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


 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2009 

                              ----------                              


                       WEDNESDAY, APRIL 16, 2008

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 9:41 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Daniel K. Inouye (chairman) 
presiding.
    Present: Senators Inouye, Feinstein, Mikulski, Murray, and 
Stevens.

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF LIEUTENANT GENERAL ERIC B. SCHOOMAKER, 
            SURGEON GENERAL, UNITED STATES ARMY AND 
            COMMANDER, UNITED STATES ARMY MEDICAL 
            COMMAND

             OPENING STATEMENT OF SENATOR DANIEL K. INOUYE

    Senator Inouye. I'd like to welcome all of the witnesses as 
we review the DOD medical services and programs. There will be 
two panels. First we'll hear from the Service Surgeon General, 
General Eric Schoomaker, Admiral Adam Robinson, Jr., and 
Lieutenant General James G. Roudebush.
    Then we'll hear from our Chiefs of the Nurse Corps, General 
Gale Pollock, Admiral Christine Bruzek-Kohler, and Major 
General Melissa Rank.
    While many of our witnesses are now experts at these 
hearings, I'd like to welcome the General, and Admiral Robinson 
to our subcommittee for the first time. I look forward to 
working with all of you to ensure the future of our military 
medical programs and personnel.
    Over the past few years, decisions by leaders of the 
Department forced the military healthcare system to take 
actions which are of grave concern to many of us in this 
subcommittee.
    For example, in 2006, DOD instituted the efficiency wedge, 
cutting essential funding from our military treatment 
facilities. These funding decreases were taken from the budget 
before the service could even identify potential savings, 
raising numerous concerns over the proper way to budget for our 
military health system, especially during a war.
    To help alleviate this shortfall, Congress provided relief 
to the services in fiscal year 2007 and 2008, and directed that 
the Department of Defense reverse this trend in future years. 
And we are encouraged to hear that the Department of Defense is 
making a concerted effort to restore these funding shortfalls 
in the next fiscal year.
    A military to civilian conversion was another alarming 
directive established by DOD. As we saw in the so-called 
``efficiency wedge,'' adjustments were forced upon the services 
without the necessary research into short-term and long-term 
feasibility and affordability. Since DOD had no plans to 
reverse this course, Congress directed it to halt 
implementation.
    I'm aware of the difficulties this presents to the service 
medical accounts, and the service military personnel accounts, 
and so I look forward to working with all of you to address 
these issues during our deliberations on the fiscal year 2009 
DOD appropriations bill.
    For the third year in a row, the Department is requesting 
the authority to increase fees for retired military in order to 
decrease the exponential growth in military healthcare costs. 
While I recognize the Department's dilemma, the approach must 
not cause undue financial burden on our military retirees.
    To compound the problem, DOD's fiscal year 2009 budget 
request assumes that $1.2 billion requests--comes out in 
savings associated with this authority, which will likely be 
rejected, once again, by this Congress.
    These are some of the challenges, I think, we will face in 
the coming year. We continue to hold this valuable hearing with 
service Surgeons General and the Chiefs of the Nurse Corps as 
an opportunity to raise and address these and many other 
issues.
    And so I look forward to your statements and note that your 
full statements, all of them, will be made part of the record, 
and it is now my pleasure to call upon the senior member of 
this subcommittee, my vice chairman, Senator Stevens.

                    STATEMENT OF SENATOR TED STEVENS

    Senator Stevens. Thank you very much, Mr. Chairman, again, 
my apologies for being late.
    I welcome General Schoomaker and Admiral Robinson, and of 
course, I'm happy to see General Roudebush here again. I would 
ask that my statement along with a statement from Senator 
Cochran be placed in the record, in view of the fact that I've 
already delayed this hearing.
    Senator Inouye. Without objection, so ordered.
    [The statements follow:]
               Prepared Statement of Senator Ted Stevens
    Thank you, Mr. Chairman.
    I also want to welcome the Surgeons General and the Chiefs of the 
Nurse Corps today, who are here to testify on the current state of the 
military medical health system and the medical readiness of our armed 
forces.
    General Schoomaker and Admiral Robinson, I welcome both of you in 
your first appearance before this subcommittee. We look forward to 
working with you in the future on the tough medical issues that face 
our military and their families.
    General Roudebush, it is nice to see you here again.
    This past year has shown great progress in addressing the health 
needs of our soldiers, sailors, marines and airmen, whether it be 
mental and psychological counseling after deployments, or more enhanced 
prosthetics that gets our servicemembers back into the fight. I 
experienced a prime example of how joint our medical health care system 
can be, when the Air Force stepped up at Elmendorf Hospital and 
provided quality care for the returning Army brigade at Fort Richardson 
this past November. To my knowledge, it is the only Air Force hospital 
taking care of an Army brigade.
    It is amazing how the medical corps of each service are always 
willing to step up and deliver the highest quality of care to those who 
are constantly putting their lives on the line, no matter what uniform 
they wear.
    There will be many more challenges that will face the future of 
military healthcare, and I look forward to working with all of you in 
the future to ensure that we continue to make progress. Thank you for 
your testimony.
                                ------                                

