momentum. The concept is simple: providing opportunities for nurses 
temporarily assigned in out-patient or non-clinical settings to refresh 
their technical skills by working a minimum of 168 hours per year at 
the bedside. For many of our out-patient facilities, this means 
affiliating with local medical centers for innovative patient care 
partnerships. Where available, our medical technicians are capitalizing 
on these partnerships. Said an airman from Kirtland Air Force Base 
(AFB), New Mexico, ``The Veterans Affairs (VA) rotation . . . was a 
great way to get hands-on experience and exposure to emergency and 
inpatient settings.''
    In 2006, we gained access to eight complex medical-surgical, 
emergency trauma and critical care training platforms in which to 
sustain clinical skills for our officer and enlisted nursing personnel. 
An extraordinary benefit emerging at nearly all training sites has been 
exposure to--and appreciation for--the unique missions of various 
agencies. We are encouraged by reports of how affiliations with our 
Federal health partners have fostered collegiality between nurses. 
Among these affiliations, two are with civilian organizations (Miami 
Valley Hospital in Dayton, Ohio and Iowa HealthCare in Des Moines, 
Iowa). Federal Tort Laws make securing affiliations with civilian 
organizations particularly challenging, so I applaud the hard work 
expended at the local level. Nursing personnel from the 3rd Medical 
Group (MDG) DOD/Veterans Affairs Joint Venture Hospital and the Alaska 
Native Medical Center have collaborated on continuing education and 
professional development programs for many years. Their partnership 
expanded recently to include rotations in pediatric, medical-surgical 
and critical care units--experiences long-sought to bolster currency at 
home station and in deployed settings.
    In addition to sustainment, we have robust entry-level training 
platforms. The 882nd Training Group at Sheppard AFB, Texas graduated 
1,638 Total Force Aerospace Medical Service Apprentice (AMSA) students 
in fiscal year 2006. AMSA students have the unique experience of 
training on technologically advanced simulations systems. Life-like 
mannequins simulate clinical patient scenarios, allowing students to 
learn and gain hands-on experience in a controlled environment. As they 
progress through training, students are challenged with increasingly 
complex scenarios. This training module was recognized by 2nd Air Force 
as a ``Best Practice''.
    Landstuhl Regional Medical Center became our 10th Nurse Transition 
Program (NTP) training site and the first NTP hosted in a joint 
facility. With the addition of the Landstuhl Regional Medical Center 
NTP, we have increased overall enrollment to 160 nurses in this Air 
Force Medical Service entry-level officer program.
    We depend on the Uniformed Services University of the Health 
Sciences (USUHS) Graduate School of Nursing (GSN) to prepare many of 
the Family Nurse Practitioners (FNPs) and Certified Registered Nurse 
Anesthetists (CRNAs) needed to fill our mission requirements. 
Currently, 57 percent of our 49 FNPs and 52 percent of our 143 CRNAs 
are USUHS graduates. The GSN enrolled 46 Air Force nurses this fall in 
Perioperative Specialty, FNP, and CRNA programs. Overall, Air Force 
nurses represented 41 percent of the GSN student population. Once 
again, all 13 of our CRNA candidates passed the National Certification 
Exam before graduating this past December. We would like to acknowledge 
the support of faculty, and recognize Lieutenant Colonel Adrienne 
Hartgerink for her selection as Military Faculty Member of the Year.
    We are pleased with the collaborative research endeavors available 
to GSN students. Air Force nurses have published their research in 
professional journals and presented their work at the national level. 
Ten of our nurses were among the GSN students contributing to a 
landmark study that analyzed more than 11,000 reported perioperative 
medication errors. The recommendations emerging from this research have 
significant implications for patient safety, and will lead to better 
outcomes for patients in all U.S. healthcare organizations. 
Collaborative clinical training occurred as well. The Mike O' Callaghan 
Federal Hospital at Nellis AFB in Nevada and National Naval Medical 
Center were formally designated as Phase II Nurse Anesthesia Clinical 
Sites. Air Force nursing has successfully integrated training platforms 
at every level.
                           clinical successes
    We are also logging significant improvements at home-station 
treatment facilities. The 81st MDG at Keesler AFB, Mississippi 
celebrated another post-Katrina milestone with the opening of a new 
labor, delivery, recovery and postpartum unit. The new labor and 
delivery unit is staffed with six OB/GYN physicians, one nurse midwife, 
nine military and three civilian nurses, as well as seven medical 
technicians. More staff will be arriving over the coming year to 
coincide with projected increases in prenatal caseload.
    At the 23rd MDG, Moody AFB, Georgia, Major Jennifer Trinkle and a 
team of nurses instituted a nurse-run Active Duty Fast-Track Clinic 
using pre-defined care protocols. The fast-track made a measurable 
impact on their business plan and increased overall productivity of the 
facility. Exit surveys revealed patients liked the ``express'' 
experience, and nursing teams enjoyed more interaction with patients.
    A Tri-Service nurse consortium, chartered at Landstuhl Regional 
Medical Center, addressed complex infection control issues affecting 
global war on terrorism casualties. Their initiatives included 
modifying specimen collection intervals to reduce bacterial 
colonization of acinetobacter baumannii, instituting contact 
precautions for all intensive care unit admissions, and switching to 
waterless/antibacterial bathing protocols. These efforts have the 
potential to become benchmark infection control practices for 
participating National Nosocomial Infections Surveillance System 
hospitals.
                           caring for our own
    The cornerstone of military capability is a fit and ready force; 
however, the undeniable consequence of continued exposure to 
polytraumatic injuries is profound risk to the health of our nursing 
staff. Although vast resources are available to airmen and their 
families prior to deployment, lessons from earlier conflicts have 
taught us some returning warriors--warrior medics among them--have 
difficulty resuming personal and professional activities. Dr. Michael 
Murphy, an Assistant Professor of Surgery at the Indiana University 
School of Medicine and OIF veteran, offered this Veteran's Day tribute: 
``There is . . . a group of forgotten veterans . . . who carry with 
them the ghosts of war that will haunt them forever . . . nursing staff 
(assigned to) forward surgical teams and combat support hospitals.'' To 
that end, every airman completes a Post Deployment Health Re-Assessment 
(PDHRA) survey at some point during their 90 to 180 day post-deployment 
window. At the local level, nurses are connecting those at risk with 
appropriate primary care or mental health providers.
    We recognize caring for our own includes caring for those who care, 
looking after airmen and their families and educating all concerned on 
signs and symptoms of stress. Over the past year, we have promoted 
awareness and neutralized stigmas associated with seeking help by 
incorporating post traumatic stress and compassion fatigue discussions 
with nurses attending symposiums, conferences and senior leader 
gatherings. We are now pursuing targeted interventions to ensure we 
have the appropriate resources available for our nurses and medical 
technicians when they return to home.
                        professional development
    The goal of Nurse Corps (NC) professional development is to produce 
nursing leaders for the Air Force Medical Service. We accomplish this 
goal by creating role-specific skill-sets and competencies to enhance 
current job performance and prepare junior officers for success in the 
future. Our nursing Development Team (DT) convenes quarterly to ensure 
NC officers are afforded deliberate career progression. The DT 
competitively selects our squadron commander and chief nurse 
candidates, both of which represent pivotal career leadership 
milestones. Additionally, the DT selects, through a board process, 
those leaders who will most benefit from developmental education in 
residence. This year three outstanding NC officers were selected for 
senior developmental education.
    Professional development also serves as a powerful retention tool. 
Seventy-five percent of Air Force nurses responding to our 2006 DT 
Assessment Tool survey stated educational opportunities positively 
influenced them to stay in the military. In addition to professional 
military education and pinnacle leadership positions, the NC supports 
very robust educational opportunities. Three percent of Total Force 
nurses are funded for advanced academic degrees and specialty training 
every year. For 2006, these included 69 nurses selected for the nurse 
practitioner programs, 21 nurses selected for clinical nurse 
specialists' education, and 14 nurses selected for other advanced 
degrees. Eighteen nurses were selected for very competitive fellowships 
to include emergency room/trauma/critical care, Advanced Executive 
Development programs, Advanced Education and Training programs, Joint 
Commission and Accreditation Association for Ambulatory Health Care 
fellowships, and numerous others. In addition to professional military 
education and advanced degree programs, we continued our specialty 
courses for operating room nursing, neonatal intensive care nursing, 
infection control, perinatal/OB nursing and the Health Professions and 
Education and Training Course. In 2006, we trained 66 Total Nursing 
Force flight nurses and 172 Total Nursing Force Aeromedical Evacuation 
technicians at our Flight School at Brooks City Base in San Antonio. 
This program continues to be a vital training platform for our 
increasing requirements for clinical Aeromedical Evacuation crews in 
support of global war on terrorism.
    Purposeful assignment selection and rank-appropriate developmental 
education opportunities will ensure our nurses have the requisite 
skills and experience to succeed in deployed operations and future 
leadership roles. I want to especially thank Dean Bester of USUHS for 
the continued support, which makes much of our advanced education a 
huge success.
                              recognition
    Air Force nurses and medical technicians were recognized for 
outstanding performance by various professional organizations this 
year. The Air Force Association is an independent, nonprofit, civilian 
education organization promoting public understanding of aerospace 
power and the pivotal role it plays in the security of the Nation. They 
recently selected Air Force Medical Service Expeditionary Medics to 
receive the AFA Outstanding Air Force Team of the Year award for their 
direct support of the warfighter and our expeditionary efforts. Seven 
Total Force medics will accept this award on behalf of the entire Air 
Force Medical Service at the end of March.
    Last fall, Lieutenant Colonel Leslie Claravall, 374th Medical 
Operations Squadron Commander at Yokota AB, Japan was honored as one of 
the 2006 Ten Outstanding Young Americans. Since 1938, this project has 
recognized 10 Americans each year who exemplify the best attributes of 
the Nation's young people.
    In July 2006, the National Nursing Staff Development Organization 
presented national awards to two Air Force nurses at their annual 
conference. Lieutenant Colonel Lola Casby and Major Francis Desjardins 
won the Excellence in Educational Technology and Excellence in the Role 
of Professional Development Educator Awards, respectively. Lieutenant 
Colonel Sandy Bruce, Consultant to the Air Force Surgeon General for 
Nursing Education and Training, was appointed editor-in-chief of the 
next edition of Core Curriculum for Staff Development, and five Air 
Force nurses were named to the editorial board. This manual, endorsed 
by National Nursing Staff Development Organization, is widely accepted 
as the standard of practice for healthcare educators. For the first 
time, an Air Force nurse was named Research Consultant to the 
International Council of Nurses (ICN). The ICN is a federation of more 
than 120 national nurses' associations representing millions of nurses 
world-wide. Colonel John Murray was also selected as a Fulbright 
Visiting Scholar for research, another first for military nursing.
    Our medical technicians were similarly honored for outstanding 
achievement. Master Sergeant Charles Cremeans, an independent duty 
medical technician assigned to the 786th Security Forces Squadron at 
Ramstein AB, Germany, was awarded the 2006 Lewis L. Seaman Enlisted 
Award for Outstanding Operational Support. Air Force independent duty 
medical technicians have won this award 3 of the past 4 years, 
validating their unique role in operational healthcare missions. 
Sponsored by the Association of Military Surgeons of the United States, 
this prestigious award recognizes an enlisted professional of the Army, 
Navy, Air Force or Coast Guard, who has demonstrated compassionate, 
quality patient care and service, clinical support, or healthcare 
management.
    Technical Sergeant Shannon McBee, an Aeromedical Evacuation 
technician assigned to Pope AFB, North Carolina was awarded the 2006 
Airlift Tanker Association's Specialized Mission Award. During the 
award presentation, General Duncan McNabb told the audience, ``In time 
of war, when we are doing 900 sorties a day . . . there's one 
individual who stands out above all others . . .'' While deployed, 
TSgt. McBee flew 28 missions in Iraq and Afghanistan, sometimes under 
fire, to provide critical nursing care to more than 300 wounded 
people--from special operations soldiers to children who stepped on 
land mines.
    Some of the most rewarding recognition came in the form of 
spontaneous acknowledgement from our professional colleagues. During a 
regional nursing conference, Air Force nurses Major Prudence Anderson, 
Major Wendy Beal, and Captain Charlotta Leader presented Deployed 
Military Nursing from Ground to Air; focusing on the EMEDS concept, en 
route care processes and Aeromedical Evacuation missions. As they 
concluded their presentation, there was a moment of silence followed by 
a standing ovation. ``It was an honor to represent military nursing . . 
. to be so appreciated in our community,'' they said.
                        recruiting and retention
    Nurses remain at the top of Gallup's annual poll assessing honesty 
and professional ethics. However, public confidence has yet to 
translate into larger recruiting pools. In fact, a U.S. Department of 
Health and Human Services report (http://bhpr.hrsa.gov/nursing/) 
projects demand shortfalls will reach 17 percent by 2010 and 27 percent 
by 2015. Clearly, Air Force nursing will need to capitalize on every 
opportunity to recruit and retain nurses.
    In fiscal year 2006, we achieved 80 percent (281) of our total 
recruiting goal (350). This was a significant improvement over fiscal 
year 2005's 69 percent. Graduates of our scholarship programs brought 
overall accessions up to 92 percent of goal. We attribute our success 
to larger financial incentives, which combined the options of accepting 
an accession bonus and Health Professions Loan Repayment for nursing 
school loans. Our fiscal year 2006 accession bonus options were $15,000 
for a 3-year commitment or $20,000 for a 4-year commitment. We have 
increased the bonus for fiscal year 2007 ($25,000/4yrs), and are 
optimistic this will get us even closer to goal. Direct accessions 
accounted for the majority of our fiscal year 2006 recruits, but we 
also attracted new nurses via ROTC scholarships, Line of the Air Force 
(LAF) funded enlisted to BSN and Airman Enlisted Commissioning 
Programs.
    Mirroring our Sister-Services' successful enlisted commissioning 
programs, we are aggressively pursuing a specific Nurse Enlisted 
Commissioning Program. We gained LAF support for 12 student ``starts'' 
over the next 2 years, and anticipate exponential growth of this 
program for the next 5-10 years.
    As calendar year 2006 came to a close, the NC inventory was a 
gravely concerning 85 percent. We retired 166 officers and separated 
another 188, for a net loss of 354 experienced nurses. We know our 
attrition rates spike at the 4-5 year point as nurses complete their 
initial service commitment; and again at 7-9 years, when nurses face 
disparate promotion opportunity. In response, we initiated a $15,000 
critical skills retention bonus targeting nurses completing their 
initial commitment in the Air Force, and will be closely monitoring its 
impact on retention for this year group.
    Compensating for our second attrition spike will be much harder, 
but we have made progress this year. LAF acknowledged inequities in 
colonel-grade billets, and validated 100 percent of the NC position 
descriptions submitted to the Air Force Colonel Grade Review Board. As 
a result, we have conservatively estimated a 45 percent gain in NC 
colonel-grade billets over the next year.
    We are especially pleased with the increased number of validated 
master clinician billets at our larger hospitals and medical centers. 
This is significant because it will provide an avenue for some of our 
most clinically experienced senior nurses to remain in patient care 
settings without sacrificing opportunities for promotion and 
advancement. We are now a few steps closer to bringing NC promotion 
opportunity in parity with other Air Force categories constrained by 
the Defense Officer Personnel Management Act. These are tremendous 
strides for the NC, although the effect they will have upon major-grade 
and lieutenant Colonel-grade promotion opportunity is not yet clear.
                       transformation initiatives
    The Air Force Medical Service has deployed transformation 
initiatives this year using the principles of Air Force Smart 
Operations 21 (AFSO21). The primary goal of AFSO21 is to eliminate 
redundant processes that compete against priority missions for time, 
manpower, and money. In 2006, the Air Force Medical Service became the 
first DOD service to align with the Accreditation Association for 
Ambulatory Health Care, Inc. (AAAHC) for surveys of our ambulatory care 
clinics. Our partnership with The Joint Commission continues for 
surveying our inpatient facilities. In the words of our senior 
healthcare inspector, ``Our new partnership with AAAHC will allow us to 
significantly integrate (military) inspections and accreditation 
findings in our reports . . . while reducing duplication of effort . . 
. a great example of AFSO21 principles at work.''
    The 39th MDG at Incirlik AB, Turkey provided another example. They 
applied AFSO21 strategies to their Medical Right Start Program, an Air 
Force medical service wide process of enrolling beneficiaries into the 
local health care system upon arrival to a new duty station. They 
streamlined their process by relocating all points of service to a 
central location at their Military Treatment Facility (MTF) and 
scheduling all Right Start Orientation enrollment activities on a 
single day. They estimate annual savings of $106,000 and 1,630 duty 
hours by implementing these customer-focused process improvements.
    By far, the most challenging initiative has been the conversion of 
military positions to civilian equivalents needed to support a leaner 
military medical force posture. The Air Force nursing services civilian 
inventory includes more than 1,000 nursing personnel in advanced 
practice, licensed and paraprofessional roles. Nationally, the demand 
for nursing personnel far exceeds the supply, creating a competitive 
market that favors qualified candidates. In 9 months of active 
recruiting, we have hired 11 nurse practitioners and nurse specialists, 
59 clinical nurses, and 41 paraprofessional nursing personnel (Licensed 
Practical Nurses (LPNs), Emergency Medical Technicians and Operating 
Room (OR) technicians). Although we hired 86 percent of the clinical 
nurses programmed for fiscal year 2006, we were significantly less 
successful with other civilian hires, especially LPNs and OR 
technicians. Through active recruiting, hiring bonuses where warranted, 
and use of direct hire authority, we are cautiously optimistic about 
reaching our fiscal year 2007 goal of accessing 211 additional civilian 
nursing personnel.
                            joint endeavors
    Our International Health Specialty Nurses organized several 
important initiatives supporting the goals of Theater Security 
Cooperation. Among them, was a bilateral project to enhance the 
infection control capability of nurses serving in the Vietnam (VN) 
military. Facilitated by the Center of Excellence (COE) for Disaster 
Management and Humanitarian Assistance and funded through Presidential 
Emergency Plans for AIDS/HIV Relief (PEPFAR), this project builds upon 
previous U.S.-VN military nursing exchanges. During the first phase of 
this project, VN nurses will travel to Wichita Falls, Texas for 
didactic training at Sheppard AFB and then transition to Tripler Army 
Medical Center (TAMC) for clinical experience. A total of eight VN 
nurses will be trained; with the first two scheduled to begin in March. 
The second and third phases involve U.S. nurses traveling to VN to 
assist newly-trained VN nurses with Infection Control Program 
implementation at their four largest military hospitals. The University 
of Hawaii, College of Nursing collaborated with DOD and COE partners to 
develop the educational framework and gather supporting data. This 
project meets Theater Security Cooperation goals of capacity building, 
building competent coalition partner, interagencies, interoperability, 
access, and influence.
    A joint capital venture between the 1st MDG at Langley AFB, 
Virginia and the Naval Medical Center Portsmouth is underway. This 
venture establishes a Special Care Nursery at Langley AFB that accepts 
transfers of moderately ill neonates from the Naval Medical Center 
Portsmouth, thus enabling them to preserve bed-space for more critical/
acutely ill neonates. This partnership will allow beneficiaries to 
continue care within the Military Health System, a benefit to both 
medical facilities and their patient population.
    Air Force nurses actively participated in monthly System-wide 
Trauma Continuum of Care video teleconferences in 2006. The 
complexities of issues addressed were astounding, and included 
standardizing pressure-related baldness and skin ulceration 
surveillance and prevention, managing complex pain issues during en 
route care, standardizing burn management and resuscitation 
documentation, reducing mortality and morbidity associated with under/
over fluid resuscitation, and reducing ventilator-associated 
pneumonias. This world-wide, DOD/Veterans Affairs performance 
improvement forum, facilitated successful outcomes and improved quality 
of life and functionality for recovering global war on terrorism 
casualties.
    Twenty-four medics from the 52nd MDG, Spangdahlem AB, Germany 
deployed to Tamale, Northern Ghana where they joined 22 Ghanaian 
military medical staff for MEDFLAG 06. Operations required extensive 
interoperability. Participants gained experience in deploying to 
austere locations, interacting with host nation military and 
governmental organizations, observing/understanding local customs, 
integrating healthcare teams of multiple specialties and several units/
Service components, procuring supplies and equipment, and reallocating 
personnel and resources to meet changing mission requirements. Everyday 
at sunrise, teams loaded supplies and convoyed to villages where 
thousands stood waiting for medical, dental and optometry care. Over 
3,200 patients received care in just 4 days, and U.S. medical personnel 
were able to learn about, see and treat a myriad of chronic and 
tropical diseases rarely seen in the United States. A letter of 
appreciation signed by Pamela Bridgewater, U.S. Ambassador to Ghana, 
summed up the impact made by our medics, ``In my many years of Foreign 
Service I can think of no other time that I was so proud to be an 
American than on my visit to the MEDFLAG sites in the Northern Region. 
. . . I (saw) first-hand the professionalism of U.S. (military) 
personnel and the strong ties of cooperation fostered in a short period 
of time. I (directly) witnessed the positive effect that the U.S. 
military presence had on the population of that deprived region. This 
is truly a case where we are winning the hearts and minds just by being 
who we are and doing what we do so well, helping others.''
                                research
    Our patients have benefited from cutting edge research conducted by 
Air Force nurses, particularly in the realm of operational clinical 
readiness. Colonel Peggy McNeill, an Air Force doctoral student, is 
examining the performance of medical aircrew in a simulated military 
aircraft cabin environment. CCATTs provide intensive specialty care to 
nearly 10 percent of the global war on terrorism casualties transported 
on military cargo aircraft, and yet we have limited understanding of 
how in-flight stressors impact medical aircrew and affect their 
cognitive and physical performance on long Aeromedical Evacuation 
missions. Her findings will enhance patient outcomes by maximizing 
operational performance of medical personnel in the Aeromedical 
Evacuation environment.
    Due to the nature of their injuries and stressors of flight, combat 
casualties are at high risk for having an inadequate supply of oxygen 
in their blood. Traditional methods of monitoring for this complication 
are not possible with combat casualties experiencing severe burns, 
amputations, decreased body temperature, or massive swelling. Research 
being conducted by Lieutenant Colonel Marla DeJong will provide 
clinicians with valuable information about the ability of specialized 
monitoring devices to provide more accurate patient assessment data 
needed to care for acutely and critically ill patients in flight.
    Lieutenant Colonel Karen Weis, a graduate of Air Force-sponsored 
doctoral education, studied the impact of deployment on psychosocial 
experiences of pregnancy. Her findings indicated effective maternal 
identification, or pregnancy acceptance, was dependent upon the 
husband's presence in the first and early second trimesters of 
pregnancy. As a result, an evidence-based program has been developed to 
provide timely family support to pregnant military wives with deployed, 
or deploying, husbands.
    Air Force nurses received generous financial support from the Tri-
Service Nursing Research Program (TSNRP) to conduct the type of 
research just described. In addition to research studies, the TSNRP 
Resource Center funded the creation of an operational pocket guide for 
nurses. Designed as a concise reference for deployed nurses, it 
contains the most current evidence-based practice recommendations for 
operational health care. Topics range from critical care of blast 
victims to psychological first aid and culturally appropriate pain 
assessment and management.
            base realignment and closure (brac) integration
    Air Force nurses are working alongside Sister-Service colleagues to 
achieve functional nursing integration. Here in the National Capital 
Region, Air Force critical care nurses assigned to Andrews AFB, 
Maryland are now augmenting staff at Walter Reed Army Medical Center. 
BRAC integration is affording Air Force nurses additional opportunities 
to maintain operational currency in complex patient care platforms, 
while serving the needs of critically ill and injured military heroes 
and their families.
    In San Antonio, we are moving forward with plans to relocate 
enlisted medical basic and specialty training to a Tri-Service Medical 
Education and Training Campus (METC) at Fort Sam Houston. METC will 
capitalize on synergy created by co-located training programs. We have 
fiercely protected our Community College of the Air Force degree 
granting to Air Force students, and are exploring the feasibility of 
extending authority to our Sister Services.
    The Air Force Surgeon General Consultants for nursing specialties 
are working with their Tri-Service counterparts to solidify scopes of 
practice that reflect nursing care in joint environments. The Nurse 
Consultants are incorporating Service-specific requirements and 
civilian benchmarks to establish a single scope of practice for each 
specialty, thereby easing transition into joint units and providing 
nurses with a clear understanding of their roles and responsibilities.
                             our way ahead
    For the past year, I have connected with nursing leadership teams 
at every one of our military treatment facilities; learning more about 
their mission priorities, challenges, and concerns. These conversations 
have assured me Air Force nursing stands ready for the exciting and 
challenging events ahead.
    Mister Chairman and distinguished members of the committee, it is 
my honor to be here today representing nearly 18,000 men and women that 
make up our Total Nursing Force. Thank you for the considerable support 
you have given us this year and thank you for inviting me to tell our 
story.