               Prepared Statement of Senator Thad Cochran
    Mr. Chairman, I am pleased to join the members of the committee in 
welcoming our witnesses this morning.
    I think it is important to note that while each of the service 
secretaries and chiefs testified before this committee on separate 
occasions over the last few weeks, the medical leadership of all the 
services join us today as a group, representing the truly joint effort 
that they have undertaken to care for our military members, veterans, 
family members. The efforts of the men and women you represent, from 
the battlefield, to the hospitals and clinics, have been nothing short 
of heroic.
    I look forward to discussing medical care for our forces and to 
hearing how this year's request ensures the necessary resources are 
provided so our servicemembers and their families receive the best care 
possible.

    Senator Inouye. And now may I call upon one who is looked 
upon by the medical Services as the angel, Senator Mikulski.
    Senator Stevens. Angel?

                STATEMENT OF SENATOR BARBARA A. MIKULSKI

    Senator Mikulski. I don't know--even Senator Stevens was 
taken aback.
    Thank you very much, Mr. Chairman. I just want to welcome 
both the Surgeons General, as well as the head of the military 
Nurse Corps here.
    I want our military to know that many of our colleagues are 
over on the White House lawn welcoming the Pope. They're in 
search of a miracle, and I'm here in search of one, too.
    But, we look forward to your testimony today, to talk about 
the momentum and achievements that we've made to move beyond 
the initial Walter Reed scandal, to look at the shortages of 
healthcare providers in the military, because the ops tempo is 
placing great stress on physicians, nurses and other allied 
healthcare, and also the clear relationship between the 
military and the Veterans Administration (VA)--essentially the 
implementation of the Dole-Shalala report, and how we're moving 
forward on that.
    The rest of my comments will be reserved for, actually, in 
my questions, and I'll just submit the rest of my statement 
into the record.
    Thank you very much, Mr. Chairman.
    Senator Inouye. I thank you.
    [The statement follows:]
           Prepared Statement of Senator Barbara A. Mikulski
    Our military health care system must be reformed to focus on 
people. It is not enough to have the right number of doctors, if there 
are not enough nurses and not enough case managers or other allied 
professionals to support both the wounded warrior and the military 
health care workers that care for the wounded warrior.
    Technology won't solve these problems. Meaningful health care 
reform must address the underlying organizational problem to ensure we 
have a system that serves. We must recruit and retain first-rate health 
care professionals. We must break down the stovepipes between the DOD 
military health system and the VA long-term care system to ensure our 
wounded warriors a fast and effective transition between systems.
    Over 30,000 troops have been wounded in Iraq and Afghanistan. Our 
troops shouldn't be wounded twice. We know that acute care for our 
injured troops has been astounding. We have historic rates of survival 
and we owe a debt of gratitude to our military medical professionals. 
While we have saved their lives, we are failing to give them their life 
back. I have visited Walter Reed and met with outpatients. I'm so proud 
of their service and sacrifice for our Nation, and so embarrassed by 
the treatment they have received.
    I'm grateful to the Dole-Shalala commission for their excellent 
report. Their report should be the baseline for reforming our military 
health system. To ensure our military health system serves our wounded 
warriors and their families, supports their recovery and return, and 
simplifies the delivery of care and disabilities.
    We need our Surgeons General and the heads of our Military Nurse 
Corps to fight hard to achieve this reform. To fight hard to break down 
stove pipes between DOD and the VA, to recruit and retain first-rate 
doctors, nurses, case managers, and other allied health professionals 
that support them, to ensure a fast and effective path from DOD to VA 
systems, and to think out of the box on solutions to address the 
nursing shortage.
    Our soldiers have earned the best care and benefits we can provide. 
They should not have to fight another war to get the care they need.