    Senator Inouye. And now may I call upon Admiral Bruzek-
Kohler. Admiral.
STATEMENT OF REAR ADMIRAL CHRISTINE M. BRUZEK-KOHLER, 
            DIRECTOR, NAVY NURSE CORPS, DEPARTMENT OF 
            THE NAVY
    Admiral Bruzek-Kohler. Good morning, Chairman Inouye, 
Ranking Member Stevens, and distinguished members of the 
subcommittee. It is an honor and privilege to speak to you 
again about our 4,100 outstanding Active and Reserve Navy 
nurses and the selfless contributions they make in operational, 
humanitarian, and traditional missions at home and abroad. My 
written statement has already been submitted for the record, 
and I'd like to highlight just a few of those key issues.
    Amidst the Nation's nursing shortage and the continuation 
of what is now 5 years of our engagement in Operations Iraqi 
and Enduring Freedom, I am proud to say we are projected to 
meet our direct accession goals for the first time in 4 years. 
This success can be attributed to our increased recruiting 
efforts, attendance at a diverse range of nursing conferences, 
but most importantly, because we stress that every Navy nurse 
is a Navy recruiter.
    As a result, we have recently made a request to increase 
our direct accession opportunities. This increase will help 
fortify the healthcare assets which support the deployment of 
additional soldiers and marines as recently requested by our 
Commander in Chief.
    Throughout our career continuum, our Navy nurses are 
responsive, capable, and continually ready to provide the 
finest care anytime, anywhere. Our clinical sustainment policy 
ensures our nurses are ready to deploy at a moment's notice and 
provide superior clinical care from operational platforms in 
Iraq to humanitarian missions in Southeast Asia. In our 
military treatment facilities in the United States and abroad, 
Navy nurses are at the forefront of providing comprehensive 
mental and physical care to our returning heroes.
    To address their needs, 13 deployment health clinics have 
been established across the Nation. In these clinics, a 
specialized team of nurses, providers, and allied health 
professionals ensure personnel returning from operational 
deployments receive health assessments and follow-up care. 
Naval Medical Center San Diego has created a multidisciplinary 
program that coordinates hospital assets and personnel, 
offering a wide range of medical, surgical, behavioral health, 
and rehabilitative care to those injured in the service of our 
country.
    In these settings and at many of our military treatment 
facilities, mental health nurses and nurse practitioners help 
meet the psychosocial needs of our returning personnel and 
their families. We intend to further capitalize on these 
practitioners in both the inpatient and outpatient arenas, as 
well as in operational assignments.
    Beyond our military treatment facilities, Navy nurses serve 
honorably and courageously with Navy and Marine Corps 
operational units around the globe. In 2006, Navy nurses on 
board the U.S.N.S. Mercy conducted a successful 5-month 
Southeast Asia humanitarian mission. Joining the Navy medicine 
team on this mission were medical assets from the United States 
Air Force and Army, from Canada, India, Malaysia, Australia, 
and nongovernmental organizations.
    At Landstuhl Regional Medical Center, nearly 100 Reserve 
Nurse Corps officers work alongside their Army and Air Force 
colleagues, providing lifesaving care to America's selfless and 
courageous warriors. The mental and physical stress of 
providing day-to-day nursing care to our critically wounded 
necessitates that we acknowledge the demands of our profession 
and the importance of caring for our caregiver, who may so 
often place the needs of others over self.
    Our educational programs and policies support nursing 
operational readiness, the warfighter, and provide 
opportunities for graduate level studies. These programs help 
sustain continued growth in clinical knowledge and expertise 
and improve the quality of care. Our advanced practice nurses 
from these programs are actively conducting research and 
implementing healthcare programs that directly benefit the 
active duty member and all our beneficiaries. On an annual 
basis, we shape our graduate education training program based 
on our healthcare and operational support requirements.
    Our civil service and contract nurses are integral members 
of the Navy medicine team, and their support and efforts are 
essential in ensuring we provide quality nursing to all 
entrusted to our care. We recruit and retain the very best of 
these nurses through a number of programs and initiatives, from 
the superior qualification bonus to the accelerated promotion 
program. In the last 2 years we have made great strides in 
increasing our civilian nursing workforce, and continue to 
reassess all programs to ensure we can attract the best 
qualified nurses.
    In the last year our Active and Reserve Navy nurses have 
answered the call of a grateful Nation and are proud members of 
the One Navy Medicine Team. By partnering with civilian and 
military healthcare organizations, our nurses provide the 
finest care worldwide and make a positive and meaningful 
difference in the lives of our uniform service members, their 
families, our retired heroes and beneficiaries.
    Our future requires that we align with the mission of our 
armed forces while simultaneously meeting advances in 
professional nursing practice. The uniqueness of military 
nursing is our dynamic ability to seamlessly integrate critical 
nursing specialties into compassionate care for America's sons 
and daughters, our soldiers, marines, sailors, and airmen. We 
will continue the exemplary tradition of Navy nursing 
excellence by focusing on interoperability and working 
alongside our military and civilian colleagues.

                           PREPARED STATEMENT

    I greatly appreciate the opportunity to share these 
accomplishments and issues with you, and I look forward to 
continued work as the Director of the Navy Nurse Corps. Thank 
you, sir.
    Senator Inouye. Thank you very much, Admiral.
    [The statement follows:]
     Prepared Statement of Rear Admiral Christine M. Bruzek-Kohler
                              introduction
    Good morning, Chairman Inouye, and distinguished members of the 
committee. I am Rear Admiral Christine Bruzek-Kohler, the 21st Director 
of the Navy Nurse Corps and the Chief of Staff, Bureau of Medicine and 
Surgery. It is an honor and privilege to speak to you again about our 
outstanding 4,100 Active and Reserve Navy nurses and their 
contributions in operational, humanitarian, and traditional missions on 
the home front and abroad. Over the last year, we faced numerous 
challenges from the continuing war in Iraq, and the global war on 
terrorism, to conducting overseas humanitarian missions in Southeast 
Asia. The performance of all Navy nurses, in particular our wartime 
nursing specialties of mental health, nurse anesthesia, critical care, 
family nurse practitioner, emergency medicine, perioperative, and 
medical/surgical, has been exemplary in all theaters of operations and 
healthcare settings. Navy nurses, with the support of our outstanding 
civil service and contract nurses, answered the call of duty with 
outstanding dedication and provided hope and comfort to all those in 
need.
    The primary component of success in the Navy Nurse Corps has been 
our ability to clearly articulate and demonstrate our military 
relevance. To accomplish this, our nurse leaders recently met to review 
our 2006 strategic goals and objectives and determine our way ahead for 
2007 and beyond. The outcome of this meeting resulted in the 
establishment of six priorities for Navy nursing that are specifically 
aligned with the vision and goals of the Chief of Naval Operations and 
the Surgeon General. To chart our course and navigate our achievements 
into the future, these six priorities include: Clinical proficiency to 
sustain our readiness; alignment of educational programs to meet future 
mission requirements; shaping the Nurse Corps to meet missions of the 
future; development of an executive leadership model for future Nurse 
Corps leaders; joint partnership to create a nursing productivity 
model; and implementation of a robust Nurse Corps communication 
program. Addressing each category, I will highlight our achievements 
and issues of concern.
                   readiness and clinical proficiency
    Throughout the career continuum, Navy nurses are responsive, 
capable, and continually ready to provide the finest care, ``Anytime, 
Anywhere.'' Our clinical sustainment policy ensures our nurses are 
ready to deploy at a moment's notice and provide superior clinical care 
from operational deployments in Iraq, to humanitarian missions in 
Southeast Asia. At military treatment facilities, in the operational 
theater, on humanitarian missions, and working in a joint environment, 
Navy nurses are clinically agile and trained to mission requirements. 
Working with our sister services, we continue to define scopes of 
nursing practice and competencies to ease integration and cross-
utilization within the military healthcare system.
    At our military treatment facilities at home and abroad, Navy 
nurses are at the forefront of providing comprehensive mental and 
physical care to our returning heroes. To fully address their needs, 13 
Deployment Health Clinics have been established across the country. 
Here, a specialized team of nurses, medical providers and allied health 
professionals ensure all personnel returning from operational 
deployments receive timely and thorough medical screenings and follow-
up care. For those wounded warriors returning from overseas, Naval 
Medical Center (NMC) San Diego offers a multidisciplinary program of 
care via the Comprehensive Combat Casualty Care Center. This service 
offers a wide range of medical, surgical, behavioral health and 
rehabilitative care to those wounded in the service of our country.
    Nurses in a variety of settings within the Navy are at the 
forefront of providing behavioral health, case management, and 
community health nursing. Our mental health nurses and practitioners 
are working with deployed personnel pre- and post-deployment in a 
variety of settings to ensure their behavioral needs are fully 
addressed. We are in the process of recognizing the advanced skills of 
the mental health nurse practitioners and anticipate utilizing their 
expertise as advance practice nurses in the near future. As healthcare 
systems experts, our Nurse Corps case managers liaise between civilian, 
Department of Veterans Affairs, and our military treatment facilities 
to ensure our wounded warriors have complete and rapid access to all 
their physical and behavioral health needs. Additional rehabilitative 
support comes from the Navy-Marine Corps Relief Society, whose visiting 
nurses partner with our Navy nurses in order to provide greater 
stateside services through the newly formed Visiting Nurse Combat 
Casualty Assistance Program.
    For our sailors, marines and all our beneficiaries, Navy nursing is 
proud to provide the best family-centered care. Throughout our medical 
treatment facilities, nurse led mother-baby initiatives continue to 
improve quality of life and bring deployed family members closer 
together. Naval Hospital Camp Lejeune, North Carolina opened a newly 
renovated mother-baby unit serving both Marine Corps Air Station Cherry 
Point and Marine Corps Base, Camp Lejeune. The 18 new labor and 
delivery suites greatly expand access to care and provide special 
features such as a Level II nursery for newborns who require close 
monitoring and lactation consultation for maternal support. Innovative 
family-centered nursing practice at the Mother-Infant Care Center at 
the National Naval Medical Center (NNMC) resulted in this unit being 
named the ``Best Nursing Team'' by Advance for Nurses Magazine. At the 
NNMC and Naval Hospital Camp Pendleton, deployed family members are 
afforded the opportunity to participate in the labor and delivery of 
their newborns via video and telephone conferencing. Whether at home or 
abroad, our family-centered care is the foundation of support to all 
our service members.
    Beyond our medical treatment facilities, Navy nurses continue to 
serve with pride in a variety of operational and humanitarian theaters. 
During the past year, Navy nurses from both active and reserve 
components were deployed throughout the world as members of joint 
military, humanitarian and multi-national missions. Our nurses served 
with pride in Navy and Marine Corps operational units around the globe: 
Kuwait, Iraq, Djibouti, Afghanistan, Bahrain, Qatar, Canada, Germany, 
Honduras, Peru, Indonesia, Philippines, Pakistan, Thailand, South 
Korea, East and West Timor, Vietnam, Bangladesh, Republic of Georgia 
and Guantanamo Bay, Cuba. Nursing care services for both operational 
and humanitarian missions were delivered by surgical teams, U.S. Marine 
Corps Surgical Companies, Shock Trauma Platoons, the Forward 
Resuscitative Surgical Systems, and the Enroute Care System Teams for 
casualty evacuation. In addition, care was provided in expeditionary 
medical facilities, on Navy hospital ships, aircraft carriers, 
amphibious ships, and at our military treatment facilities. At 
Landstuhl Regional Medical Center, almost 100 Nurse Corps Reserve 
officers are working side-by-side with their Army and Air Force 
colleagues giving direct care to our returning casualties.
    Providing care to the citizens of the world, our humanitarian 
missions reflect America's generosity and compassion. These efforts 
greatly enhance America's image as an ambassador of goodwill. In 2006, 
Navy nurses on board the hospital ship USNS Mercy, concluded a 5 month 
Southeast Asia humanitarian mission. In conjunction with the Navy 
medicine team, our medical personnel partnered with the U.S. Air Force, 
U.S. Army, the nations of Canada, India, Malaysia, and Australia and 
with non-governmental organizations. Together, the agencies and 
partnering countries delivered emergency/trauma, critical care, post-
anesthesia care, pediatric and medical surgical services in a mutually 
supportive environment.
    The mental and physical stress of day to day nursing care provided 
to our critically wounded uniformed personnel necessitates that we 
acknowledge the demands of our profession and the importance of balance 
and care for the caregiver. To address these demands, efforts involving 
mental health support out-reach teams, psychological injury first aid 
training, and collaborative healthcare peer support services are made 
available to all of our nurses. In addition, our nurses are encouraged 
to take advantage of all family support services and command sponsored 
morale, welfare and relief opportunities.
                    education programs and policies
    Our education programs and policies support nursing operational 
readiness, the warfighter, and provide opportunities for graduate level 
advance practice to improve quality of care at home and abroad. At our 
medical treatment facilities, our nurses are provided the very best 
clinical training environments to sustain and improve their clinical 
skills. To hone these clinical skills for operational deployment, we 
have numerous initiatives and programs to ensure their clinical 
abilities in the field are of the highest level. To guarantee continued 
growth in clinical knowledge and expertise, our graduate education 
program provides masters and doctoral level training for our Navy 
nurses. Our advance practice nurses from these programs are actively 
conducting research and implementing healthcare programs that directly 
benefit the warfighter and all our beneficiaries.
    Ensuring our nurses' clinical skills are of the highest caliber, we 
continue to utilize, reassess and seek out the best clinical training 
programs. Our robust Nurse Internship Programs at NNMC, in Bethesda, 
Maryland; and NMC Portsmouth, Virginia; and NMC San Diego, California, 
continue to provide professional guidance and mentorship to our new 
Navy and civilian nurses. We have initiated a pilot perinatal training 
program to ensure continued quality care and patient safety for our 
nurses going to overseas facilities. This program will provide our 
junior nurses the skills they need to work in the labor and delivery 
environment. We have implemented a new component for nurses developing 
critical care skills through the use of web-based training. This 
program is based on the American Association of Critical Care Nurses 
Essentials for Critical Care and coupled with bedside training, 
provides the most up-to-date clinical training for our critical care 
nurses. Certification in wound care provides our nurses with the state-
of-the-art skills to care for our trauma patients returning from 
combat.
    In addition to training within our facilities, our nurses are 
actively collaborating with our sister services to promote continuously 
improved quality clinical care. To maintain clinical proficiency, our 
nurses at U.S. Naval Hospitals in Naples and Rota have a collaborative 
staff sharing agreement with the Landstuhl Regional Medical Center. At 
Landstuhl, our nurses are able to enhance and maintain their clinical 
skills in emergency room, neonatal, mother/baby and critical care. 
Supporting joint training opportunities, NMC Portsmouth, in 
collaboration with Langley Air Force Base created a 10-week Neonatal 
Intensive Care Course that provides training to staff in anticipation 
of opening a new level II nursery at Langley. This joint project will 
expand the ability to care for pre-term infants in the Tidewater, 
Virginia area. In addition, the Navy and Air Force formed a partnership 
involving the critical care course at the NNMC. This training 
accompanied by follow on clinical rotations enabled the Air Force 
Nurses to attain critical care skills while simultaneously supporting 
the medical mission.
    Advance practice nurses at our facilities continue to improve 
quality of care through implementation of national healthcare protocols 
as well as sound nursing research findings. Several quality and patient 
safety protocols from the Institute of Healthcare Improvements were 
adopted for use in our military treatment facilities. A sampling of 
current Nurse Corps clinical research underway includes: Affects of 
Total Parenteral Fluid on the Nutritional Status of Premature Neonates, 
Efficacy of a Nurse Run Outpatient Behavioral Therapy Program, Extra-
Amniotic Balloon Insertion Comparison Study, and Affects of Healthcare 
Industry Representatives in the Operating Room.
    Beyond the military treatment facility, our nurses receive 
specialized clinical training to enhance their critical wartime nursing 
skills to provide immediate care in any operational setting. Navy 
nurses have maximized available training opportunities through the Navy 
Trauma Training Course at the Los Angeles County/University of Southern 
California Medical Center; Joint Combat Casualty Care Course in San 
Antonio, Texas; and Military Contingency Medicine/Bushmaster Course at 
the Uniformed Services University Graduate School of Nursing in 
Bethesda, Maryland. Operational training has been integrated into the 
Navy Nurse Corps Anesthesia Program and every nurse is deployment ready 
on the day of graduation. Other operational medical training programs 
Navy nurses take part in include the: Enroute Care Course, at Fort 
Rucker, Alabama, Field Medical Service Officer Course, at Camp Lejeune, 
North Carolina, and Advance Burn Life Support course provided by the 
Defense Medical Readiness Institute. Collaborating with our civilian 
medical communities, our nurses at NMC San Diego, California, maintain 
an agreement with Scripps Medical Center for trauma training in their 
emergency room.
    Navy nurses continue to support joint training opportunities in a 
variety of environments that provide the foundation for combined 
operational medicine. In Operation Northern Lights, Navy nurses helped 
support the Army's field exercise at Fort McCoy, Wisconsin, by jointly 
operating a 30-bed field hospital under simulated wartime conditions. 
In preparation for future operational and humanitarian missions, Navy 
nurses on board the hospital ship USNS Comfort, participated in an 
international medical mass casualty drill in Halifax, Nova Scotia, 
involving Canadian forces and the British Royal Navy. Supporting the 
concept of interoperability, Navy nurses in the Reserve Component have 
worked seamlessly with the Defense Medical Readiness Training 
Institute, sponsoring and teaching three major professional trauma 
programs. The programs conducted on-site at San Antonio, Texas 
included: Advanced Burn Life Support, Joint Combat Casualty Care 
Course, and Pre-Hospital Trauma Life Support. Furthermore, these were 
exported to several regional training sites to maximize participation. 
Working with our civilian and military counterparts provides Navy 
nurses important clinical training and mutual operational support 
opportunities.
    The experiences gained in the operational environment have enabled 
Navy nurses to be at the forefront of implementing the latest 
operational medicine training programs. At Navy Medicine Manpower, 
Personnel, Training, and Education Command, our nurses are part of a 
team working on the Expeditionary Medicine Web-Based Training Project. 
This web-base training will support clinical operational training and 
include combat-related medical skill and knowledge. To provide 
realistic casualty training to our forces at sea and land, 
Expeditionary Strike Group Five home-based in San Diego introduced a 
medical simulation mannequin called ``SimMan.'' Critical care nurses 
with the strike group have used this device to train key personnel on 
essential life-saving medical techniques and assessments. Navy nurses 
have been instrumental in the development of the Combat Lifesaver 
Trainers course at the Field Medical Service School. This program 
teaches select corpsmen how to train marines in life-saving skills that 
bridge the gap between basic first aid and the corpsmen.
    In addition, nursing research is actively being carried out to 
support warfighter readiness. A sampling of these studies include: 
Affects of Redeployment on Military Medical Personnel, Smokeless 
Tobacco Use Among Female Marines and Sailors Returning from Deployment, 
Coping Intervention for Children of Deployed Parents, Describing 
Chronic Disease Conditions in the Crews of Small Ships, Assessment of 
the Navy Shipshape Weight Management Program, Developing a Care for the 
Caregiver Mental Health Promotion Model, and Perceived Barriers Toward 
Emergency Contraception in Female Soldiers Deployed in Support of 
Operation Iraqi Freedom.
    Working with the civilian community, Navy nurses have provided 
integral disaster, readiness training and nursing education support. At 
Naval Health Care Clinics New England, our nurses participate and 
provide essential emergency response training with the local community. 
In the National Capital Area, NNMC nurses played an essential role in 
coordinating and collaborating with the community in the area-wide mass 
casualty drill. Given the current shortage of nursing school faculty 
across our country, we continue to provide clinical nursing experiences 
at our military treatment facilities while functioning as clinical 
nurse preceptors, educators and adjunct professors in support of 
schools of nursing throughout the country.
    Our Navy Nurse Corps graduate education programs continue to enable 
Navy medicine to improve the quality of care for our sailors, marines, 
and their families. On an annual basis, we shape our graduate education 
training plan based on our health care and operational support 
requirements. We select our most talented nurse leaders to attend 
accredited universities around the country to attain their masters and 
doctorate degrees, which has also proven to be an invaluable retention 
tool. In addition, a plethora of continuing education courses and 
specialized training opportunities are available to further enhance 
solid clinical skills.
    The Tri-Service Nursing Research Program (TSNRP) has played an 
integral role in contributing to successful patient outcomes, quality 
care, and support for the warfighter. Since its inception in 1992, 
TSNRP has supported over 300 research studies in basic and applied 
science and involved more than 700 military nurses as principal and 
associate investigators. A sample of Navy Nurse Corps studies includes: 
Clinical Knowledge Development of Nurses in an Operational Environment; 
Factors Associated with the Onset of Depression in Navy Recruits; 
Interventions to Maximize Nursing Competencies for Combat Casualty 
Care; and Research to Practice in the Military Health Care System. 
Overall, approximately one quarter of the TSNRP studies have been 
conducted by Navy nurse researchers.
    There have been numerous publications attesting to the expertise of 
our Navy nurses, noted in the American Journal of Nursing, Archives of 
Psychiatric Nursing, American Journal of Public Health, Military 
Medicine, Association of Operating Room Nurses Journal, Dimensions of 
Critical Care Nursing, Critical Care Nursing Clinics of North America, 
American Association of Nurse Anesthesia, and American Journal of 
Critical Care. In addition, Navy nurses have been invited to present 
innovative practice and research findings at the Sigma Theta Tau 
Nursing Honor Society's regional conferences, Annual Meeting of the 
Association of Military Surgeons of the United States, American 
Association of Nurse Anesthetists, American Academy of Ambulatory Care 
Nursing Convention, American Academy of Nurse Practitioner's 
Conference, and Naval Reserve Association.
    It is this personal dedication to the highest clinical proficiency 
and continuing education that makes us proud members of the military 
healthcare system. Our advance practice nurses are an integral part of 
the Navy medicine team. Continued professional development focused on 
operational medicine and evidence-based health care are key to our 
support of the warfighter as we provide the finest care to our 
uniformed service members and beneficiaries.
                             force shaping
    Maintaining the right force structure is essential to meeting Navy 
medicine's overall mission by validating nursing specialty 
requirements, and utilizing the talent and clinical expertise of our 
uniformed and civilian nurses. We are focused on our operational 
missions, and wartime specialties: nurse anesthesia, family nurse 
practitioner, critical care, emergency, mental health, medical-surgical 
and perioperative nursing. Through force shaping, we are creating the 
optimum structure for the present and the future.
    Navy Nurse Corps recruiting has often struggled in competing with 
civilian institutions and other government agencies for America's 
finest nurses. However, for the first time in 4 years we are projected 
to meet our direct accession goal. This can be attributed to the 
tireless efforts of Navy Nurse Corps recruiters, recent increases in 
our Nurse Accession Bonus, and the Health Professions Loan Repayment 
Program for recruiting. In addition, our pipeline programs continue to 
be immensely successful and are the primary recruitment source for 
future Nurse Corps officers. Our pipeline programs include the Nurse 
Candidate Program, Medical Enlisted Commissioning Program, Naval 
Reserve Officer Training Corps Program, and Seaman to Admiral Program. 
These pipeline programs are our lifeline to ensure a steady supply of 
trained and qualified Nurse Corps officers in the future and are 
critical in assisting us to maintain desired manning levels. To this 
end, the Seaman to Admiral Program has been increased in order to 
expand our enlisted personnel's opportunity to become Navy nurses. 
Overall, I am very proud of our recruiting efforts, but our retention 
of Nurse Corps officers is still of great concern.
    Retention poses a greater challenge with only 67 percent of active 
duty Nurse Corps officers deciding to remain on active duty after their 
first obligated decision point. At the end of calendar year 2006, our 
manning end strength decreased to 91 percent in the active component, 
with a deficit of 286 Navy nurses. Within our wartime specialties, 
shortfalls have been identified in the nurse anesthesia and family 
nurse practitioner communities.
    To counter these deficiencies, a number of programs and initiatives 
have been implemented. The Health Professions Loan Repayment Program 
has been extremely successful and the applicants exceeded available 
positions for the last 2 years in a row for both retention and 
recruiting. The Certified Registered Nurse Anesthesia specialty pay was 
increased to assist in retaining this critical wartime specialty. Our 
Nurse Corps recruiters, to enhance recruitment and promote diversity, 
expanded their presence at a variety of national nursing conferences: 
Association of Operating Room Nurses, Association of Critical Care 
Nurses, Emergency Nursing Association, National Black Nurses 
Association, National Association of Hispanic Nurses, and National 
Student Nurses Association. Nurse Corps officers are serving as mentors 
of our students in the Nurse Candidate and Naval Reserve Officer 
Training Corps Programs to provide professional growth while enhancing 
retention. We have also established specific identification codes to 
identify our advanced practice Nurse Corps officers with expertise as 
adult, critical care, and emergency room nurse practitioners. This 
provides military treatment facilities key data to recognize the 
professional abilities of these advanced practice nurses and to utilize 
their expertise in the role of primary care nurse practitioners. These 
identification codes further assist Navy medicine to accurately 
identify and utilize nurse practitioners in expanded operational 
assignments. Last year, we proposed a Critical Skills Retention Bonus 
for officers who entered service in fiscal year 2004 and fiscal year 
2005. We did not meet direct accession goals for these 2 fiscal years. 
The retention bonus is specifically targeted to improve retention of 
Nurse Corps officers who entered active service during these 2 fiscal 
years. In addition, I have personally written to many of the Deans of 
Nursing throughout the country outlining the benefits of a Navy career. 
Navy Nurse Corps officers are highly encouraged to utilize every 
opportunity to recruit new nurses and take on the career enhancing 
assignment as nurse recruiters. We will continue to closely monitor our 
end strength throughout the year, evaluate newly initiated programs, 
and explore other options to retain our nurses.
    In the Navy Nurse Corps reserve component, recruitment and 
retention continues to be of great concern. We continue to have 
difficulties recruiting and retaining our critical wartime specialties. 
To address this, fiscal year 2007 Nurse Accession Bonuses remain 
focused on critical wartime specialties. The Nurse Accession Bonus for 
the reserves has been beneficial in recruiting the professional nurse 
with less than 1 year of experience. To attract civilian perioperative 
nurses, we have opened our perioperative training programs in 
Jacksonville, Florida, and Camp Pendleton, California, to include 
reserve nurses. As a pipeline program, our Hospital Corpsman to 
Bachelor of Science in Nursing Program continues to be successful. With 
our increased rate of mobilizations to Landstuhl and Kuwait, and 
contributory support to our medical treatment facilities, it is 
imperative that we meet our nursing specialty requirements and explore 
all options to support our recruitment and retention efforts.
    Civil Service and contract nurses are integral members of the Navy 
medicine team and their support and efforts are essential in ensuring 
we provide quality nursing to all entrusted to our care. We recruit and 
retain the very best of these nurses through a number of programs and 
initiatives. The Direct Hire Authority from the National Defense 
Authorization Act of 2003 gives commands the flexibility to offer 
nursing positions directly to interested candidates. The Superior 
Qualifications Bonus gives commands the option to offer a higher basic 
pay rate based on exceptional experience and/or education. A 
recruitment bonus based on a percentage of their base pay and a 
relocation allowance may also be utilized. Other recruitment and 
retention tools available include Special Salary Rates, Retention 
Allowance, Student Loan Repayment Program, Tuition Assistance, payment 
for licenses/credentials, and the Accelerated Promotion Program. For 
those new to the nursing profession, we have expanded the Nurse 
Internship Program at our major naval medical centers, to include 
civilian nurses. In the last 2 years, we have made great strides in 
increasing our civilian nursing workforce and continue to reassess all 
programs to ensure we attract and retain the very best for the Navy 
medicine team.
    Our success in meeting the mission in all care environments 
requires that we continuously reassess our measures of effectiveness, 
adjust personnel assignments, and revise training plans. We continue to 
closely monitor the national nursing market environment to ensure Navy 
nursing recruiting and retention efforts remain competitive.
                         leadership development
    Leadership development begins the day our nurses take the 
commissioning oath as Navy officers and is continuously refined 
throughout an individual's career with increased scope of 
responsibilities, upward mobility, and pivotal leadership roles within 
the field of nursing and healthcare in general. Our Navy nurses are 
proven strategic leaders in the field of education, research, clinical 
performance, and health care executive management. To help prepare them 
for these roles, a variety of leadership courses are offered: Navy 
Corporate Business Course, Service War Colleges, Military Healthcare 
System Capstone Symposium, Interagency Institute for Federal Healthcare 
Executives, Wharton's Nurse Executive Fellows Program, Basic and 
Advanced Medical Department Officers Course, and the Joint Operations 
Medical Managers Course. To ensure we continue a legacy of nursing 
excellence, it is critical that we identify those leadership 
characteristics and associated knowledge, skills and abilities that are 
directly linked to successful executives in Navy medicine. A Nurse 
Corps study (Palarca, 2007), in conjunction with Baylor University, has 
identified the key leadership competencies and associated knowledge, 
skills, and abilities specific to mid-level and senior executive Nurse 
Corps officers. The competencies identified for mid-level Nurse Corps 
officers include: management; leadership; professional and personal 
development; deployment readiness and interoperability; communications; 
and regulatory guidelines. The competencies identified for senior 
executive Nurse Corps officers include: business management; executive 
leadership; professional development; global awareness and 
interoperability; communications; and personnel management. This 
information will provide the basis for ongoing leadership development 
of our mid-grade through senior executive officers as they advance in 
executive medicine.
    To meet today's challenges, nurse leaders must be visionary, 
innovative and actively engaged across joint service and other agencies 
to maximize our medical capabilities. Nurse Corps officers continue to 
reach new heights of clinical and operational leadership fulfilling 
roles as: Regional Director, TRICARE West Region; Chief of Staff, 
Bureau of Medicine and Surgery; Commanding Officer, USNS Comfort; First 
Surgical Company Commander, Iraq; Officer in Charge, Camp Doha, Kuwait; 
Commanding Officer, Coronado Battalion U.S. Naval Sea Cadet Corps; 
President, National Student Nurses Association; and commanding and 
executive officers of military treatment facilities around the world. 
Navy Nurse Corps officers have been recognized in a variety of media 
wide publications: New York Times Nurse of the Year Runner-Up, 
Washington Post Nurse of the Week, and Best Nursing Team of 2006 by 
Advance for Nurses Magazine. Within the reserve component, our 
dedicated Navy nurses are in key leadership positions in their units, 
when recalled to active duty, as well as in their civilian 
organizations, professional associations and local communities. 
Examples of key leadership positions include Deputy Commander, Navy 
Medicine National Capitol Area; Deputy Director for Navy Personnel, 
Landstuhl Regional Medical Center; commanding officers of Operational 
Health Support Units; CEOs of healthcare companies; administrators of 
hospitals; directors for nursing services; and faculty positions in 
colleges of nursing. Navy nursing remains committed to creating an 
environment which enhances leadership opportunities for tomorrow's 
future senior healthcare executives.
                              productivity
    Increasing healthcare costs, coupled with balancing higher patient 
acuities with available nursing resources, requires accurate and 
efficient management of our manpower assets. To address this we are 
taking steps to maximize our nursing human resources. In San Diego, 
California, a nurse-managed Pediatric Sedation Center was established 
for those procedures that normally required the main operating room. 
This initiative reduced main operating room utilization and provided a 
more pleasant environment for those families requiring the service of 
the Pediatric Sedation Center. In Quantico, Virginia, the nurse-run 
Wound Clinic instituted several nurse-focused standard operating 
procedures to address ailments that would otherwise require physician 
intervention. In Camp Lejeune, North Carolina, the branch medical 
clinic sends nursing personnel directly to the School of Infantry to 
address healthcare issues on-site versus requiring medical clinic 
visits. In Portsmouth, Virginia, nurses from the local reserve unit 
have performed over 84,000 man hours of operational and clinical 
support over the last 27 months. This constituted a cost savings of 
over $4 million to NMC Portsmouth.
    To maximize the identification of nursing productivity, a Tri-
Service Patient Acuity Scheduling System Working group has been formed. 
The purpose of the group is to develop business strategies for 
inpatient and outpatient acuity assessment and scheduling; and to 
develop a military healthcare system information technology to 
transform and standardize the methodology for capturing, reporting, and 
communicating patient acuity, staff scheduling, and productivity across 
the services. The Navy Nurse Corps, with our sister uniformed services, 
continues to seek out the most effective productivity models to 
maximize our healthcare resources.
                             communication
    Communicating through a comprehensive plan ensures all reserve and 
active Nurse Corps officers receive the most accurate, timely, and 
official information. A team of 24 active and reserve Nurse Corps 
officers coordinated and created a comprehensive set of Nurse Corps 
communication modalities: Nurse Corps web-page, weekly newsletter, 
monthly video-teleconferencing, Nurse Corps news update, Nurse Corps 
email database, bi-monthly senior Nurse Corps officers update, and 
semi-annual all Nurse Corps Admiral's Call. The aggressive 
implementation and the coordination of these modalities resulted in a 
greater awareness of the many beneficial programs we have for Nurse 
Corps officers. For example, our successful Health Professions Loan 
Repayment Program had a significant increase in the number of 
applicants this past year because of our ability to ``get the message 
out'' efficiently and expeditiously. By streamlining the communication 
process, synchronizing the methodology of delivery, and tapping into 
the latest technology we have seamlessly connected the Navy Nurse Corps 
around the world.
    Beyond the Navy Nurse Corps, we continue to actively communicate 
with our uniformed and civilian counterparts. At the monthly Federal 
Nursing Service Council meeting, the nursing leadership of the Army, 
Navy, Air Force, Public Health Service, Department of Veterans Affairs 
and the American Red Cross meet to discuss the challenges facing our 
respective organizations. Furthermore, the Nurse Corps Chiefs of the 
other uniformed services and I meet regularly to address our common 
military nursing issues and opportunities to partner jointly on 
resolutions. Joint operations, cooperation, and communication are the 
foundation for future success in providing the highest quality of care 
for all our beneficiaries.
                            closing remarks
    In the last year, our active and reserve Navy nurses have answered 
the call of a grateful Nation and are proud members of the One Navy 
Medicine Team. By partnering with civilian and military health care 
teams, our nurses provide the finest care worldwide and make a positive 
and meaningful difference in the lives of our uniformed service 
members, their families, our retired heroes, and beneficiaries. The 
basis of our future requires that we align with the mission of our 
armed forces while adapting to the advances in professional nursing 
practice. The uniqueness of military nursing is our dynamic ability to 
seamlessly integrate the critical nursing specialties into the 
healthcare needs of soldiers and marines on the field, and our sailors 
at sea. We continue the exemplary tradition of Navy Nursing Excellence 
by focusing on interoperability and working side-by-side with our 
military and civilian colleagues.
    I appreciate the opportunity of sharing the accomplishments and 
issues that face Navy nursing. I look forward to continuing our work 
together during my tenure as Director of the Navy Nurse Corps.