    Senator Inouye. And now our first witness, Lieutenant 
General Eric B. Schoomaker, Surgeon General of the United 
States Army.
    General.
    General Schoomaker. Thank you, sir. Chairman Inouye, 
Senator Stevens, Senator Mikulski, and other distinguished 
members of the subcommittee, thank you for providing me this 
opportunity to discuss Army medicine, and the Defense Health 
Program. I truly appreciate the opportunity to talk to you 
today about the important work that's being performed by the 
dedicated men and women, both military and civilian, of the 
United States Army Medical Department, who personify the AMEDD 
value of selfless service.
    Sir, as you mentioned in your opening comments, this is 
about taking care of people, this is about taking care of 
soldiers and their families and members of the uniformed 
services as a whole, and so let me start by talking about how 
we, in the AMEDD, are working to promote best practices in 
care, and addressing some of the concerns about rising costs.
    In the Army Medical Department, we promote clinical best 
practices by aligning our business practices with incentives 
for clinicians for our administrators and commanders. We simply 
don't fund commanders with what they received last year with an 
added factor for inflation which rarely, in past years, has 
covered the true medical inflation, anyway.
    We also don't pay, simply, for productivity, we are not 
just about building widgets of care--we focus on quality and 
best value for the efforts of our caregivers. At the end of the 
day, that's what our patients and that's what my own family 
really wants, they want to remain healthy, and they want to be 
better for their encounters with our healthcare system. And we 
address that through the emerging science of evidence-based 
medicine, and focusing on clinical outcomes. We want to be 
assured that we're just not building widgets of healthcare, 
that don't relate, ultimately, to improvement in the health and 
well-being of our people, and ultimately I think this is what 
they deserve.
    We've used a system in Army medicine of outcomes-based 
incentives for almost 4 years now. It was implemented across 
the entire medical command last year after the initial trial of 
several years in the Southeast Regional Medical Command where I 
was privileged to command. I believe very strongly in this 
approach, it promotes our focus on adding value to people's 
lives through our efforts in health promotion and healthcare 
delivery, and frankly what this has resulted in the Army, in 
the last 3 to 4 years, has been a measurable improvement in the 
health of our population, and the delivery of more healthcare 
services, every year, since 2003.
    As Army medicine and the military health system move 
forward, I have three principal areas of concern that will 
require attention over the course of the next year, and 
probably the next decade.
    These concerns relate to, first of all, our people. I think 
as you've so aptly pointed out, sir, the people are the 
centerpiece of the Army, and they're the centerpiece of Army 
medicine.
    Second, we're focused upon--I'm focused upon the care that 
we deliver, and our distributed system of clinics and 
hospitals, what we call ``the direct care system,'' the 
uniformed healthcare system.
    And finally, I'm concerned about our aging facility 
infrastructure.
    Let me begin with our people--the professionalism, the 
commitment and the selfless service of the men and women in 
Army medicine really, deeply impresses me, whether they're on 
the active side in the Reserve component, or civilians. And 
frankly, throughout this 5 or 6 years of conflict, without the 
Reserve components, we could not have survived. I've been in 
hospitals, and in commands in which as many as one-half or two-
thirds of our hospitals have been staffed by Reserve component, 
mobilized nurses and physicians, administrators who are back-
filling their deployed counterparts.
    Nothing is more important to our success than a dedicated--
our dedicated workforce. I've charted our Deputy Surgeons 
General, Major General Gale Pollock, whom you'll hear from in a 
few minutes. Also, dual-hatted as our Chief of the Army Nurse 
Corps, and our new Deputy Surgeon General I brought with me 
today, David Rubenstein, Major General David Rubenstein, to 
develop a comprehensive human capital strategy for the Army 
Medical Department that's going to carry us through the next 
decade, and make us truly the employer of choice for healthcare 
professionals.
    An effective human capital strategy is going to be a 
primary focus of mine for the duration of my command. 
Recruiting and retaining quality professionals cannot be solved 
by a one-size-fits-all mentality. Rather, we need to address 
our workforce with as much flexibility and innovation, and 
tailored solutions as possible, specific to corps, specific to 
individuals, specific to career development.
    Your expansion of our direct hire authority for healthcare 
professionals in last year's appropriations bill was a clear 
indicator to me of your willingness to support innovative 
solutions in solving our workforce challenges. And as our human 
capital strategy matures, I will stay closely connected to you 
and your staff to identify and clarify any emerging needs or 
requirements.
    Second, I'd like to emphasize the importance of the direct 
care system, in our ability to maintain an all-volunteer force. 
One of the major lessons that has been reinforced throughout 
the global war on terror (GWOT) over the last several years, is 
that the direct care system is the foundation for caring for 
wounded, ill, and injured soldiers, sailors, airmen, marine, 
Coast Guardsman.
    All of our successes on the battlefield, through the 
evacuation system, and in our military medical facilities, 
derives from this direct care system that we have. This is 
where we educate, where we train, where we develop the critical 
skills that we use to protect the warfighter and save lives. 
Frankly, the success of combatants on the battlefield to 
survive wounds is a direct relationship--direct reflection--of 
what skills are being taught and maintained in our direct care 
system, every day.
    As a foundation of military medicine, the direct care 
system needs to be fully funded, and fully prepared to react 
and respond to national needs, particularly in this era of 
persistent conflict. The Senate--and this subcommittee in 
particular--has been very supportive of our direct care system, 
and I thank you for recognizing the importance of our mission, 
and providing the funding that we need.
    Last year, in addition to funding the direct care system in 
the base budget, you provided additional supplemental funding 
for operations and maintenance, for procurement, for research 
and development and I thank you for providing these additional 
funds. Please continue this strong support of Army facilities 
and our system of care, and for the entire joint medical direct 
care system.
    My last concern is that we maintain a medical facility 
infrastructure that provides consistent, world-class healing 
environments. We need environments that improve clinical 
outcomes, patient and staff safety, that recruit and retain 
staff, and I think those of you who are familiar with some of 
our newer facilities know that instantly, it sends the message 
to staff and patients alike, that we as a nation, are invested 
in their care and in their development.
    The quality of our facilities, whether it's medical 
treatment, research and development, or support functions, is a 
tangible demonstration of our commitment to our most valuable 
assets--our military family, and our military health systems 
staff.
    In closing, I want to assure the Senate that the Army 
Medical Department's highest priority is caring for our wounded 
ill and injured warriors and their families--I'm proud of 
Army--of the Army Medical Department's efforts for the past 232 
years, and especially over the last 12 months. I'm convinced 
that, in coordination with the Department of Defense, the 
Department of Veterans Affairs, we've turned the corner on 
events over the last year.
    I greatly value the support of this subcommittee, and I 
look forward to working with you closely over the next year. 
Thank you for holding this hearing today, and thank you for 
your continued support of the Army Medical Department and 
warriors that we are most honored to serve.
    Thank you, sir.
    Senator Inouye. I thank you very much, General.
    [The statement follows:]
      Prepared Statement of Lieutenant General Eric B. Schoomaker
    Chairman Inouye, Senator Stevens, and distinguished members of the 
subcommittee, thank you for providing me this opportunity to discuss 
Army medicine and the Defense Health Program. I have testified before 
congressional committees three times this year about the Army Medical 
Action Plan and the Army's care and support for our wounded, ill, and 
injured warriors. It is the most important thing we do and we are 
committed to getting it right and providing a level of care and support 
to our warriors and families that is equal to the quality of their 
service. However, it is not the only thing we do in Army medicine. In 
fact, the care we provide for our wounded, ill, and injured warriors 
currently amounts to about 9 percent of the outpatient health care 
managed by Army medicine. I appreciate this opportunity to talk with 
you today about some of the other very important work being performed 
by the dedicated men and women--military and civilian--of the U.S. Army 
Medical Department (AMEDD) who personify the AMEDD value ``selfless 
service.''
    As The Surgeon General and Commander of the U.S. Army Medical 
Command (MEDCOM), I oversee a $9.7 billion international healthcare 
organization staffed by 58,000 dedicated soldiers, civilians, and 
contractors. We are experts in medical research and development, 
medical logistics, training and doctrine, health promotion and 
preventive medicine, dental care, and veterinary care in addition to 
delivering an industry-leading health care benefit to 3.5 million 
beneficiaries around the world.
    The MEDCOM has three enduring missions codified on our new Balanced 
Scorecard:
  --Promote, sustain, and enhance soldier health;
  --Train, develop, and equip a medical force that supports full 
        spectrum operations; and
  --Deliver leading-edge health services to our warriors and military 
        family to optimize outcomes.
    In January of this year I traveled to Iraq with a congressional 
delegation to see first-hand the incredible performance of Army 
soldiers and medics. I was reminded again of the parallels between how 
the joint force fights and how the joint medical force protects health 
and delivers healing. I have had many opportunities over the last year 
to meet wounded, ill and injured soldiers, sailors, airmen and marines 
returning from deployments across the globe. On one occasion, I spoke 
at length with a young Air Force Non-Commissioned Officer--an Air Force 
Tactical Air Controller in support of ground operations in Afghanistan 
who had been injured in an IED explosion. His use of Effects Based 
Operations to deliver precision lethal force on the battlefield and in 
the battle space was parallels the use of precision diagnostics and 
therapeutics by the joint medical force to protect health and to 
deliver healing. We strive to provide the right care by the right 
medic--preventive medicine technician, dentist, veterinarian, community 
health nurse, combat medic, physician, operating room or critical care 
nurse, etc.--at the right place and right time across the continuum of 
care.
    Effects Based Operations are conducted by joint forces in the 
following manner:
  --Through the fusion of intelligence, surveillance, and 
        reconnaissance;
  --Through the coordinated efforts of Civil Military, Psychological, 
        and Special Operations capabilities to include the combined 
        efforts of Coalition & host-nation forces;
  --Through precision fires from appropriate weapon systems with 
        coordinated mortar, artillery, and aerial fires in an effort to 
        reduce collateral damage to non-combatants and the surrounding 
        environment;
  --By going beyond the military dimension--it also involves nation 
        building through humanitarian assistance operations which are 