    Senator Inouye. And now may I call upon General Pollock.
STATEMENT OF MAJOR GENERAL GALE S. POLLOCK, DEPUTY 
            SURGEON GENERAL, U.S. ARMY, AND CHIEF, ARMY 
            NURSE CORPS, DEPARTMENT OF THE ARMY
    General Pollock. Aloha, Mr. Chairman, and distinguished 
members of the subcommittee. It is again my great honor and 
privilege to speak before you today on behalf of the nearly 
10,000 officers of the Army Nurse Corps. It is your continued, 
unwavering support that has enabled Army nurses to provide the 
highest quality care for our soldiers and their family members.
    Our vision of advancing professional nursing and 
maintaining leadership in research, education, and the 
innovative delivery of healthcare is at the forefront of all we 
do. Army nurses serve in clinical and leadership roles in 
medical treatment facilities in the United States and abroad, 
in combat divisions, forward surgical teams, combat stress 
teams, civil affairs teams, combat support hospitals, and 
coalition headquarters.
    We have transitioned the Army community health nurse to the 
Army public health nurse, a role that is necessary as we face 
future threats within our homeland and theaters of operation. 
These nurses now support combat theaters of operations in civil 
affairs and the rebuilding of healthcare infrastructure.
    Our transition to the psychiatric nurse practitioner role 
makes these nurses critical to the support of our soldiers in 
theater as well as and their families following deployment. In 
addition, these psychiatric nursing specialists either lead or 
support programs related to post-traumatic stress management 
and the reintegration of soldiers and families.
    Our family nurse practitioners are filling critical roles 
during deployments, proving themselves as significant force 
multipliers. Their performance has validated their 
interchangeability as primary care and trauma providers.
    We have also moved forward with the registered nurse first 
assist perioperative subspecialty. Incorporating the registered 
nurse first assist into our structure enhances our ability to 
recruit and retain perioperative nurses, and sustains our 
clinical experience base while offering nurses an expanded role 
within the perioperative clinical nursing specialty.
    Combat operations provided many lessons learned, 
particularly the need for early trauma training for all of the 
AMEDD team. The trauma nursing core course sponsored by the 
Emergency Nurses Association continues to be the standard for 
training for new Army nurses, and serves as a refresher during 
predeployment training for all nurses. We also provide the 
advanced burn life support course in the captains career 
course.
    From the beginning of combat operations in Iraq, Army 
nurses transported severely wounded patients by air within 
theater. Although they performed superbly, most had little or 
no training in aviation medicine or enroute care. Therefore, we 
developed the joint enroute care course to provide concise, 
realistic, and relevant trauma transport team training to all 
AMEDD personnel.
    Always one of our successes, the U.S. Army graduate program 
in anesthesia nursing once again ranked second in the Nation. 
However, I remain concerned about the nursing shortage which is 
affecting not just anesthesia nursing but all of our advanced 
nursing specialties.
    Starting in January 2006, new graduates assigned to Tripler 
Army Medical Center completed a Nurse Internship Program. They 
were assigned to a home room nursing unit, and over the next 6 
months were scheduled for rotations that exposed them to 
medicine, surgery, critical care, emergency rooms and trauma, 
psychiatry, pediatrics, and labor and delivery.
    The Tri-Service Nursing Research Program which you 
established in 1992 is a truly successful program. Army nurse 
researchers, in collaboration with their Navy and Air Force 
colleagues, are actively involved in the Tri-Service Nursing 
Research Program's Center of Excellence in Evidence-Based 
Nursing Practice. I hope that the current lack of funding will 
be corrected.
    While the AMEDD team continues to provide quality health 
care, its members work to advance healthcare delivery systems 
in countries around the world. The Army nurses assigned in 
Afghanistan spearheaded an initiative to teach local Afghan 
doctors and nurses state-of-the-art techniques in providing 
perioperative surgical and nursing care. Nurse practitioners at 
the 121 Combat Support Hospital in Korea support Korean 
advanced practice nursing students by providing observational 
experiences to students as part of their clinical rotations. We 
remain an extremely busy corps, participating in joint military 
nursing endeavor programs in Vietnam, Kuwait, and the Kingdom 
of Saudi Arabia.
    A competitive civilian market and current operational 
demands cause all of the challenges that we face to exacerbate 
the shortage of nurses and nursing educators. Currently I have 
a deficit of 254 officers, primarily in the company grades and 
in critical specialties such as anesthesia, critical care, 
perioperative, and OB/GYN nursing. We are constantly monitoring 
the status of our recruiting and retention efforts.
    A recent review of personnel records by the Department of 
the Army indicated that the Army Nurse Corps has the highest 
attrition rate of any officer branch in the Army. Ongoing 
research indicates that Army nurses leave the service primarily 
because of the length of deployment and the absence of 
specialty pay.
    For Reserve component nurses, my primary concern is the 
imbalance of professionally educated officers in the company 
grades. So many of them are prepared at the associate degree or 
diploma level that over the past few years only 50 percent are 
educationally qualified for promotion or leadership. We are 
grateful that the Chief of the Army Reserve is focusing 
recruitment incentives on those nurses educated at the 
baccalaureate level and funding the Specialized Training and 
Assistance Program for their BSN completion.
    We continue adapting to the new realities of this long war, 
but remain firm on providing the leadership and scholarship 
required to advance the practice of professional nursing. We 
will maintain our focus on sustaining readiness, clinical 
competency, and sound educational preparation, with the same 
commitment to serve those service members who defend our Nation 
that the Army Nurse Corps has demonstrated for the past 106 
years.