        worked in close coordination with Non-Governmental 
        Organizations (NGOs) and Other Government Agencies (OGAs). I 
        should note here that Army, Navy and Air Force medicine play an 
        increasing role in this aspect of the U.S. military's Effects 
        Based Operations through our contributions to humanitarian 
        assistance and nation-building.
    The Army Medical Department and the joint military force do the 
exact same thing as the warfighters but for a different effect--our 
effect is focused on the human being and the individual's health. The 
parallel to our warfighting colleagues is apparent and the consequences 
of success in this venture are equally important and critical for the 
Nation's defense.
    The Joint Theater Trauma System (JTTS) coordinated by the Institute 
for Surgical Research of the U.S. Army Medical Research and Materiel 
Command (USAMRMC) at Fort Sam Houston, Texas, provides a systematic 
approach to coordinate trauma care to minimize morbidity and mortality 
for theater injuries. JTTS integrates processes to record trauma data 
at all levels of care, which are then analyzed to improve processes, 
conduct research and development related to trauma care, and to track 
and analyze data to determine the long-term effects of the treatment 
that we provide.
    The Trauma Medical Director and Trauma Nurse Coordinators from each 
service are intimately involved in this process and I can't stress 
enough how critical it is that we have an accurate and comprehensive 
Electronic Health Record accessible at every point of care--this is our 
fusion of intelligence from the battlefield all the way to home 
station.
    We also help shape the outcomes before the soldiers ever deploy 
through our Health Promotion and Preventive Medicine efforts. We 
continue to improve on our outcomes by leveraging science and lessons 
learned through Research & Development and then turning that 
information into actionable items such as the Rapid Fielding Initiative 
for protective and medical equipment, improved combat casualty care 
training, and comprehensive and far-reaching soldier and leader 
training.
    We make use of all of our capabilities, much as the warfighter 
does. We use the Joint Medical Force--our Combat Support Hospitals & 
Expeditionary Medical Support, our Critical Care Air Transport teams, 
Landstuhl Regional Medical Center, and a timely, safe medical 
evacuation process to get them to each point of care. We fully 
integrate trauma care and rehabilitation with far forward surgical 
capability, the use of the JTTS, establishing specialty trauma 
facilities and rehabilitation centers of excellence, and treating our 
patients with a holistic approach that we refer to as the Comprehensive 
Care Plan.
    It is important to understand that the fusion of information about 
the mechanisms of injury, the successes or vulnerabilities of 
protective efforts, the results of the wounds and clinical outcome can 
be integrated with operational and intelligence data to build better 
protection systems for our warriors--from vehicle platform 
modifications to better personal protective equipment such as body 
armor. We call this program Joint Trauma Analysis and Prevention of 
Injury in Combat (JTAPIC) and it is comprised of multiple elements of 
data flow and analysis. The JTAPIC Program is a partnership among the 
intelligence, operational, materiel, and medical communities with a 
common goal to collect, integrate, and analyze injury and operational 
data in order to improve our understanding of our vulnerabilities to 
threats and to enable the development of improved tactics, techniques, 
and procedures and materiel solutions that will prevent or mitigate 
blast-related injuries. One way this is accomplished is through an 
established, near-real time process for collecting and analyzing blast-
related combat incident data across the many diverse communities and 
providing feedback to the Combatant Commanders. Another example of 
JTAPIC's success is the process established in conjunction with Project 
Manager Soldier Equipment for collecting and analyzing damaged personal 
protective equipment (PPE), such as body armor and combat helmets. 
JTAPIC partners, to include the JTTS, the Armed Forces Medical 
Examiner, the Naval Health Research Center, and the National Ground 
Intelligence Center, conduct a thorough analysis of all injuries and 
evaluate the operational situation associated with the individual 
damaged PPE. This analysis is then provided to the PPE developers who 
conduct a complete analysis of the PPE. This coordination and analysis 
has led to enhancements to the Enhanced Small Arms Protective Inserts, 
Enhanced Side Ballistic Inserts and the Improved Outer Tactical Vests 
to better protect our soldiers.
    These efforts have resulted in unprecedented survival rates from 
increasingly severe injuries sustained in battle. Despite the rising 
Injury Severity Scores, which exceed any experienced by our civilian 
trauma colleagues in U.S. trauma centers, the percentage of soldiers 
that survive traumatic injuries in battle has continued to increase. 
Again, this is due to the fusion of knowledge across the spectrum of 
care that results in better equipment, especially personal protective 
equipment like body armor; better battlefield tactics, techniques, and 
procedures; changes in doctrine that reflect these new practices; and 
enhanced training for not only our combat medics but the first 
responder--typically non-medical personnel who are at the scene of the 
injury.
    One of our most recent examples involves the collection of data on 
wounding--survivable and lethal. Careful analysis of the information 
yielded recommendations for improvements to personal protective 
equipment for soldiers. This is a combined effort of the JTTS and their 
partners coordinated by the Institute of Surgical Research. Another 
combined effort being managed by USAMRMC is the DOD Blast Injury 
Research Program directed by Congress in the 2006 National Defense 
Authorization Act. The Program takes full advantage of the body of 
knowledge and expertise that resides both within and outside of the DOD 
to coordinate medical research that will lead to improvements in the 
prevention, mitigation or treatment of blast related injuries. The term 
``blast injury'' includes the entire spectrum of injuries that can 
result from exposure to an explosive device. Most of these injuries, 
such as penetrating and blunt impact injuries, are not unique to blast. 
Others, such as blast lung injury are unique to blast exposure.
    The chitosan field dressing, the Improved First Aid Kit, the Combat 
Application Tourniquet, and the Warrior Aid and Litter Kit are a 
sampling of some of the advances made in recent years through the 
combined work of providers, researchers, materiel developers, and 
others. These protective devices, treatment devices, and improvements 
in tactics, techniques and procedures for initial triage and treatment 
through tactical evacuation, damage control, resuscitation, and 
resuscitative surgery, strategic evacuation are all illustrative of the 
results of this application of ``Effects Based Operations'' to a 
medical environment. These advances directly benefit our soldiers 
engaged in ground combat operations.
    The concept of Effects Based Operations extends to our work in 
healthcare in our garrison treatment facilities as well. There are many 
substantial benefits from focusing on the clinical outcome of the many 
processes involved in delivering care and in harnessing the power of 
information using the Electronic Health Record. In the AMEDD, we 
promote these clinical best practices by aligning our business 
practices with incentives for our clinicians, administrators and 
commanders. We don't simply fund our commanders with what they received 
last year with an added factor for inflation. This would not cover the 
real escalation in costs and would lead to bankruptcy. We also don't 
just pay for productivity. Although this remains a key element in 
maximizing the resources of a hospital or clinic to care for the 
community and its patients, quality is never sacrificed. Like the Army 
and the joint warfighting force, we aren't just interested in throwing 
a lot of ordnance down-range. We--like the Army--want to know how many 
targets were struck and toward what positive effect. At the end of the 
day, that is what our patients and what my own family wants: they want 
to remain healthy and they want to be better for their encounters with 
us, which is best addressed through an Evidence Based Medicine 
approach. Ultimately, this is what they deserve.
    We have used a system of outcomes-based incentives for almost 4 
years now--it was implemented across the entire MEDCOM last year after 
an initial trial for several years in the Southeast Regional Medical 
Command. I believe strongly in this approach. It promotes our focus on 
adding value to peoples' lives through our efforts as a health 
promotion and healthcare delivery community. Last year alone we 
internally realigned $112 million to our high performing health care 
facilities. Our efforts have resulted in the Army being the only 
service to increase access to healthcare by delivering more services 
every year since 2003.
    A robust, sustainable healthcare benefit remains a critical issue 
for maintaining an all volunteer Army in an era of persistent conflict. 
Increased health care demand combined with the current rate of medical 
cost growth is increasing pressure on the defense budget and internal 
efficiencies are insufficient to stem the rising costs. Healthcare 
entitlements should be reviewed to ensure the future of our high 
quality medical system and to sustain it for years to come.
    I've talked a lot about joint medicine and our collaborative 
efforts on the battlefield, and I strongly believe it represents future 
success for our fixed facilities as well. In the National Capital 
Region (NCR), Walter Reed Army Medical Center will close and merge with 
the National Naval Medical Center to form the Walter Reed National 
Military Medical Center. The DOD stood up the Joint Task Force Capital 
Medicine to oversee the merging of these two facilities and the 
provision of synchronized medical care across the NCR. The process 
starts this fiscal year and is on track to end in mid-fiscal year 2011. 
Transition plans include construction and shifting of services with the 
goal of retaining current level of tertiary care throughout.
    San Antonio is the next location that will likely see a lot of 
joint movement with establishing the Defense Medical Education Training 
Center and combining the capabilities of the Air Force's Wilford Hall 
Medical Center and the Brooke Army Medical Center into a jointly-
staffed Army Medical Center. I see potential for great value in these 
consolidations as long as we work collaboratively and cooperatively in 
the best interests of all beneficiaries. We have proven that joint 
medicine can work on the battlefield, and at jointly-staffed Landstuhl 
Regional Medical Center. I have no doubt that Army medicine will 
continue to lead DOD medicine as we reinvent ourselves to define and 
pursue the distinction of being world-class through joint and 
collaborative ventures with our sister services.
    As Army medicine and the Military Health System (MHS) move forward 
together, I have three major concerns that will require the attention 
of the Surgeons General, the MHS leadership, and our line leadership. 
The continued assistance of the Congress will also be helpful. These 
concerns relate to the role of the direct care system, the aging 
infrastructure of our medical facilities, and the importance of 
recruiting and retaining quality health care professionals.
    One of the major lessons reinforced over the last year is that the 
direct care system is the foundation for caring for our wounded, ill, 
and injured service members. All of our successes on the battlefield, 
through the evacuation system, and in our military medical facilities 
spring forth from the direct care system. This is where we educate, 
train, and develop the critical skills that we use to protect the 
warfighter and save lives. As the foundation of military medicine, the 
direct care system needs to be fully funded and fully prepared to react 
and respond to national needs, particularly in this era of persistent 