                           PREPARED STATEMENT

    Again, thank you for the opportunity to appear before you 
today. I look forward to your questions.
    Senator Inouye. Thank you very much, General Pollock.
    [The statement follows:]
          Prepared Statement of Major General Gale S. Pollock
    Mr. Chairman and distinguished members of the committee, it is 
again an honor and great privilege to speak before you today on behalf 
of the nearly 10,000 officers of the Army Nurse Corps. The Army Nurse 
Corps is today 106 years Army strong. It has been your continued 
unwavering support that has enabled Army nurses, as part of the larger 
Army Medical Department (AMEDD) team, to provide the highest quality 
care for our soldiers and their family members.
                               deployment
    The Army Nurse Corps remains fully engaged in our Nation's defense 
and in support of its strategic goals. Our vision of advancing 
professional nursing and maintaining leadership in research, education, 
and the innovative delivery of healthcare is at the forefront of all we 
do. Army nurses provide expert healthcare in every setting in support 
of the AMEDD mission and the military health system at home and abroad. 
There are currently over 400 Army Nurse Corps officers from all three 
components deployed in support of operations in 16 countries around the 
world. From April 2006 to March 2007, we deployed over 560 Army nurses 
for a total of 204,009 man-days in a hazardous duty area. We mobilized 
an additional 1,616 Army Reserve Nurses in support of the total AMEDD 
mission, deploying 181 to Iraq and Afghanistan. They serve in clinical 
and leadership roles in medical treatment facilities in the United 
States and abroad, in combat divisions, forward surgical teams, combat 
stress teams, civil affairs teams, combat support hospitals (CSHs), and 
coalition headquarters.
    Today, the 28th CSH from Fort Bragg, North Carolina; the 21st CSH 
from Fort Hood, Texas; and the Army Reserve's 399th CSH from 
Massachusetts are deployed to Iraq. The 14th CSH from Fort Benning, 
Georgia has just redeployed from Afghanistan. The 31st CSH from Fort 
Bliss, Texas arrived in theater early this year to replace the 21st 
CSH. While these units deploy, others are being sourced, equipped, 
manned, and trained to sustain the ongoing mission in support of the 
global war on terror.
             transformation/advancing professional nursing
    The Army Nurse Corps continues the process of self-examination and 
transformation to maintain the competencies required to face the 
complexities of health care in the 21st century. Last year, I described 
a few of the initiatives that we have pursued and I want to provide you 
an update.
    We have made great strides in transitioning the Army community 
health nurse to the Army public health nurse role--one that is 
necessary as we face future threats within our homeland and theaters of 
operation. The curriculum for the Army public health nurse has been 
modified to include public health officer roles and responsibilities, 
training in epidemiology, and the management of large population groups 
in the event of a pandemic or major disaster. In addition, the 
curriculum details the role of the Army public health nurse in combat 
theaters of operations to include civil affairs and the rebuilding of 
healthcare infrastructure. At the graduate nursing level, Army public 
health nurses will be directed to programs offering either a Master's 
in Public Health, such as the Uniformed School of Health Sciences 
(USUHS) or to civilian institutions offering a Public Health Nursing 
graduate degree.
    While we have only recently transitioned to the psychiatric nurse 
practitioner role, with our first group of nurses attending graduate 
school beginning in 2006, our psychiatric clinical specialists have 
been critical to the support of our soldiers in theater as well as 
soldiers and their families following deployments. Since March of 2006, 
five psychiatric nurse clinical specialists have deployed in place of 
clinical psychologists and all have performed spectacularly. On our 
installations, the clinical specialists have either led or participated 
in programs related to post traumatic stress management and in the 
reintegration of soldiers and families.
    Our family nurse practitioners (FNP) continue to be a valued asset 
of the AMEDD team. They are filling critical roles during deployments, 
proving themselves to be a significant force multiplier. In addition to 
providing outstanding primary care across our facilities, they have 
taken on provider roles within the Brigade Combat Teams at level II. 
Last year, 19 FNP's deployed in place of physician assistants. Their 
performance has validated their interchangeability as primary care and 
trauma providers. More recently, three FNP's were assigned to support 
special operations missions around the world.
    To ensure that our nurse practitioners have the skills to 
transition from academia into practice, we have incorporated a post 
graduate preceptorship program for new graduates. We also began putting 
nurse practitioners through advanced trauma training programs prior to 
deployment ensuring they have the necessary skills to function in their 
advanced practice roles. In addition, we put one of our family nurse 
practitioners, CPT Ida Montgomery through the Army flight surgeon's 
course at Fort Rucker, Alabama.
    We are also continuing to strategically move forward with the 
registered nurse first assist (RNFA) perioperative subspecialty. The 
RNFA expands the scope of practice of the perioperative nurse to 
function as first assistants to the surgeon in the operating room, 
optimizing the utilization of general surgeons. During times of war, 
the RNFA can provide enhanced capabilities to the forward surgical 
team, the CSH, and be a major contributor to the successful outcomes of 
military surgeries during combat operations. Incorporating RNFAs into 
our structure also enhances our ability to recruit and retain 
perioperative nurses. Historically, perioperative nurses sought 
advanced education in roles unrelated to the perioperative arena due to 
a lack of advanced opportunities in that field. With the RNFA, we can 
preserve our clinical experience base while offering nurses an expanded 
role within the Perioperative Clinical Nursing Specialty. Our 
perioperative nursing consultant, Col. Linda Wanzer, has incorporated 
this training into the Perioperative Clinical Nurse Specialists program 
at USUHS. The current inventory of Army nurses trained as first assists 
is 14. There are currently three RNFA students enrolled in USUHS and 
three completing their internship. In the past year, five RNFA's have 
deployed in support of contingency operations as advanced practice 
Perioperative Clinical Nurse Specialists.
    I am proud of the entire AMEDD team caring for the wounded warriors 
along the entire medical evacuation continuum. Another area in which we 
continue to advance professional nursing practice is in the area of 
case management. A world-class nurse case management model assures the 
seamless transitioning of our soldiers from the battlefield to home. 
There are currently 2,204 medical hold soldiers assigned to military 
medical treatment facilities and another 1,431 assigned to community 
based health care organizations. Today there are 272 nurse case 
managers assigned throughout the AMEDD health care system providing 
inpatient and outpatient care of our active duty, medical hold 
soldiers, retirees, and dependents. Reports from the field indicate 
that case managers are effectively and efficiently coordinating 
appropriate and quality health care for this population of ill and 
injured soldiers. Soldiers report high satisfaction regarding their 
case managers and prefer to have Army nurses manage their health care. 
With such demonstrated successes, we are developing and implementing 
strategies for the preparation of our new RN case managers to meet the 
special needs of our soldiers. We are also standardizing case 
management practices and documentation across the AMEDD and helping 
with the implementation of Veterans Administration and Department of 
Defense (DOD) clinical practice guidelines that will enhance the 
collaboration of medical, nursing, and other specialties as well as 
standardize best practices.
    As the Army works to rebalance its forces, we are also working to 
adapt to the circumstances of this long global war on terror. We are 
rapidly applying lessons learned and developing training to ensure we 
provide the best care across the health care continuum. At the AMEDD 
Center and School, the Department of Nursing Science has incorporated 
those lessons into all courses offered to Army nurses, licensed 
practical nurses (LPN), and combat medics. We have had a number of 
other successes in both ongoing and new initiatives that I would like 
to share with you.
    The U.S. Army Graduate Program in Anesthesia Nursing once again 
ranks second in the Nation. We are equally proud of the USUHS 
Registered Nurse Anesthesia Program. However, I remain concerned about 
the crisis that continued shortages of certified registered nurse 
anesthetists (CRNA) presents to the AMEDD. We are moving ahead and 
increasing enrollment in the U.S. Army Graduate Program in Anesthesia 
Nursing (USAGPAN), and working on issues related to their retention. 
The largest class in the program's history of 43 Army students will 
start in June 2007. To accommodate this class and assure sustained 
throughput, four new civilian faculty members were added to the 
didactic phase of the course at the AMEDD Center and School. Each of 
the clinical locations now have a military director and civilian deputy 
director in order to maintain fidelity in training when directors 
deploy.
    Combat operations over the past 5 years have provided many lessons 
learned, and probably none more important than the need for early 
trauma training for all of the AMEDD team. Trauma rotations are now 
mandatory for all students in the Graduate Anesthesia Program. The 
Trauma Nursing Core Course (TNCC) sponsored by the Emergency Nurses 
Association continues to be the standard for training new Army nurses 
during the Officer Basic Leaders Course. In 2006, 292 entry level 
nurses were trained in all aspects of trauma care lead by Ltc. Anthony 
Bohlin. The course teaches the principles of optimal care of the trauma 
patient and how that care is best accomplished within a systematic team 
framework. In addition TNCC has also become a standard part of pre-
deployment training for all nurses.
    With significant burn injuries being seen in both Iraq, 
Afghanistan, as well as during humanitarian operations last year in 
Pakistan, we have identified the requirement for advanced burn care 
training for our teams. In response, the Department of Nursing Science 
at the AMEDD Center and School integrated the Advanced Burn Life 
Support (ABLS) Course into the Captains Career Course. The course 
designed for physicians, nurses, physicians assistants, nurse 
practitioners, therapists, and paramedics provides guidelines in the 
assessment and management of the burn patient during the first 24 hours 
post injury. The first class will take place in May 2007 for 
approximately 130 Army nurses of all specialties providing this 
advanced skill set to seasoned clinicians. The ABLS course has also 
been identified as a critical course for all clinicians deploying to 
theater.
    Providing nursing care in austere environments has been the 
cornerstone of Army nursing. The art of field nursing has been 
integrated into every major course taught at the AMEDD Center and 
School. During fiscal year 2006, upgraded field medical equipment was 
purchased for the Camp Bullis training site. The result is students 
training on equipment identical to that which they will encounter in 
the theater of operations. This not only enhances their competency but 
also strengthens their confidence in the field technology ultimately 
providing better care to our ill and injured soldiers.
    From the beginning of combat operations in Iraq, nurses have 
transported severely wounded patients by air within theater. They 
performed superbly, but most had little or no training in aviation 
medicine or enroute care. During Operation Iraqi Freedom rotations IV-
VI there were 450 critical care transport missions from two hospitals 
in Iraq. To assure that the Army provided appropriate training to 
medical attendants, the U.S. Army School of Aviation Medicine Fort 
Rucker, Alabama developed the Joint Enroute Care Course. The purpose of 
the course is to provide concise, realistic, relevant enroute trauma 
transport team training to flight medics, registered nurses, physician 
assistants, and physicians. Since the program opened in June 2006, 
approximately 77 Army nurses have completed the training. We expect 
three more iterations of the course this fiscal year to train an 
additional 105 medical personnel. To enhance exposure to patients' 
requirements during medical evacuation, the Department of Nursing 
Science has integrated aspects of this course into programs at the 
AMEDD Center and School.
    As reported last year, the Department of Nursing Science at the 
AMEDD Center and School broke ground for a new general instruction 
building which is scheduled to open in July 2007. The $11.1 million, 
55,000 square foot building, named in honor of Brigadier General 
Lillian Dunlap, 14th Chief of the Army Nurse Corps, will house all four 
branches of the Department of Nursing Science; the U.S. Army Practical 
Nurse Branch, the Operating Room Branch, the Army Nurse Professional 
Development Branch, and U.S. Army Graduate Program in Anesthesia 
Nursing Branch.
    The training of enlisted medical personnel is a critical mission of 
the AMEDD Center and School and we continue to update and improve the 
educational processes and curriculum. The Surgical Technologist (68D) 
Program is a 19-week course preparing entry level operating room 
technicians. Previously, students are trained for 9 weeks at the AMEDD 
Center and School and were sent to 1 of 23 locations for hands-on 
clinical training. To improve the quality and standardize the training, 
the number of clinical sites has been reduced to 14 to include a newly 
forged partnership with the San Antonio VA Medical Center. This 
reorganization of the training process has markedly improved 68D 
training by increasing the number of dedicated faculty across fewer 
locations.
    The Surgical Technologist Branch continues to work on the Inter-
Service Training Review to conduct an analysis of Army, Air Force, and 
Navy commonalities in training surgical technologists. The goal in 2007 
is to explore the mechanisms for certification of students with this 
specialty. The 68D Branch also conducted a rapid train-up program for 
USAR 68D's preparing for deployment and is producing a distance 
learning program to assist in pre-deployment training.
    I remain fully committed to making sure we smoothly transition our 
new Army nurses into the organization and clinical practice. It is 
demonstrated very clearly in the professional literature and from 
feedback from our officers that a solid orientation and preceptorship 
are directly linked to, clinical skill development, job satisfaction, 
and ultimately retention. We continue to work towards the establishment 
of an enhanced new graduate internship program across the Army. In the 
meantime, some facilities have changed how new nurse graduates are 
indoctrinated by incorporating feedback from redeploying nurses and 
including an array of clinical experiences within the first year to 
maximize clinical skill acquisition. Starting in January 2007, new 
graduates assigned to Tripler Army Medical Center complete a nurse 
internship program overseen by Ms. Shelia Bunton, Ltc. Patricia 
Wilhelm, and Ltc. Mary Hardy. They are assigned to a ``home room'' 
nursing unit and over a 6-month period are scheduled for rotations that 
expose them to medicine, surgery, critical care, emergency/trauma, 
psychiatry, pediatrics, and labor and delivery. The first 12 officers 
will graduate from the inaugural internship in June 2007 with a much 
more rounded clinical skill sets.
    The national nursing shortage and unprecedented nursing staff 
turnover have required us to examine our care delivery model and 
processes to continue to achieve quality clinical outcomes. In a Bureau 
of Labor Statistics report dated February 2004 indicated that the 
production of new registered nurses is not keeping pace with nurse 
retirements and the aging nursing workforce. Total job openings which 
include both job growth and replacement of nurses will produce 1.1 
million nursing job vacancies by the end of the decade. Based on these 
statistics, a group of senior Nurse Corps leaders and civilians from 
across the AMEDD are examining and piloting a relationship based 
nursing care model that focuses on patient and family centered care, 
Registered Nurse led teams, clearly defined nursing roles and 
responsibilities, education, experience, and the scope and standards of 
nursing practice. The initial pilot began in January of 2007 at Tripler 
Army Medical Center and is expected to become a model for the delivery 
of nursing care across the Army regardless of the team, facility, or 
region in which nursing care is being delivered.
    Evidenced-based practice is the process by which nurses use the 
body of knowledge to develop best nursing practices based on clinical 
outcomes. Army nurse researchers, in collaboration with their Navy and 
Air Force colleagues, are heavily vested in the TriService Nursing 
Research Programs' Center of Excellence in Evidenced-Based Nursing 
Practice. Projects to bring research findings to the bedside are 
underway at Walter Reed, Brooke, Madigan, and Tripler Army Medical 
Centers. These projects are part of a larger effort to improve patient 
outcomes and reduce costs by standardizing care. They teach nurses how 
to critique research and incorporate the relevant findings into patient 
care. Nurses involved in these projects increase their knowledge, 
become motivated to further their education, and are becoming involved 
in research projects, much earlier in their careers.
    Tripler Army Medical Center and Martin Army Community Hospital at 
Fort Benning, Georgia were selected as test sites by the DOD Patient 
Safety Center to establish rapid response teams (RRT). The purpose of 
the teams is to provide critical care nursing and respiratory therapy 
teams to assess patients exhibiting early clinical symptoms of decline. 
These teams provide expert resources to novices nurse to assist in 
assessment and intervention for at risk or high acuity patients. The 
pilot programs are clearly demonstrating that the RRT's are highly 
successful in preventing patient complication with early expert 
intervention, providing nursing staff support and training new and less 
experienced nursing staff.
    Each year, the U.S. Pharmacopedia's (USP) Center for the 
Advancement of Patient Safety conducts an in-depth analysis of 
medication errors using data captured from MEDMARX. This year, the U.S. 
Pharmaocpedia has collaborated with the Uniformed Services University 
of the Health Sciences and the Association of Perioperative Registered 
Nurses on the data analysis and report. This marks the first time USP 
has worked with partners on the report, and the collaboration has 
produced multi-dimensional analysis. The analysis and data collected 
will help hospitals nationwide and throughout the Department of Defense 
reduce and prevent medication errors and related costs due to patient 
injury, further hospitalization and treatment.
                         leadership in research
    The TriService Nursing Research Program (TSNRP), established in 
1992, provided military nurse researchers funding to advance research 
based health care improvements for the war fighters and their 
beneficiaries (S.R. 107-732). TSNRP actively supports research that 
expands the state of nursing science for military clinical practice and 
proficiency, nurse corps readiness, retention of military nurses, 
mental health issues, and translation of evidence into practice.
    TSNRP is a truly successful program. Through its state of the art 
grant funding and management processes, TSNRP has funded over 300 
research studies in basic and applied science and involved more than 
700 military nurses as principal and associate investigators, 
consultants, and data managers. TSNRP funded study findings have been 
presented at hundreds of national and international conferences and are 
published in over 70 peer-reviewed journals. Army Nurse Corps studies 
focus on the continuum of military health care needs from pre-and post-
deployment health to nursing specific practices necessary to best care 
for the warrior in theatre. The Army nurse research portfolio includes 
a study by Col. Richard Ricciardi that evaluated the metabolic cost and 
the consequences of wearing body armor, finding that wearing body armor 
significantly increases workload. His findings have implication for the 
amount and type of work commanders can expect soldiers to perform and 
put additional emphasis on the importance of soldiers maintaining a 
normal body weight and physical fitness as part of overall readiness.
    Col. Stacey Young-McCaughan is assessing the prevalence, severity, 
and characteristics of pain and sleep disturbance to determine how they 
impact physical and psychological outcomes in soldiers with extremity 
trauma sustained during service in Operation Enduring Freedom (OEF) and 
OIF.
    Our improvements in battlefield medical and trauma care, has 
resulted in unforeseen advances in treatment for both military and 
civilian populations. These advancements largely come from dedicated 
research teams co-located with deployed combat hospitals. These teams 
have been deployed since at least WWI and continue to be along side our 
providers today. We are at a phase in the war in Iraq that we can 
collect data, conduct comprehensive and detailed analysis, and develop 
focused improvement that will result in practice change while still in 
theater. Ltc. Veronica Thurmond PhD, a nurse researcher, is part of the 
6-person deployed combat casualty research team (DC2RT) located in 
Baghdad Iraq with the 28th CSH. This dedicated research and analysis 
team is operating under Multi-National Coalition Iraq (MNC-I) DOD 
Assurances of Compliance for the Protections of Human Subjects and 
complies with all research regulatory and ethical guidelines. The 
researchers collaborate with subject matter experts in the United 
States on all aspects of their research.
    I would like to highlight some of the ongoing areas of research the 
team is focused on which will ultimately result in practice changes 
that save lives. These areas include: Registry of emergency airways at 
combat hospitals, burn outcomes at the CSH, damage control vascular 
surgery, effects of blast-concussive injuries, acinetobacter skin 
colonization among deployed soldiers, survey of tourniquet use, and 
outcomes of patients receiving blood transfusions in a combat 
environment. There are also numerous studies in various stages of 
development.
    Army nurse researchers and our doctoral students continue to focus 
their efforts on military relevant issues. They are conducting a number 
of studies that foster excellence and improve the nursing care we 
provide. They are researching issues including recruit health; clinical 
knowledge development; the provision of care for the traumatically 
injured; objectively measuring nursing workload; and the impact of 
deployments on service members and their families. For example, LTC(P) 
Lisa Latendresse at USUHS is working to identify the variables 
predictive of phantom limb pain in combat casualties with lower 
extremity amputations.
    The U.S. Graduate Program in Anesthesia Nursing has had a very 
active research/scholarship program year in 2006. Most of the research 
involves investigation of interactions of herbal medications with 
anesthesia and hypothermia. Eleven research projects were presented at 
the American Association of Nurse Anesthetists (AANA) convention; five 
posters were presented at American Surgeons of the United States 
(AMSUS); five research studies were presented at Phyllis J. Verhonick 
Conference; and three at State conventions. One student group received 
the AANA Program Director's Outstanding Student Research Award. Ltc. 
Thomas Ceremuga received the Army Nurse of the Year Award, and Dr. 
Norma Garrett received the AANA Researcher of the Year Award. The 
faculty and students have over $1,000,000 in external funding from 
TriService Research Nursing Program, AANA, and Air Force Medical 
Evaluation Support. Six student projects have been approved for funding 
in 2007. Thirteen research articles and three chapters written by 
students and faculty were accepted in 2006 and are in press.
    We acknowledge and appreciate the faculty and staff of the USUHS 
Graduate School of Nursing for all they do to prepare advanced practice 
nurses to serve America's Army. They train advanced practice nurses in 
a multidisciplinary military-unique curriculum that is especially 
relevant given the current operational environment. Our students are 
actively engaged in research and the dissemination of nursing knowledge 
through the publication of journal articles, scientific posters, and 
national presentations. In the past year alone there have been over 21 
research articles, publications, abstracts, manuscripts, and national 
presentations by faculty and students at USUHS.
                   collaboration/innovative delivery
    The AMEDD team collaborating with government and non-government 
organizations around the world has helped streamline care where it was 
otherwise fragmented and introduced innovations in the delivery of 
care. I would like to share with you some examples of these innovations 
and collaborative partnerships.
    The 21st CSH nurses have seamlessly supported the transition of 
medical care to over 4,000 detainees from Abu Ghraib to Camp Cropper 
and have continued to improve the medical care of that population. 
Efforts like those of 1st. Lt. Michelle Racicot demonstrate how Army 
nurses continue to improve health care on the ground in Iraq. She 
designed a data base for over 10,000 tuberculosis patients to track 
when laboratory testing and medication refills were required. Her 
efforts improved the quality of care and follow-up while reducing the 
spread of this infectious disease in the detainee population. 
Similarly, Cpt. Nicole Candy and 1st. Lt. Sharon Owen developed an 
outpatient wound care clinic that manages up to 45 patients a day with 
complex wound care needs. The program has drastically reduced wound 
infection rates and freed up inpatient beds.
    While the AMEDD team continues to provide quality health care, its 
members work to advance health care delivery systems in the countries 
around the world. Between April 2006 and January 2007, the 14th CSH 
initiated a formal program in Bagram, Afghanistan to train nearly 50 
Afghan military and civilian nurses. In Salerno, Afghanistan, Ltc. 
Bruce Schoneboom, Maj. Elizabeth Vinson, and Maj. Tanya Sanders worked 
with the Khowst Provincial Teaching Program. These Army nurses 
spearheaded an initiative to teach local Afghan doctors and nurses 
state of the art techniques in providing perioperative surgical and 
nursing care. They were instrumental in teaching over 15 Afghan 
providers and were involved in the care of over 600 local nationals. 
They trained providers in conscious sedation, burn and wound care, 
airway management, postoperative management, and sterile technique. At 
the end their rotation, the 14th CSH opened the Khowst Afghan-American 
Comprehensive Surgical Clinic designed to serve the local Afghan 
community.
    Army nurses around the world continue to work collaboratively 
through practice and educational partnerships. In Korea, the 121st CSH 
shares a collegial and enriching partnership by providing continuing 
nursing education. Nurse practitioners at the 121st CSH support Korean 
Advanced Practice Nursing (APN) student from Yonsei University by 
providing observational experiences to students as part of their 
clinical practicum. This opportunity allows Korean nurses to see APNs 
functioning within that role. In return, the partnership with Yonsei 
University provides Army nurses with continuing education activities 
and supports professional practice partnerships.
    Last year I mentioned the Vietnam Military Subject Matter Expert 
Exchange that was started in December 2005. We continue working with 
that country to help establish structures and processes to enhance 
military nursing in Vietnam. To date this has included trips by Army 
nurses and subject matter experts to Hanoi as part of a health care 
systems assessment, as well as a visit by a Vietnamese Delegation to 
Tripler Army Medical Center, the University of Hawaii, the AMEDD Center 
and School, and Brooke Army Medical Center. I am firmly committed to 
partnerships that advance health care delivery and professional nursing 
practice in emerging nations.
    Army nurses continue making contributions toward building 
sustainable medical infrastructure throughout the world. Earlier this 
year, Ltc. Charlotte Scott was dispatched to Kuwait as part of an 
informatics team to advise the Kuwaiti military and civilian health 
care systems on medical information technology capabilities. Also this 
year the Kingdom of Saudi Arabia requested a group of medical and 
nursing advisors from the AMEDD to enhance capabilities of military 
medical treatment facilities within the Kingdom. The team included a 
nurse executive, Col. Diana Ruzicka, a perioperative nurse, Ltc. 
Lawrence Crozier, and a medical surgical nurse, Ltc. Gerdell Phyall, to 
make a comprehensive assessment of the system and make recommendations 
for sustainable improvements.
    Despite a sustained upswing in enrollments in baccalaureate nursing 
programs, the need for nurses continues to outpace the number of new 
graduates. Baccalaureate programs continue to turn away tens of 
thousands of qualified applicants each year, many due to faculty 
shortages. We remain committed to partnering with the civilian sector 
to address this and other issues contributing to the worldwide shortage 
of professional nurses. We are currently researching ways to encourage 
our retired officers to consider faculty positions as viable second 
career choices.
                        recruiting and retention
    The future of the Army Nurse Corps depends on our ability to 
attract and retain the right mix of talented professionals to care for 
our soldiers and their families. In addition to the shortage of nurses 
and nurse educators, competitive market conditions and current 
operational demands continue to be a challenge as we work to ensure we 
have the proper manning to accomplish our mission. With a current 
deficit of 254 officers, primarily in the company grades and in 
critical specialties, such as anesthesia, critical care, perioperative, 
and OB/GYN nursing, we are continuously monitoring the status of our 
recruiting and retention efforts.
    We access officers for the Active Component through a variety of 
programs, including the Reserve Officers' Training Corps (ROTC), the 
Army Medical Department Enlisted (AMEDD) Commissioning Program, the 
Army Nurse Candidate Program, and direct accession recruiting, with 
ROTC optimally being our primary accession source. We reported to you 
last year that since 1999, we have accessed an average of 16 percent 
fewer officers than required. That proved to be true last fiscal year 
as well, despite rate increases to the Nurse Accession Bonus, increased 
funding for the AMEDD Enlisted Commissioning Program, and a substantial 
commitment of personnel resources to the recruiting effort. However, 
there are positive trends on the horizon. For the first time in several 
years, the majority of our new lieutenants came from ROTC and so far 
this year, we are seeing a 62 percent increase in accessions as 
compared to this same time last year. These are trends we hope will 
continue. We thank the U.S. Army Cadet Command and the U.S. Army 
Recruiting Command for their focused efforts at providing nurses for 
the Army Nurse Corps.
    Retention also remains under close scrutiny and we are constantly 
working to refine our retention strategy. A recent review of personnel 
records by the Department of the Army indicated that the Army Nurse 
Corps had the highest attrition rate of any officer branch in the Army. 
Ongoing research indicates that Army nurses leave the service primarily 
because of less than optimal relationships with supervisors, length of 
deployment, and the absence of specialty pay. Those who stay do so 
because of our outstanding educational opportunities and retirement 
benefits, as well as the satisfaction that comes with working with 
soldiers and their families.
    I remain very concerned about our certified registered nurse 
anesthetists (CRNAs). Our inventory is currently at 66 percent--down 
from 70.8 percent at the end of the last fiscal year. While the U.S. 
Army's Graduate Program in Anesthesia Nursing, our primary training 
program, is rated as the second best in the Nation, we have not been 
filling all of our available training seats for several years now. 
Additionally, many of these outstanding officers are opting for 
retirement at the 20 year point. The restructuring of the incentive 
special pay program for CRNAs in 2005, as well as the 180-day 
deployment rotation policy have helped stem the tide in the mid-career 
ranks and this coming June, we will start one of the largest classes in 
the history of the program. However, there is still much work to be 
done to ensure there are sufficient CRNAs to meet mission requirements 
in the future. We continue to work closely with the Surgeon General's 
staff to closely evaluate and adjust rates and policies where needed to 
retain our CRNAs.
    For Reserve Component nurses, the issue is primarily the imbalance 
of professionally educated officers in the company grades--so many of 
them are prepared at the associate degree or diploma level that over 
the past few years, only 50 percent are educationally qualified for 
promotion to major. This creates a concern for the future force 
structure of the senior ranks of the Reserve Component in the years to 
come. For this reason, we are grateful that the Chief, Army Reserve is 
focusing recruitment incentives on those nurses educated at the 
baccalaureate level and funding the Specialized Training and Assistance 
Program for BSN completion (BSN-STRAP) for both new accessions and 
existing Army Reserve nurses without a BSN. These strategies will 
assist in providing well-educated professional nurses for the Army 
Reserve in the years ahead.
    As we continue to face a significant registered nurse shortage, it 
is essential that I address the civilian nursing workforce. We also 
face significant challenges in recruiting and retaining civilian 
nurses, particularly in critical care, perioperative, and OB/GYN 
specialties. This results in an increased reliance on expensive and 
resource exhausting contract support. We must stabilize our civilian 
workforce and reduce the reliance on contract nursing that impinges our 
ability to provide consistent quality care and develop our junior Army 
nurses. To address this issue, last year the AMEDD approved recruitment 
and retention initiatives at Walter Reed Army Medical Center and 
Charles R. Darnell Army Medical Center, Fort Hood, Texas. These two 
pilot projects provided financial support for advertising, salary 
increases, and recruitment financial incentives. At Fort Hood, Texas 
the initiative was very successful in recruiting, training, and 
retaining obstetrical nurses that were very much in demand.
    The AMEDD also recently approved the limited application of a 
student loan repayment program for current and new civilian nurse 
recruits with an outstanding response. Over 70 civilian nurses opted 
into the loan repayment program with an associated 3 year service 
obligation. The program has been so successful that the AMEDD will 
continue the education loan repayment program, and seek a program to 
support civilian nurses seeking advanced degrees. We must continue such 
initiatives in the future if we are to maintain a quality nursing work 
force.
    We are also challenged in recruiting and retaining civilian nurses 
as a result of personnel regulations that date as far back as 1977. 
These regulations constrain our ability to hire in a competitive 
nursing employment market. We must have the same flexibilities as the 
Department of Veterans Affairs to recruit nurses, especially new 
graduates. Recently, I have assembled a strategic work group of 
civilian nurses and senior Army nurse leaders to look at these issues 
and help us solve some of the long term problems impacting recruitment 
and retention of our civilian work force.
    One promise of the National Security Personnel System (NSPS) is to 
attract and retain talented and motivated employees. I remain 
optimistic that NSPS will address the issues that make civil service a 
disincentive for new and practicing nurses. We have worked with the 
Navy and Air Force to standardize duty titles throughout the system. 
This will ease local marketing and facilitate the development of tiers 
for advanced practice nurses, similar to those for physicians and 
dentists. However, the delay in implementation of NSPS because of legal 
challenges by unions renews our concerns.
    More than ever, the Army Nurse Corps is focused on providing 
service members and their families the absolute highest quality care 
they need and deserve. We continue adapting to the new realities of 
this long war, but remain firm on providing the leadership and 
scholarship required to advance the practice of professional nursing. 
We will maintain our focus on sustaining readiness, clinical 
competency, and sound educational preparation with the same commitment 
to serve those service members who defend our Nation that we have 
demonstrated for the past 106 years. I appreciate this opportunity to 
highlight our accomplishments and discuss the issues we face. Thank you 
for your support of the Army Nurse Corps.