conflict. As proud as we are of our TRICARE partners and our improved 
relationship with the Department of Veterans Affairs, we must recognize 
that the direct care system is integral to every aspect of our 
mission--promoting, sustaining, and enhancing soldier health; training, 
developing, and equipping a medical force that supports full spectrum 
operations; and delivering leading edge health services to optimize 
outcomes. Congress--and this Committee in particular--has been very 
supportive of the direct care system. Thank you for recognizing the 
importance of our mission and providing the funding that we need. Last 
year, in addition to funding the direct care system in the base budget, 
you provided additional supplemental funding for operations and 
maintenance, procurement, and research and development--thank you for 
providing these additional funds. We are ensuring this money is used as 
you intended to enhance the care we provide soldiers and their 
families. Please continue your strong support of the direct care 
system.
    The Army requires a medical facility infrastructure that provides 
consistent, world-class healing environments that improve clinical 
outcomes, patient and staff safety, staff recruitment and retention, 
and operational efficiencies. The quality of our facilities--whether 
medical treatment, research and development, or support functions--is a 
tangible demonstration of our commitment to our most valuable assets--
our military family and our MHS staff. Not only are these facilities 
the bedrock of our direct care mission, they are also the source of our 
Generating Force that we deploy to perform our operational mission. The 
fiscal year 2009 Defense Medical MILCON request addresses critical 
investments in DOD biomedical research capabilities, specifically at 
the U.S. Army Medical Research Institutes of Infectious Disease and 
Chemical Defense, and other urgent health care construction 
requirements for an Army at war. To support mission success, our 
current operating environment needs appropriate platforms that support 
continued delivery of the best health care, both preventive and acute 
care, to our warfighters, their families and to all other authorized 
beneficiaries. I respectfully request the continued support of DOD 
medical construction requirements that will deliver treatment and 
research facilities that are the pride of the department.
    My third concern is the challenge of recruiting and retaining 
quality health care professionals during this time of persistent 
conflict with multiple deployments. The two areas of greatest concern 
to me in the Active Component are the recruitment of medical and dental 
students into our Health Professions Scholarship Program (HPSP) and the 
shortage of nurses. The HPSP is the major source of our future force of 
physicians and dentists. For the last 3 years we have been unable to 
meet our targets despite focused efforts. The recent authorization of a 
$20,000 accession bonus for HPSP students will provide another 
incentive to attract individuals and hopefully meet our targets. In the 
face of a national nursing shortage, the Army Nurse Corps is short over 
200 nurses. We have increased the nurse accession bonus to the 
statutory maximum of $30,000 for a 4-year service obligation. The Army 
Reserve and National Guard have also encountered difficulty meeting 
mission for the direct recruitment of physicians, dentists, and nurses. 
We have increased the statutory cap of the Reserve Component (RC) 
Health Professions Special Pay to $25,000 per year and have increased 
the monthly stipend paid to our participants in the Specialized 
Training Assistance Program to $1,605 per month and will raise it again 
in July 2008 to $1,905 per month. As you know, financial compensation 
is only one factor in recruiting and retaining employees. We are 
looking at a variety of ways to make a career in Army medicine more 
attractive. A 90-day mobilization policy has been in effect for RC 
physicians, dentists and nurse anesthetists since 2003; this policy has 
had a positive impact on the recruiting and retention of RC healthcare 
professionals. In October 2007, U.S. Army Recruiting Command activated 
a medical recruiting brigade to focus exclusively on recruiting health 
care professionals. It is still too early to assess the effectiveness 
of that new organization, but I am confident that we will see some 
progress over the next year.
    The men and women of Army medicine--whether Active Component, 
Reserve Component, or civilian--impress me every day with their 
professionalism, their commitment, and their selfless service. Nothing 
is more important to our success then our dedicated workforce. I have 
established Major General Gale Pollock as my Deputy Surgeon General for 
Force Management so that she can focus her incredible talent and energy 
on a Human Capital Strategy for the AMEDD that will make us an 
``employer of choice'' for healthcare professionals interested in 
serving their country as either soldiers or civil servants. Your 
expansion of Direct Hire Authority for health care professionals in 
last year's appropriations bill was a clear indicator to me of your 
willingness to support innovative solutions to our workforce 
challenges. As this strategy matures, I will stay closely connected to 
you and your staff to identify and clarify any emerging needs or 
requirements.
    In closing, I want to assure the Congress that the Army Medical 
Department's highest priority is caring for our wounded, ill, and 
injured warriors and their families. I am proud of the Army Medical 
Department's efforts over the last 12 months and am convinced that in 
coordination with the DOD, the Department of Veterans Affairs, and the 
Congress, we have ``turned the corner'' toward establishing an 
integrated, overlapping system of treatment, support, and leadership 
that is significantly enhancing the care of our warriors and their 
families. I greatly value the support of this Committee and look 
forward to working with you closely over the next year. Thank you for 
holding this hearing and thank you for your continued support of the 
Army Medical Department and the warriors that we are most honored to 
serve.