    Senator Inouye. May I call on Senator Stevens?
    Senator Stevens. I have to apologize. I have to leave, but 
I will make one request. I would like to have the three of you 
submit to us suggestions for changes in the law to give 
additional incentives to people to join and stay with the 
nursing corps of our armed services. I think they have been 
under extreme strain, and we ought to understand that, and we 
ought to offer great incentives to people to join and stay.
    Thank you.
    General Pollock. Thank you, sir. We will work that for you 
and get that to you quickly.
    Senator Inouye. I concur with the Senator, because we are 
competing with the general public, and if we don't do and 
provide incentives, we're not going to meet the demands.
    You are at 92 percent now?
    General Rank. Yes.
    Senator Inouye. And the Navy?
    Admiral Bruzek-Kohler. Ninety percent, sir.
    Senator Inouye. Ninety percent? And the Army?
    General Pollock. Sir, it really depends on the specialties 
that we address. Across the corporate nurse corps, I would 
estimate 90 to 92. In some of our specialties we are at 59 
percent.
    [The information follows:]

    Suggestions for changes in the law to give additional 
incentives to people to join and stay in the Nurse Corps of our 
Armed Services:
    Support Office of Personnel Management Act Relief for Nurse 
Corps and Biomedical Sciences Corps. Disparate promotion 
opportunity and timing is currently the greatest challenge in 
retaining Nurse Corps officers. In a recent survey, lack of 
promotion opportunity was the most common influence mentioned 
by the 381 responders in their decision to separate from the 
military. Promotion opportunity for Nurse Corps officers is and 
has consistently been 10-15 percent lower than other Air Force 
officers. Promotion timing for Nurse Corps officers lags 
consistently two to three years behind all other Air Force 
officers.
    Continue to support: Nurse Accession Bonus; Critical Skills 
Retention Bonuses and Incentive Special Pays; Uniformed 
Services University of the Health Sciences & Graduate School of 
Nursing; Board Certification Pay; Scholarship Programs; Health 
Professions Loan Repayment Program; and Tri-Service Nursing 
Research Program.
    Clarify legislative language (Title 10, United States Code 
Section 2107) to allow candidates over the age of 31 years to 
be eligible for financial assistance. Recently nine candidates 
over the age of 31 years were disapproved for the Airman 
Enlisted Commissioning Program based on interpretation of Title 
10, United States Code, Section 2107.

    Senator Inouye. Senator Mikulski.
    Senator Mikulski. Thank you, Mr. Chairman.

                    NURSES AND THE CONTINUUM OF CARE

    I'm so glad to see you once again, and I thank you for 
working with my staff to crack this issue of retention and 
recruitment, because it's the linchpin of delivering care. But 
in the warmest and most grateful way, I would just like I think 
just talk about the role that nurses have been playing from, as 
you say in your testimony, from battlefield to home, and the 
very intense ops tempo, the nature of the injuries, et cetera.
    I'll come back, because I know we're all well aware that 
without recruitment and retention this isn't going to work, but 
as you know, we're focusing so much now on outpatient care. 
General Pollock, I'd like to start with the testimony on page 8 
in which you raise some very important issues, and then have 
our other leadership respond.
    You talk about the AMEDD team caring for the wounded 
warriors, and the medical evacuation continuum, et cetera. You 
also talk about this continuum of care and nurses as case 
managers. Could you share with us, what is the role of nursing 
both in outpatient care, or is there any in rehabilitation, for 
the three services?
    And then I'm going to get to my point two. One of the 
issues that came up in the Walter Reed series and we're hearing 
everywhere is the so-called case manager. Now, you all are 
nurses. I'm a professionally trained social worker. The 
question is, do we have enough? Who are these so-called case 
managers?
    Because here when I see nurse case managers, I breathe a 
sigh of relief, because you know the medicine but you look at 
the whole person, including these 19-year-old spouses or maybe 
the 50-year-old mother. So could you, one, just talk with us 
about the role in the continuum of care, in addition to the 
acute care continuum that has been both brilliant and stunning 
and all--we can't say enough good things.
    General Pollock, can we start with you? And then what would 
it take for you to be able to continue to do this?
    General Pollock. Yes. There's a couple of pieces that I 
would like to answer for you----
    Senator Mikulski. I know there's not----
    General Pollock [continuing]. So I'll focus on your 
question of case management.
    Senator Mikulski. You see where I'm trying to get to?
    General Pollock. Yes, yes.
    Senator Mikulski. Which is what is the role of the nurses, 
but we really need to have good case managers if we're going to 
oversee the continuum of care back home.
    General Pollock. Ma'am, I think this is a second- and 
third-order effect of the transition from inpatient care that 
Senator Inouye spoke of, that we provided during Vietnam, that 
no longer exists. Now, 90 percent of the healthcare that we 
provide is done in the ambulatory setting.
    And in the past, when it was done as an inpatient, the 
nurse was the coordinator, the communicator, the teacher, the 
educator--the coercer, as Senator Inouye has talked, the story 
about how he learned to light a cigarette again, and start to 
understand that he could care for himself. We do all of those 
things, but when we made the national transition to ambulatory 
care, no one thought of the importance of having nurses 
actively engaged to ensure that continuity of care.
    And, as a result, in the Army we were significantly 
downsized. ``Well, if you're not going to do inpatient care, 
then we don't need you.'' That has been a major challenge for 
us, because although we know we need to do care management, 
case management in the outpatient arena, our first priority was 
to use the nurses to ensure that people survived that very 
traumatic event so that they would eventually need outpatient 
care.
    Unfortunately, particularly at Walter Reed, I don't have 
enough case managers. Now, the case managers that they have 
been using, there were three social workers and the rest were 
retired enlisted soldiers who they believed understood how to 
care for a soldier, which they did, but they didn't understand 
healthcare and the need to bring all those pieces together to 
assure that the patients would have the highest quality 
outcome.
    Senator Mikulski. Well, with the indulgence of the Chair, 
when they use the term ``social worker,'' you know, that can 
range from just a term to those of us who have MSWs. And I'm 
not saying an MSW should do this, but I come with a body of 
knowledge, a particularly trained skill set, and a code of 
ethics. That's the triad which we stood on, regardless of how 
we practice, including here.
    But my question was, are these bachelor of arts people? Are 
these trained social workers, because they would at least know 
how to work----
    General Pollock. The social workers, ma'am, I was up at 
Walter Reed last week meeting with the case managers, meeting 
with the staff, to help them to endure the negativity of the 
press, because it's been very, very difficult for the staff. 
They're working very, very hard, and to see on the front page 
of the paper every day and to hear on the news every night that 
the Nation is now thinking that what they do has no value, that 
they're not doing a good job, this has been devastating for the 
personnel of the Army Medical Department. So I wanted to spend 
time with them and reassure them----
    Senator Mikulski. And we want to reassure them, too, that 
the fault is not at the mid-level hands-on, it's where was the 
leadership?
    General Pollock. So that's why I know, ma'am, that three of 
those, that group that had been in the case management bucket, 
three were social workers who were MSM-prepared and were 
certified, and the rest of them were retirees that they thought 
would be adequate to manage the issues, not realizing how 
complex it was.

                            CASE MANAGEMENT

    Senator Mikulski. Do you believe that as we look ahead to 
the new world order, both for Army, the marines, the 
caregivers, there will be Air Force involved, that we should 
reclaim the heritage of nurses as case managers----
    General Pollock. Absolutely.
    Senator Mikulski [continuing]. Particularly the move from 
acute care to maybe outpatient, et cetera, and then also 
ensuing, and that this is a need?
    General Pollock. Oh, absolutely, it's a need, and it's one 
that nurses are particularly skilled for. What I would really 
like to see is for the Nation to understand that once someone 
has a diagnosis of any chronic condition, they then receive a 
nurse case manager to ensure that all of the pieces that need 
to come together so they can live at their highest quality of 
functioning is addressed.
    Senator Mikulski. Admiral?
    Admiral Bruzek-Kohler. Thank you, Senator Mikulski.
    In the Navy we have 106, approximately 106 active duty and 
civil servant nurses who are presently engaged in case 
management. Case management is a catch-all, in my opinion----
    Senator Mikulski. Yes.
    Admiral Bruzek-Kohler [continuing]. Of following the care 
of a category or categories of patients. In my opinion, when we 
moved care into the outpatient arena, there was a period of 
time when nurses were trying to determine exactly what their 
role was in the ambulatory care setting. Many thought they were 
clinic managers, many thought they were receptionists, some 
thought they were appointment clerks, but in reality they were 
case managers.
    Senator Mikulski. In reality they were nurses.
    Admiral Bruzek-Kohler. And they were nurses.
    Senator Mikulski. Nurse is an identity.
    Admiral Bruzek-Kohler. Yes.
    Senator Mikulski. I mean, it is an identity.
    Admiral Bruzek-Kohler. And their role in an ambulatory 
setting as a case manager is different than the role of case 
manager that you refer to, in today's world, in a wartime 
scenario. So while case management is fielded by nurses, by 
active duty and civil servant nurses, it's more of a 
multidisciplinary team.
    As I mentioned in my oral testimony, San Diego has created 
a multidisciplinary team because it's not just about nursing 
care. Clearly it's about the rehabilitative care, the mental 
healthcare, and the continuum of assets that we have to pull 
together to make certain that the care of the patient is 
holistic and appropriate. Nurses are leading these teams in 
many cases. And if they are not the team leader, they are still 
filling a significant role as a member on the team.
    Do we have enough? I don't think you ever have enough 
nursing care, and I don't think we ever have enough nurses. 
Clearly, as we have shown, we are not achieving our end 
strength goals. But case management is, in my opinion, one of 
the most important services a professional nurse offers our 
wounded servicemembers as they return home from war.
    Senator Mikulski. Well, I think I'm going to share with the 
subcommittee leadership, we want again the ideas for 
recruitment and retention, because whatever job the nurse does, 
you need the nurse. The length of deployment issue, if we 
could--I know Senator Stevens has talked about financial 
incentives, but the length of deployment and who makes those 
decisions and what would be your recommendations.
    And the other, what I thought was so interesting was that 
for those that are already nurses, you noted were either the 
so-called hospital trained and then the associate of arts, but 
your point was, if they could get--and correct me if I'm wrong, 
General Pollock and others--that if they could have the ability 
while they are within military nursing to then move to the next 
level of education, that this in and of itself would be both 
recruitment but you would also be not recruiting a per capita 
slot.
    You're recruiting someone who is trained, absorbs the 
culture, which is different than working for a doc-in-a-box. I 
mean, it's what we said about why people want to be in military 
medicine. So is this where you see an opportunity for both your 
next level leadership as well as keeping good people, that they 
could go from an associate of arts degree to a bachelor's 
degree, or a bachelor's degree to get specialized training? Did 
I understand the testimony right, or am I off base?
    General Pollock. Yes, some of it, and some of it is----
    Senator Mikulski. Yes, I am off base, and yes, I'm right? 
That's okay.
    General Pollock. For our Reserve component, we are working 
very hard to provide more opportunities for them to make their 
transition, because they are the only officers among the three 
militaries who are allowed to access without a baccalaureate 
degree. So it's very important, because that education is 
required for officers in our military, it's very important that 
they complete that education. So the funding for them to 
complete that education as part of their military experience 
would be fabulous, because then the big reason that people use 
for not completing their education is, they can't afford to 
stop working and caring for their families.
    The piece that you raised, though, ma'am, about case 
management for us, and we talked for a moment about the 
transition that we made to ambulatory care in the Nation, with 
this being a long war, with the threats that these terrorists 
pose to our homeland, this is not going to be just an issue for 
military nursing or military healthcare. We are going to need a 
plan for the assisted living, for the rehabilitation of our 
citizens, should they start to become injured.
    Senator Mikulski. But right now we could start with our 
military. They are an identifiable population for which we have 
a moral and a legal obligation, and if we got that right, then 
the civilian, I think this is where we could lead civilian 
planning in medicine.
    General Pollock. Thank you, and I would like to submit for 
the record the responses to your concerns about the length of 
deployment and the nurses' concerns about that deployment.
    Senator Mikulski. Right. Well, Mr. Chairman, I know we 
could continue this very excellent and instructive 
conversation. But I think what we want to know is, how do we 
keep what we've got and recruit the new that are as talented 
and dedicated as your leadership. And the other is really the 
role now of nursing in the continuum, to be sure that the 
continuum works for both the patient but for the system.
    And I think you are the leadership team. I mean, nursing, 
by the very nature that it can coordinate the medical and the 
psychosocial needs and understand that, I think is there. So as 
a social worker, I'm happy to be part of your multidisciplinary 
team. Thank you.
    General Pollock. Thank you.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Inouye. Several of the members would like to submit 
questions, and I hope that you will respond accordingly. 
General Rank, Admiral Kohler, and General Pollock, in behalf of 
the subcommittee, I thank you very much for your participation 
in our hearings. I can assure you that your words will be taken 
very seriously.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
          Questions Submitted to Vice Admiral Donald C. Arthur
            Questions Submitted by Senator Richard J. Durbin
                     nurse corps: shortage impacts
    Question. The U.S. Bureau of Labor Statistics (BLS) has projected 
that by 2014, our nation will need an additional 1.2 million new and 
replacement nurses. In 2004, 72 percent of hospitals were experiencing 
a nursing shortage. The ongoing conflicts in Iraq and Afghanistan have 
increased the need for qualified nurses in military medical facilities. 
Unfortunately, the military faces the same difficulty in recruitment 
and retention of nurses. In addition, the average age of retirement of 
nurse faculty is 62.5 years and it is expected that 200 to 300 
doctorally prepared faculty will be eligible for retirement each year 
from 2005 through 2012 just as more than 1 million replacement nurses 
will be needed.
    Can you please elaborate on the impact that the nursing shortage 
has had on the Armed services? Do you feel that you are sufficiently 
staffed and have the adequate resources to engage in aggressive 
recruiting efforts?
    Answer. We recognize that our recruiters have often struggled in 
competing with civilian institutions and other government agencies for 
the same group of nurses. Yet for the first time in four years, the 
Navy Nurse Corps is projected to meet its direct accession goal. This 
can be attributed to the tireless efforts of Navy Nurse Corps 
recruiters, recent increases in our Nurse Accession Bonus and the 
Health Professions Loan Repayment Program.
    Additionally, our pipeline programs continue to be quite successful 
and serve as the primary recruitment source for future Nurse Corps 
officers. The Nurse Candidate Program, Medical Enlisted Commissioning 
Program, Naval Reserve Officer Training Corps Program and Seaman to 
Admiral Program ensure a steady supply of trained and qualified Navy 
Nurses who are critical to maintaining desired manning levels.
    Attentive monitoring of the national nursing market, coupled with 
periodic evaluation and modification of the aforementioned programs 
help maintain our competitiveness and viability amidst civilian 
recruiting initiatives for America's nursing workforce.
                    nurse corps: shortage challenges
    Question. What do you think are the major challenges compounding 
the nursing shortage in the Armed Services?
    Answer. The continuation of our ongoing engagement in Iraq has not 
become a deterrent to recruiting prospective nurses to join our ranks. 
Instead we have found that the decision to leave active service is more 
related to concerns regarding the length of deployments in which our 
nurses support our war fighters and humanitarian missions. A six month 
geographic separation from family and friends is typically deemed 
acceptable. Concerns arise when the potential for lengthening 
deployments is discussed to extend beyond six months.
    Other factors which contribute to the nursing shortage in the Armed 
Services include recruitment challenges posed by: regional areas that 
have few schools of nursing; and highly competitive civilian markets 
for the same available nursing pool.
                        nurse corps: recruiting
    Question. Can you please speak to the issue of faculty shortage and 
its implications on the ability for the Armed Services to recruit 
additional nurses?
    Answer. Navy Nurses welcome the opportunity to assist our 
colleagues in academia. We have served as clinical nurse preceptors, 
educators and adjunct professors in support of schools of nursing 
throughout the country. This interface with America's colleges and 
universities provides a unique perspective of Navy Nursing and avails 
possible recruitment opportunities for our corps.
    The Troops-to-Nurse Teachers program offers some salient proposals 
to amend the shortage of nursing faculty. We must be assured that this 
amendment will not become an incentive for Nurse Corps officers to 
leave the active component of military service. We would also recommend 
that the Troops-to-Nurse Teachers program be modeled after the DANTES 
Troop-to-Teachers program under the purview of the U.S. Department of 
Education.
                         traumatic brain injury
    Question. It is estimated that as many as 2 of every 10 combat 
veterans from Iraq/Afghanistan are returning with concussions of 
varying degrees of severity. With 1.4 million vets already having 
served, that would mean up to 280,000 people (and that number grows 
with every new soldier, sailor, marine, and airman deployed) requiring 
some sort of screening/treatment.
    Do we currently have the capacity to screen, diagnose and treat all 
of these service members in the Defense and Veterans health care 
systems today and in the future?
    Answer. Identifying, evaluating and treating service members and 
veterans suffering from brain injuries is of highest priority for Navy 
Medicine. The current criteria for sustaining brain injury was derived 
from sports medicine models and works well for athletes on the playing 
field; however, over-pressurization such as that caused by an IED 
correlates irregularly with signs and symptoms of classic ball-field 
sustained closed head injuries such as concussion. Over-pressurization 
may produce occult and sometimes subtle damage and service members 
often wrongfully believe that if they are able to ``walk away from it'' 
they are well.
    The extraordinarily high rate of occurrence the press is reporting 
(``upwards of 20 percent of combat veterans'') cannot be definitively 
ascertained without conducting sophisticated neuropsychological 
testing. The most prudent approach employs a conservative, low 
threshold of suspicion for administrating neuropsychological screening 
tools. This is precisely the approach in use by the National Naval 
Medical Center (NNMC), Bethesda Brain Injury Center.
Screening/Identification
    Navy medical personnel maintain heightened awareness to possible 
TBI-related symptoms in service members, using increased indices of 
suspicion when performing medical assessments. There is not one 
specific tool used to evaluate service members for TBI. Each of the 
Services and the Veterans Administration (VA) have developed tools.
    On the battlefield, Navy medical personnel use the Military Acute 
Concussion Evaluation (MACE), a screening tool identifying symptoms in 
service members involved in blast events. Mental health personnel 
assigned to USMC I Marine Expeditionary Force utilized the Combat 
Trauma Registry (CTR) to document and identify TBI-related symptoms in 
Marines seeking in-theater mental health care. At NNMC, all inpatients 
with the diagnosis of trauma from any deployment are evaluated for 
blast injuries using the Repeatable Battery for the Assessment of 
Neuropsychological Status (RBANS).
    DOD and Navy Medicine use the Post Deployment Health Assessment 
(PDHA) immediately following deployment, Post Deployment Health Re-
Assessment (PDHRA) at 90 to 180 days post-deployment and the Periodic 
Health Assessment (PHA); a health evaluation tool completed once a year 
on all active and reserve Navy and Marine Corps service members 
screening questions for TBI will be added to these assessments.
Treatment
    We do not know if we have sufficient capacity to fully evaluate, 
diagnose and treat an unknown but increasing number of service members 
returning who may have varying degrees of concussion. It is anticipated 
that the need for services to OIF/OEF patients will continue to 
increase significantly due to troop surges. As a result, the increased 
screening for TBI in the field and at Landstuhl Regional Medical Center 
and the necessary follow up care for TBI patients will require new 
resources.
    In addition to the screening tools mentioned in the previous 
section, the Navy continues its collaboration with the VA to share 
resources in joint ventures to improve the immediate and long term care 
of our wounded warriors. A training program for providers in screening 
and identifying concussion injuries is currently being developed. 
Education of family members in identifying behavioral changes of 
returning spouses from OIF/OEF and the seeking of medical attention has 
been in place at the Navy Family Service Centers for the last two 
years. Additionally, command family briefs and command ombudsmen assist 
in the education of family members.
    Over the past two years NNMC has developed special expertise in 
blast injuries and has created the Traumatic Stress and Brain Injury 
Program to identify, assess, and treat patients with traumatic brain 
injuries.
    As the Global War on Terror continues we anticipate a prevalence of 
TBI that relates to the number of personnel directly exposed to blast. 
At NNMC, neuropsychological services are heavily involved in the 
evaluation and treatment of OIF/OEF patients with TBI. They routinely 
screen all returning OIF/OEF casualties arriving for any medical 
reason. Due to this need, psychological and neuropsychological testing 
and cognitive rehabilitation services have been severely limited/
eliminated to other beneficiaries. They have identified additional 
personnel requirements to continue to evaluate and treat the majority 
of casualties returning with TBI, including psychiatrists, 
psychologists, recreational therapists, case managers with expertise in 
brain injury, social worker/substance abuse counselors and marriage and 
family therapist at a cost of over $3,000,000 annually.
    We continue to learn a great deal as we care for OIF/OEF 
casualties. This new expertise will serve as a foundation for future 
requirements. With appropriate resources, NNMC's programs being 
developed at other Naval Medical Treatment Facilities and the VA's 
hospitals will expand capacity to serve the emerging number of patients 
and offer a broader range of services.
                                 ______
                                 
            Questions Submitted by Senator Pete V. Domenici
                      traumatic brain injury (tbi)
    Question. I am very worried about the number of our men and women 
who are suffering traumatic head and brain injuries on the battlefield. 
I am also very worried about those servicemembers who may not suffer 
actual physical brain or functional impairment but who nonetheless are 
suffering because of the stress and psychological effects of the war.
    Traumatic brain injury (TBI) and post traumatic stress disorder 
(PTSD) are often times very difficult to identify and diagnose. These 
injuries may manifest themselves months after troops have returned home 
from battle or have recovered from other injuries. They can also be 
amongst the most difficult injuries to treat, frequently requiring 
months or years of rehabilitation and therapy.
    Some doctors are calling TBI the ``signature injury'' of the Iraq 
campaign. Body armor is helping many soldiers survive bomb and rocket 
attacks, but they are suffering brain injury and brain damage as a 
result of the blasts. What is being done to screen, identify, and treat 
servicemembers who may be suffering from TBI?
    Answer. Navy medical personnel maintain heightened awareness to 
possible TBI-related symptoms in servicemembers using increased indices 
of suspicion when performing medical assessments. Unit medical 
personnel use the Military Acute Concussion Evaluation (MACE) developed 
by the Defense Veterans Brain Injury Center (DVBIC). MACE is a 
battlefield screening tool used to identify symptoms in servicemembers 
involved in blast events. Additionally, mental health personnel 
assigned to USMC I MEF use the Combat Trauma Registry (CTR) to document 
presenting symptoms. This registry includes neuropsychological 
screening questions to identify TBI-related symptoms in Marines seeking 
in-theater mental health care.
    Post-deployment screening occurs immediately following deployment 
using the Post Deployment Health Assessment (PDHA), and again at 90 to 
180 days using the Post Deployment Health Re-Assessment (PDHRA). The 
PDHRA includes a question regarding exposure to blast incident or motor 
vehicle accident. DOD (Health Affairs) plans additional TBI-related 
screening questions to the PDHA, the PDHRA, and the Periodic Health 
Assessment (PHA).
    All casualties evacuated to the National Naval Medical Center 
(NNMC), Bethesda receive neuropsychological screening with appropriate 
treatment and follow-up for later-onset symptoms. Abnormal TBI screens 
receive 3-month follow-up, and referral to appropriate level of 
treatment as needed. A dedicated NNMC database tracks all casualty 
treatment/follow-up. The Physical Evaluation Board (PEB) process and VA 
OIF/OEF Coordinators also track patients to ensure continuity of care.
   post traumatic stress disorder (ptsd) identification and treatment
    Question. This war is going to create a high number of patients who 
need mental health care because of the stress of battle and the 
traumatizing, often life-threatening events they are witnessing. What 
is being done to help identify those servicemembers who may suffer from 
PTSD or otherwise need assistance dealing with their combat-related 
experiences? Once identified, what help is being provided to these 
servicemembers?
    Answer. Prevention is at the forefront of the continuum that 
includes early identification and intervention of PTSD. Closely aligned 
with warfighters while in garrison, providers teach Marines and their 
leaders on signs of combat stress and how to prevent it. Navy Medicine 
has also established a Deployment Health Directorate and identified a 
Combat/Operational Stress Control Consultant to coordinate prevention 
and treatment efforts.
    Sailors and Marines receive Post Deployment Health Assessment 
(PDHA) immediately following deployment and Post Deployment Health Re-
Assessment 90-180 days later. Additionally, Navy Medicine has 
established 13 Deployment Health Centers (DHCs)--non-stigmatizing 
portals for identification and care. Through February 2007, DHCs 
conducted more than 4,000 encounters (in excess of 3,700 primary care 
and 420 mental health visits).
    When intervention is necessary the PIES (Proximity, Immediacy, 
Expectancy, Simplicity) principle is used as treatment by embedded 
mental health personnel in deployed units (USMC OSCAR teams and Carrier 
Group Clinical Psychologists). The Navy uses best practice guidelines 
for mental health treatment such as the VA/DOD jointly developed 
clinical practice guidelines. Moreover, the Navy has partnered with 
other services to establish a Center for Deployment Psychology, 
providing education and training on treatment of PTSD and other combat 
stress disorders. Extensive in-theater research efforts are also 
underway to identify mental health needs, guide development of 
appropriate prevention and treatment programs, and ensure adequate in-
theater mental health support.
  transition of cases of servicemembers suffering from ptsd/tbi to va 
                      facilities and civilian life
    Question. What is being done to help servicemembers suffering from 
PTSD and TBI as they transfer from Service-run programs to Veteran 
Affairs facilities and civilian life?
    Answer. Patient information for the hospitalized service member is 
coordinated with the assistance of the case manager or discharge 
planner when they transfer from a service-run program to VA or to 
civilian life. Providers may change as the patient transitions through 
the continuum of care; it is expected that transfer of the case history 
will be seamless.
    The National Naval Medical Center (NNMC) has a system to review 
each individual trauma patient during a meeting called Trauma Rounds. 
This is a bi-weekly multi-disciplinary team care meeting in which 
inpatient care is revisited, patient progress is reviewed, and the plan 
for discharge is implemented. Case management is an integral component 
of the inpatient Trauma Rounds.
    Each patient at NNMC is assessed prior to discharge for indicators 
of TBI or PTSD. When patients are discharged, case managers are 
sensitive to TBI and PTSD issues and monitor patients through the 
continuum of care, referring to appropriate resources when needed.
    Navy Medicine and the VA carefully coordinate the transfer of cases 
from one to the other. Key components of this coordination effort 
include regular case-specific management VTCs between facilities, 
ongoing medical tracking/case management, deployment of Veteran Health 
Administration (VHA) Liaison staff at major Military Treatment 
Facilities (MTFs) (NNMC Bethesda, NH Camp Pendleton, NMC San Diego), 
detailing of active duty providers to select polytrauma VHA facilities, 
and administrative coordination between a Navy MTF and the treating VA 
facility.
    In addition, there are multiple administrative programs to assist 
the patient and family as the individual transitions from Department of 
the Navy system Service to the Veterans Administration or civilian 
life. These include: Marines for Life-Injured Support Program, Military 
Severely Injured Joint Operations Center, SIMS Pilot Program, Military 
One Source, Fleet Liaisons, Marine Corps Extension Program, Military 
Severely Injured Support, Navy Safe Harbor, Fleet and Family Services, 
Chaplain Corps, Navy and Marine Corps Relief Society, Wounded Warrior 
programs, and Navy Safe Harbor.
                                 ______
                                 
      Questions Submitted to Lieutenant General James G. Roudebush
            Questions Submitted by Senator Richard J. Durbin
                           medical readiness
    Question. The U.S. Bureau of Labor Statistics (BLS) has projected 
that by 2014, our nation will need an additional 1.2 million new and 
replacement nurses. In 2004, 72 percent of hospitals were experiencing 
a nursing shortage. The ongoing conflicts in Iraq and Afghanistan have 
increased the need for qualified nurses in military medical facilities. 
Unfortunately, the military faces the same difficulty in recruitment 
and retention of nurses. In addition, the average age of retirement of 
nurse faculty is 62.5 years and it is expected that 200 to 300 
doctorally prepared faculty will be eligible for retirement each year 
from 2005 through 2012 just as more than 1 million replacement nurses 
will be needed.
    Can you please elaborate on the impact that the nursing shortage 
has had on the Armed Services? Do you feel you are sufficiently staffed 
and have the adequate resources to engage in aggressive recruitment 
efforts?
    Answer. Currently the national nursing shortage is not impacting 
the Air Force Nurse Corps' ability to meet deployment requirements to 
include supplementing Army taskings. The shortage is impacting the home 
station business plans due to military registered nurse recruiting and 
retention shortfalls. Significant increases in contract dollars are 
being used to backfill vacant military positions or to shift workload 
to the TRICARE Managed Care Support Contract network. Additionally, 
early evidence indicates limited success in efforts to fill military-
to-civilian conversions (privatization) of registered nurse positions; 
however, the number of conversions in fiscal years 2006 and 2007 are 
limited. The larger numbers in fiscal years 2008 to 2013 will be 
extremely challenging to fill. We will evaluate hiring and retention 
success in every execution year.
    Based on recent successes in recruiting for fiscal year 2006 (92 
percent of goal), we feel confident that our monetary incentive package 
has proven successful in achieving adequate manpower. However, field-
level nurse recruiters have been cut for fiscal years 2007 and 2008 so 
it is unclear what impact this will have on recruiting effectiveness. 
Additionally, we are aggressively working to diversify accessions 
sources by expanding the enlisted Bachelors of Science in Nursing 
program from 7-10 per year up to 50 per year.
    Question. What do you think are the major challenges compounding 
the nursing shortage in the Armed Services?
    Answer. Three major challenges standout as compounding the nursing 
shortage with the Air Force Medical Services: (1) Recruiting (active 
and civilian workforce), (2) retention, and (3) deployment operational 
tempo for a few specialties. These challenges are all compounding the 
nursing shortage in the Air Force Nurse Corps.
    As the market for nurses becomes more competitive it is imperative 
for the Air Force to keep up with financial incentives to recruit a 
qualified workforce. In fiscal year 2006, we achieved 92 percent of our 
accessions goal. This was a significant improvement over fiscal year 
2005's 69 percent. We attribute our success to larger financial 
incentives, which combined the options of accepting a nurse accession 
bonus and Health Professions Loan Repayment for nursing school loans. 
We also attracted new nurses with Reserve Office Training Corps 
scholarships. Our fiscal year 2006 accession bonus options were $15,000 
for a 3-year commitment or $20,000 for a 4-year commitment. In 
collaboration with our sister services we have increased the bonus for 
fiscal year 2007 ($25,000/4 years).
    Air Force salaries are relatively competitive starting in the Major 
rank category; however, for novice nurses the military salary falls 
short. Our nurse accession bonus for fiscal year 2006 proved to be 
successful in filling the salary gap.

------------------------------------------------------------------------
                                             Military       RN National
                                            Annual Pay     Average 2004
------------------------------------------------------------------------
1 Lt....................................      $29,631.60      $57,784.00
2 Lt....................................       38,876.40       57,784.00
Capt....................................       52,704.00       57,784.00
Maj.....................................       70,588.80       57,784.00
Lt Col..................................       83,617.20   \1\ 77,140.00
Col.....................................      100,742.40   \1\ 77,140.00
------------------------------------------------------------------------
\1\ Mean annual salary for Medical and Health Services Managers (i.e.
  Director, Nursing Services, Chief Nurse, etc.) Bureau of Labor
  Statistics, May 2005.

    Additionally, we are aggressively working to diversify accessions 
sources by expanding the enlisted Bachelors of Science in Nursing 
program. After we resolve internal Air Force issues, we look forward to 
increasing the students from 7-10 per year up to 50 per year.
    Retention is currently the greatest challenge compounding the Air 
Force nursing shortage. Disparate promotion opportunity and timing are 
also great challenges of retention. In a recent survey, lower promotion 
opportunity was the most common influence mentioned by the 381 
responders in their decision to separate from the military. Promotion 
opportunity for Nurse Corps officers has consistently been 10-15 
percent lower than other Air Force officers. Promotion timing for Nurse 
Corps officers lags consistently two to three years behind all other 
Air Force Defense Officer Personnel Management Act (DOPMA)-constrained 
corps. This disparity has a 15-20 year history. Recently, we are 
experiencing improvements in opportunity and will continue to work with 
the Line of the Air Force to bring Nursing Corps promotion opportunity 
and timing in line with other officers.
    As Calendar Year 2006 came to a close, the Nursing Corps inventory 
was a gravely concerning 85 percent. We retired 166 officers and 
another 188 separated, for a net loss of 354 experienced nurses. Loss 
rates are increasing at the 4-5 year point and 9-12 year point. In 
response, we initiated a $15,000 critical skills retention bonus 
targeting nurses completing their initial commitment in the Air Force 
(4-5 year point), and will be closely monitoring its impact on 
retention for this year group. For the second attrition peak (9-12 
years) disparate promotion and timing opportunity has the greatest 
impact. We are working aggressively to resolve this problem through the 
submission of a Unified Legislation and Budgeting request for DOPMA 
relief in an effort to improve Nursing Corps promotion opportunity and 
timing.
    In addition to recruiting and retaining our active force we are 
facing the challenging initiative of converting military positions to 
civilian equivalents and hiring into those equivalents. Nationally, the 
demand for nursing personnel far exceeds the supply, creating a 
competitive market that favors qualified candidates. Through active 
recruiting, hiring bonuses where warranted, and use of direct hire 
authority, we hired 86 percent of the clinical nurses programmed for 
fiscal year 2006.
    Lastly, deployments for our critically manned specialties compound 
the nursing shortage. Of note, since September 2001, the Total Force 
Nurses have comprised 53 percent of all Air Force medical Total Force 
deployments. Out of necessity we have had to prolong deployments for 
``high demand low density'' specialties, (critical care). Deployments 
for this group are now 179 days, or 59 days longer than other deployed 
nurses. We have increased our training platforms to increase our 
numbers of nurses skilled in these specialties. Additionally, we 
continue to incentivize our specialty nurses with incentive specialty 
pay programs.
    Question. Can you please speak to the issue of faculty shortage and 
its implications on the ability for the armed services to recruit 
additional nurses?
    Answer. According to the latest projections from the U.S. Bureau of 
Labor Statistics published in the November 2005, Monthly Labor Review, 
more than 1.2 million new and replacement nurses will be needed by 
2014. Government analysts project that more than 703,000 new registered 
nursing positions will be created through 2014, which will account for 
two-fifths of all new jobs in the health care sector.
    The American Association of Colleges of Nursing (AACN) has cited 
the shortage of nursing school faculty as a major contributing factor 
in the nursing shortage. It's estimated that for 2006 approximately 
42,000 qualified applicants were turned away from baccalaureate and 
graduate nursing programs due to insufficient number of faculty, 
limited clinical sites/clinical preceptors/classroom space and budget 
constraints.
    According to an article published in the March/April 2002 issue of 
Nursing Outlook, the average age of nurse faculty at retirement is 62.5 
years. With the average age of doctorally-prepared faculty currently 
53.5 years, a wave of retirements is expected within the next ten 
years. In fact, the authors project that between 200 and 300 
doctorally-prepared faculty will be eligible for retirement each year 
from 2003 through 2012, and between 220-280 master's-prepared nurse 
faculty will be eligible for retirement between 2012 and 2018.
    According to the 2006 salary survey by The Nurse Practitioner, the 
average salary of a master's prepared nurse practitioner is $72,480. By 
contrast, AACN recently reported that master's prepared associate 
professors earned an annual average salary of $58,249.
    In 2005, 49 percent of hospital Chief Executive Officers reported 
having more difficulty recruiting registered nurses than in 2004.
    The information above was obtained from the American Association of 
Colleges of Nursing Fact Sheet.
    The end results of the nursing faculty shortage on recruitment of 
nurses for the armed forces are directly related to supply and demand. 
The number of nursing faculty retiring will decrease the number of 
students graduating from schools. The law of supply and demand would 
indicate that as the supply shrinks, there will be greater civilian 
competition for new nurses.
                                 ______
                                 
            Questions Submitted by Senator Pete V. Domenici
                           medical readiness
    Question. I am very worried about the number of our men and women 
who are suffering traumatic head and brain injuries on the battlefield. 
I am also very worried about those service members who may not suffer 
actual physical brain or functional impairment but who nonetheless are 
suffering because of the stress and psychological effects of the war.
    Traumatic brain injury (TBI) and post traumatic stress disorder 
(PTSD) are often times very difficult to identify and diagnose. These 
injuries may manifest themselves months after troops have returned home 
from battle or have recovered from other injuries. They can also be 
amongst the most difficult to treat, frequently requiring months or 
years of rehabilitation and therapy.
    Some doctors are calling TBI the ``signature injury'' of the Iraq 
campaign. Body armor is helping many soldiers survive bomb and rocket 
attacks, but they are suffering brain injury and brain damage as a 
result of the blasts. What is being done to screen, identify, and treat 
service members who may be suffering from TBI?
    Answer. We recognize that, while severe Traumatic Brain Injury 
(TBI) is readily identified, mild TBI (mTBI) can be difficult to 
identify. At our level II and III theater facilities we have 
implemented the Joint Theater Trauma System (JTTS) Clinical Practice 
Guideline (CPG) for in-theater management of mild traumatic brain 
injury (concussion). Any Service member involved in an explosion/blast, 
fall, or blow to the head and/or motor vehicle incident is considered 
to have potentially suffered a concussion and will undergo a TBI 
screening questionnaire. If a patient has a positive screen they 
undergo further evaluation using the Military Acute Concussion 
Evaluation which was developed in conjunction with Defense and Veterans 
Brain Injury Center Program.
    Treatment of TBI begins at the point of injury with level I Self-
Aid/Buddy Care and continues in theater to our level III theater 
hospitals according to the JTTS CPG for TBI. Those unable to return to 
duty are returned to a Continental United States level V Military 
Treatment Facility by aeromedical evacuation. Patients requiring 
specialized rehabilitation for traumatic brain injury, spinal cord 
injury, blind rehabilitation and post traumatic stress disorder are 
typically sent to one of the four Veterans Administration Polytrauma 
Centers for continued care using the aeromedical evacuation system. 
Individual case managers work with these patients and their families in 
arranging this specialized care.
    All returning deployed Service members are screened for mTBI using 
the DOD Post Deployment Health Assessment. Additionally, at three to 
six months after returning home the Service member undergoes a second 
evaluation, the Post Deployment Health Reassessment. Additional TBI 
screening questions are being added to these screening tools to better 
assess unrecognized TBI injuries.
    Question. This war is going to create a high number of patients who 
need mental health care because of the stress of battle and the 
traumatizing, often life-threatening events they are witnessing. What 
is being done to help identify those service members who may suffer 
from PTSD or otherwise need assistance dealing with their combat-
related experiences? Once identified, what help is being provided to 
these service members?
    Answer. We screen all members returning from deployments 
administering the DOD Post Deployment Health Assessment (PDHA). Any 
problems identified are fully assessed and any treatment required is 
done. All members undergo a second evaluation, the Post Deployment 
Health Reassessment (PDHRA), three to six months after returning home 
from deployment. To date, roughly seven percent of deployed Air Force 
personnel are diagnosed with new mental health concerns (depression, 
marital problems, anxiety, difficulties sleeping, etc.); PTSD has been 
diagnosed in 0.3 percent of our deployed personnel.
    The Air Force deploys mental health providers to offer in-theatre 
assistance to Service members to head off combat-related problems. At 
home, we have trained one hundred AF mental health providers in 
specialized PTSD training to allow them to effectively treat combat-
related PTSD. GWOT monies have been used to hire 32 additional mental 
health professionals to bolster Military Treatment Facility mental 
health care services available at our high operational tempo bases.
    Question. What is being done to help service members suffering from 
PTSD and TBI as they transfer from Service-run Programs to Veteran 
Affairs facilities and civilian life?
    Answer. The Air Force places all combat wounded and ill casualty 
patients into the Palace HART (Helping Airmen Recover Together) 
Program. Each patient is assigned a Family Liaison Officer (FLO) to 
assist during their recovery. Family liaison officers assist 
transitioning service members to coordinate follow-up appointments, 
facilitate record transfers, and aid service members and their families 
to obtain any services they may require. The program continues to 
assist service members and families until the member returns to duty or 
the fifth year anniversary of separation from service.
    Patients requiring specialized rehabilitation for traumatic brain 
injury, spinal cord injury, blind rehabilitation and post traumatic 
stress disorder are usually sent to one of the four Veterans 
Administration (VA) Polytrauma Centers for continued care. In some 
cases, Active Duty members receive rehabilitation in the VA and are 
transitioned back to the Military Treatment Facility (MTF) system if 
they have recovered sufficiently.
    Air Force mental health providers and other physicians understand 
the importance of establishing continuity of care as they transition 
from Service-Run Programs to Veteran Affairs facilities and civilian 
life. The Defense and Veterans Brain Injury Center (DVBIC) program is a 
model of interaction between the DOD and the VA system for those Airmen 
who sustain Traumatic Brain Injuries. Regular teleconferences are held 
between DVBIC physicians at VA Polytrauma Centers, case managers, and 
the referring MTFs to coordinate preparation for transition.
                                 ______
                                 
          Questions Submitted to Major General Melissa A. Rank
            Questions Submitted by Senator Daniel K. Inouye
                            air force nurses
    Question. General Rank, the combat casualty care in the Global war 
on Terror demonstrates a remarkable synergy between the Army and the 
Air Force. The ability of the Army medical care to save more lives on 
the battlefield, coupled with the ability of the Air Force to transport 
patients to higher levels of care in the United States is a true 
success story.
    How has the higher acuity level of patients requiring inter-theater 
transportation changed the structure and the training requirements of 
the Air Force Nurse Corps?
    Answer. The Global War on Terror (GWOT) demand for operational, 
clinically-current specialty nurses have steadily grown. In response, 
we have increased production of critical care and trauma nurses and 
returned nurses with specialty nursing experience to the deployment 
pool.
    Encouraged by the success of our joint training pipeline in San 
Antonio, Texas, we awarded 30 critical care and emergency fellowships 
this year and expanded our joint training platforms to include the 
National Naval Medical Center in Bethesda, Maryland and St. Louis 
University Hospital in Missouri. We have not stopped there. We are 
revising our support agreement with the University of Cincinnati 
Medical Center in Ohio to accommodate critical care nursing fellows.
    We continue to rely on our Centers for Sustainment of Trauma and 
Readiness Skills (C-STARS). These advanced training platforms are 
embedded into major civilian trauma centers throughout the continental 
United States. In 2006, this invaluable clinical immersion enabled 614 
doctors, nurses, and medical technicians to refresh operational 
currency while preparing them to deploy as Critical Care Air Transport 
Team members or clinicians in expeditionary medical support facilities.
    Strengthening operational clinical currency remains a priority. Now 
11 months old, our clinical sustainment policy continues to gain 
momentum. The concept is simple: providing opportunities for nurses 
temporarily assigned in out-patient or non-clinical settings to refresh 
their technical skills by working a minimum of 168 hours per year at 
the bedside. For many of our outpatient facilities, this means 
affiliating with local medical centers for innovative patient care 
partnerships.
    In 2006, we gained access to eight complex medical-surgical, 
emergency trauma and critical care training platforms in which to 
sustain clinical skills for our officer and enlisted nursing personnel. 
An extraordinary benefit emerging at nearly all training sites has been 
exposure to--and appreciation for--the unique missions of various 
agencies. We are encouraged by reports of how affiliations with our 
federal health partners have fostered collegiality between nurses. 
Among these affiliations, two are with civilian organizations (Miami 
Valley Hospital in Dayton, Ohio and Iowa HealthCare in Des Moines, 
Iowa). Federal tort laws make securing affiliations with civilian 
organizations particularly challenging, so I applaud the hard work 
expended at the local level. Nursing personnel from the 3rd Medical 
Group DOD/VA Joint Venture Hospital and the Alaska Native Medical 
Center have collaborated on continuing education and professional 
development programs for many years. Their partnership expanded 
recently to include rotations in pediatric, medical-surgical and 
critical care units--experiences long-sought to bolster currency at 
home station and in deployed settings.
    In addition to sustainment, we have robust entry-level training 
platforms. The 882nd Training Group at Sheppard AFB, Texas graduated 
1,638 Total Force Aerospace Medical Service Apprentice (AMSA) students 
in fiscal year 2006. AMSA students have the unique experience of 
training on technologically advanced simulations systems. Life-like 
mannequins simulate clinical patient scenarios, allowing students to 
learn and gain hands-on experience in a controlled environment. As they 
progress through training, students are challenged with increasingly 
complex scenarios.
    Landstuhl Regional Medical Center, Germany (LRMC) became our 10th 
Nurse Transition Program (NTP) training site and the first NTP hosted 
in a joint facility. With the addition of the LRMC NTP, we have 
increased overall enrollment to 160 nurses in this AFMS entry-level 
officer program.
    Additionally, we deliberately laid in higher grade positions into 
selected Unit Type Codes (UTCs) or deployment requirements driving a 
demand for increased rank for those deployment taskings. In the 
military, rank equates to experience level. This action puts more 
experienced nurses in our deployed locations where they teach, mentor 
and guide our more junior nurse corps officers.
    In addition to laying in increased grade, we reevaluated our 
substitution designation for UTC requirements. For example, between 
fiscal years 2003 to 2006, of the 78 requirements for mental health 
nursing, 15 of these were filled by clinical nurses or clinical 
psychologists. In retrospect, we realize a requirement for mental 
health nurses is best met with mental health nurses and now we are not 
allowing this substitution.
    Lastly, in fiscal year 2007 we deployed the first Air Force Joint 
Theater Trauma System Program Manager. This individual has accomplished 
much to include authoring clinical practice guidelines, conducting 
advanced research, and refining the trauma registry.
                            air force nurses
    Question. General Rank, is there a potential way to utilize our 
retired military nurses to benefit recruiting nurses into the military?
    Answer. All nurses are recruiters. We have emphasized this in the 
Air Force Nurse Corps for some time. We would hope that retired 
military nurses use every opportunity to encourage nurses to serve in 
the military.
    Question. General Rank, would you consider filling critical 
shortages in deployments from other services?
    Answer. Air Force Nursing Services is an operational capability. We 
consider all appropriate deployment scenarios. At this time, we are 
able to meet the demand for nurse and technician deployment taskings 
within the Total Nursing Force (Air National Guard, Reserve and Active 
Duty components). We will continue to support Army ``in lieu of'' 
taskings with personnel assigned to corresponding Air Expeditionary 
Force (AEF) windows. However, we make every effort to honor the AEF 
construct rather than pull from upcoming ``buckets'' to support ``in 
lieu of'' missions.
    Question. General Rank, in fiscal year 2008, the Air Force is 
planning to convert 123 Nurse Corps positions to civilian positions. 
Please comment on the status of these conversions, the process used for 
determining them and the anticipated impact on the nurse corps for 
converting nurse billets.
    Answer. Military essential positions were identified first, along 
with the critical operational readiness requirements analysis. The 
Nurse Corps recommended conversions in the outpatient and maternal 
child arenas as loss of either platform does not negatively affect the 
active duty nurses' opportunity for practicing war readiness skills.
    For the 2008 to 2013 conversions, a make vs. buy with market 
availability analysis was performed on billets available for 
conversion. This analysis compared the ``fully burdened cost'' of an 
Active Duty authorization in a given specialty with the ``fully 
burdened cost'' of a General Schedule civilian or contractor. Where a 
General Schedule civilian or contractor was less expensive than Active 
Duty, consideration was given to the market availability of that 
person/skill set. The outcome from this analysis identified the number 
of authorizations by Air Force specialty code to convert to civilian or 
contractor. The analysis included four levels of risk: Not constrained, 
minimally constrained, moderately constrained and highly constrained. 
Recommended conversions came from only the ``not constrained'' and 
``minimally constrained'' risk categories.
    The current Air Force Nursing Services civilian inventory includes 
more than 1,000 nursing personnel in advanced practice, licensed and 
paraprofessional roles. Nationally, the demand for nursing personnel 
far exceeds the supply, creating a competitive market that favors 
qualified candidates. In nine months of active recruiting, we have 
hired 11 nurse practitioners and nurse specialists, 59 clinical nurses, 
and 41 paraprofessional nursing personnel (Licensed Practical Nurses 
(LPNs), Emergency Medical Technicians and Operating Room (OR) 
technicians). Although we hired 86 percent of the clinical nurses 
programmed for fiscal year 2006, we were significantly less successful 
with other civilian hires, especially LPNs and OR technicians. Through 
active recruiting, hiring bonuses where warranted, and use of direct 
hire authority, we are cautiously optimistic about reaching our fiscal 
year 2007 goal of accessing 211 additional civilian nursing personnel.
    Question. General Rank, the Quadrennial Defense Review recommends 
aligning medical support with emerging joint force employment concepts. 
What is your vision for joint medical training?
    Answer. We support the warfighter in fully-integrated Joint 
environments. Ideally, we train as we fight because Joint 
Interoperability promotes mission success. Joint Medical Training 
Platforms are not new. We currently have them at the Uniformed Sciences 
University of the Health Sciences (USUHS) and the Graduate School of 
Nursing (GSN). We depend on USUHS and GSN to prepare many of the Family 
Nurse Practitioners (FNPs) and Certified Registered Nurse Anesthetists 
(CRNAs) needed to fill our mission requirements. Currently, 57 percent 
of our 49 FNPs and 52 percent of our 143 CRNAs are USUHS graduates. The 
GSN enrolled 46 Air Force nurses this fall in Perioperative Specialty, 
FNP, and CRNA programs. Overall, Air Force nurses represented 41 
percent of the GSN student population.
    Additionally, in San Antonio, Texas we are moving forward with 
plans to relocate enlisted medical basic and specialty training to a 
Tri-Service Medical Education and Training Campus (METC) at Fort Sam 
Houston, Texas. METC will capitalize on synergy created by co-located 
training programs. We have fiercely protected our Community College of 
the Air Force degree granting to Air Force students, and are exploring 
the feasibility of extending that authority to our Sister Services.
    Currently, enlisted joint training includes neurology, allergy, 
immunization, biomedical equipment technician (BMET), and dental 
courses. Training is available for both Air Force and Army at the U.S. 
Army Critical Care Education Fellowship and the U.S. Air Force Flight 
School. We are pursuing training affiliations with both federal and 
civilian medical centers to sustain operational currency as mentioned 
earlier. We anticipate the BMET and radiology courses as the first 
courses to move to METC in the fourth quarter of fiscal year 2009.
                                 ______
                                 
     Questions Submitted to Rear Admiral Christine M. Bruzek-Kohler
            Questions Submitted by Senator Daniel K. Inouye
            humanitarian missions effect on navy nurse corps
    Question. Admiral Bruzek-Kohler, the Navy continues to support 
humanitarian missions throughout the world, and most recently deployed 
the U.S.S. Mercy to Asia. How does participation in humanitarian 
mission affect the Navy Nurse Corps in terms of its ability to meet 
both the inpatient demands and deployment requirements? How does the 
Navy Nurse Corps measure the effectiveness of this mission?
    Answer. Regional TRICARE contracts continue the provision of 
healthcare to all beneficiaries when active forces are deployed to meet 
essential missions. A plan that includes targeted reserve component 
support and proactive case management has also allowed our nurses the 
opportunity to support both humanitarian missions and deployment 
requirements with minimal disruption to our inpatient care services.
    The provision of care to citizens of the world can positively 
affect their perceptions of America via our humanitarian missions is 
important to our Corps. Our nurses are emotionally engaged and 
professionally rewarded by these missions. Discussions with our nurses 
indicate that this experience or the prospect of an experience in a 
humanitarian mission would influence their decision to stay in the 
military.
    Qualitative methods to capture and measure our effectiveness in 
these humanitarian missions encompassed the development of a rating 
scale that evaluated the following: interoperability, host nation 
support and access and medical operations (which included right 
personnel and skill mix).
    A variety of opinion polls done in the regions visited by our 
hospital ships indicate that health diplomacy is a very powerful tool 
against the war on terrorism and the Navy Nurse Corps has become a 
vital commodity in accomplishing this mission.
                    advanced joint nursing education
    Question. Admiral Bruzek-Kohler, this Committee urged the 
establishment of a Graduate School of Nursing (GSN) at the Uniformed 
Services University (USU) for a number of years and we were gratified 
by its establishment in 1993. Recent investments have allowed the 
University to break ground on a new building. Admiral, can you tell us 
how advanced joint nursing education contributes to the recruitment and 
retention of military nurses? What do you see as the future of the 
Graduate School of Nursing?
    Answer. Joint training opportunities, such as those afforded by the 
Graduate School of Nursing (GSN) at the Uniformed Services (USU) 
University, provide our nurses with the unique opportunity to see first 
hand how closely our mission aligns with those of our sister services. 
An educational milieu in which the similarities as well as the 
differences of other services are incorporated into learning objectives 
fosters collaborative rapport, longstanding professional respect and 
enhances retention.
    The Navy Nurse Corps utilizes the Graduate School of Nursing for 
our duty under instruction selectees in the following programs: Peri-
Operative Clinical Nurse Specialist, Family Nurse Practitioner, 
Certified Registered Nurse Anesthetist and Doctorate in Nursing. The 
Uniformed Services University provides excellent advanced degrees with 
a military focus that are not typically provided in civilian programs. 
These programs have all been quite helpful in bolstering our retention.
    In the future, the Navy Nurse Corps' Peri-operative Clinical Nurse 
Specialists will be participating in the GSN's new First Assist 
Program. While our nurses are not utilized in this exact role, the 
training received will be of great value, providing our nurses with 
advanced clinical skills and leadership and management tools which are 
integral to the role of a Clinical Nurse Specialist.
    We are also exploring the feasibility of moving the Navy Nurse 
Corps Anesthesia Program (in its entirety) to the GSN and would welcome 
the GSN's offering of a Masters Degree in Nursing via distance 
education/online learning.
           impact of deployments on retention of navy nurses
    Question. Admiral Bruzek-Kohler, how have deployments impacted the 
retention of Navy nurses?
    Answer. The continuation of our ongoing engagement in Iraq has not 
become a deterrent to retaining nurses in our Corps. Instead we have 
found a greater concern in relation to the length of the deployments in 
which our nurses support our war fighters and humanitarian missions. A 
six month geographic separation from family and friends is typically 
deemed preferable. But when discussions ensue regarding lengthening 
deployments from six months to one year, greater concerns arise. Thus 
we are cognizant of keeping our deployments at close to six months when 
operationally feasible.
      military-to-civilian conversions effect on navy nurse corps
    Question. Admiral Bruzek-Kohler, I am concerned about the Navy's 
continued conversion of military to civilians given the issues we face 
about patient care and continued recruiting and retention challenges. 
How do these conversions affect the Navy Nurse Corps and what 
specialties and/or locations have been problematic?
    Answer. Indeed, the degree of flexibility in meeting both forward 
deployment requirements as well as humanitarian assistance missions 
will be tested by the military to civilian conversions as both of these 
missions have not been incorporated into our operational requirement 
algorithms.
    Currently all Navy Military Treatment Facilities are staffed at 90 
percent or above with Military Nurses. These manning levels include 
nurses who are currently deployed to Iraq and Afghanistan, causing 
staffing adjustments at some facilities during deployments. Our 
treatment facilities are experiencing challenges in recruiting civilian 
registered nurses in some nursing specialty areas (particularly in: 
emergency care, labor and delivery and pediatrics).
    Recruitment and retention initiatives for both military and 
civilian nurses have been implemented to assuage the nursing shortages 
experienced at our Military Treatment Facilities. These incentives 
include accession bonuses, Health Professional Loan Repayments, and 
submission of a Critical Skills Retention Bonus for junior nurses.
                     navy nurses in outpatient care
    Question. Admiral Bruzek-Kohler, could you describe the involvement 
of Navy nurses in the outpatient care of sailors and Marines who are 
returning from deployment?
    Answer. In our Deployment Health Clinics, a specialized team of 
nurses, providers and allied health professionals ensure personnel 
returning from operational deployments receive health assessments and 
follow-up care.
    Naval Medical Center San Diego offers a multidisciplinary program 
of care via the Comprehensive Combat Casualty Care Center. This service 
offers a wide range of medical, surgical, behavioral health and 
rehabilitative care to those wounded in the service of our country.
    In Quantico, Virginia, the nurse-run Wound Clinic instituted 
several nurse-focused standard operating procedures to address ailments 
that would otherwise require physician intervention. In Camp Lejeune, 
North Carolina, the branch medical clinic sends nursing personnel 
directly to the School of Infantry to address healthcare issues on-site 
versus requiring medical clinic visits. In Portsmouth, Virginia, nurses 
from the local reserve unit have performed over 84,000 man hours of 
operational and clinical support over the last 27 months.
    Throughout our military treatment facilities, Navy Nurses proudly 
serve alongside their civilian (Government Service and contract) 
colleagues as nurse case managers to our active duty service members.

                          SUBCOMMITTEE RECESS

    Senator Inouye. And with that, this subcommittee will stand 
in recess until March 14, at which time we will receive 
testimony from the Department of the Army.
    [Whereupon, at 12:30 p.m., Wednesday, March 7, the 
subcommittee was recessed, to reconvene at 10:30 a.m., 
Wednesday, March 14.]
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