    Senator Inouye. May I now recognize Admiral Robinson?
STATEMENT OF VICE ADMIRAL ADAM M. ROBINSON, JR., 
            SURGEON GENERAL, DEPARTMENT OF THE NAVY
    Admiral Robinson. Good morning, and thank you.
    Chairman Inouye, Senator Stevens, Senator Mikulski, 
distinguished members of the subcommittee, it is a pleasure to 
be before you, to share with you my vision for Navy medicine in 
the upcoming fiscal year.
    You have been very supportive of our mission in the past, 
and I want to express my gratitude, on behalf of all who work 
for Navy medicine, and those we serve.
    Navy medicine is at a particularly critical time in history 
as the military health system has come under increased 
scrutiny. Resource constraints are real, along with the 
increasing pressure to operate more efficiently, while 
compromising neither mission, nor healthcare quality. The 
budget for the Defense Health Program contains fiscal limits 
that continue to be a challenge. The demands for wounded 
warrior care continue to steadily increase due to military 
operations in Iraq and Afghanistan.
    At the same time, Navy medicine must meet the requirement 
of a peacetime mission of family and retiree healthcare, as 
well as provide humanitarian assistance and disaster relief, as 
needed around the globe.
    Our mission is Force Health Protection, and we are capable 
of supporting the full range of operations, from combat support 
for our warriors throughout the world to humanitarian 
assistance. As a result, it is vitally important that we 
maintain a ready force, and we achieve that by recruiting, 
training and retaining outstanding healthcare personnel and 
providing excellence in clinical care, graduate health 
education, and biomedical research, the core foundations of 
Navy medicine.
    We must remain fully committed to readiness in two 
dimensions--the medical readiness of our sailors and marines, 
and the readiness of our Navy medicine team to provide health 
service support across the full range of military ops.
    Navy medicine physicians, nurses, dentists, healthcare 
professional officers and hospital corpsmen, have steamed to 
assist wherever they have been needed for healthcare. As a 
result, it has been said that Navy medicine is the heart of the 
U.S. Navy, as humanitarian assistance and disaster relief 
missions create a synergy--an opportunity for all elements of 
national power: diplomatic, informational, military, economic, 
joint, inter-agency and cooperation with non-governmental 
organizations.
    As you know, advances in battlefield medicine have improved 
survivability rates, and these advances--leveraged together 
with Navy medicine's patient and family-centered care 
philosophy, provide us with the opportunities to effectively 
care for these returning heroes and their families.
    In Navy medicine, we empower our staff to do whatever is 
necessary to deliver the highest quality, comprehensive, and 
compassionate healthcare.
    For Navy medicine, the progress a patient makes from 
initial care to rehabilitation, and in support of the lifelong 
medical requirements drive the patient's care across the 
continuum. We learned early on that families displaced from 
their normal environment, and dealing with a multitude of 
stressors, are not as effective in supporting the patient, and 
his or her recovery. Our focus is to get the family back to a 
state of normalcy, as soon as possible, which means returning 
the patient and their family home to continue the healing 
process.
    In Navy medicine, we have a comprehensive, multi-
disciplinary care team which interfaces with all partners 
involved in the continuum of care. These partners include Navy 
and Marine Corps line counterparts, who work with us to 
decentralize care from a monolithic structure with one person 
in charge, to a disbursed network throughout our communities 
nationwide.
    Moving patients closer to home requires a great deal of 
planning, interaction, and coordination with providers, 
caseworkers, and other related healthcare professionals to 
ensure care is a seamless continuum.
    Families are considered a vital part of the care team, and 
we integrate their needs into the planning process. They are 
provided with emotional support by encouraging the sharing of 
experiences with other families--that's family-to-family 
support--and through access to mental health services.
    Currently, Navy medicine is also paying particular 
attention to de-stigmatizing psychological health services. 
Beginning in 2006, Navy medicine established deployment health 
clinics to serve as non-stigmatizing portals of entry in high 
fleet, and Marine Corps concentration areas, and to augment 
primary care services offered at the military treatment 
facilities, or in garrison.
    Staffed by primary care providers, and mental health teams, 
the centers are designed to provide care for marines and 
sailors who self-identify mental health concerns on the post-
deployment health assessment and re-assessment. The center 
provides treatment for other service members, as well, we now 
have 17 such clinics, up from 14 last year.
    Since the late 1990s, Navy medicine has been embedding 
mental health professionals with operational components of the 
Navy and the Marine Corps. Mental health assets aboard ship can 
help the crew deal with the stresses associated with living in 
isolated and unique environments.
    For the marines, we have developed OSCAR teams, operational 
stress control and readiness, which embed mental health 
professionals as organic assets in operational units. Making 
these mental health assets organic to the ship and the Marine 
Corps unit minimizes stigma, improves access to mental 
healthcare, and provides an opportunity to prevent combat 
stress situations from deteriorating into disabling conditions.
    We continue to make significant strides toward meeting the 
needs of military personnel, their families and caregivers, 
with psychological health needs, and traumatic brain injury-
related diagnoses. We are committed in these efforts to improve 
the detection of mild to moderate traumatic brain injury (TBI), 
especially those forms of traumatic brain injury in personnel 
who are exposed to blast, but do not suffer other demonstrable 
physical injuries.
    Our goal is to continuously improve our psychological 
health services throughout the Navy and the Marine Corps. This 
effort requires seamless programmatic coordination across 
existing line functions, in programs such as the Marine Corps' 
Wounded Warrior Regiment, and Navy's Safe Harbor, while working 
numerous fiscal contracting and hiring issues. Your patience 
and persistence are deeply appreciated, as we work to achieve 
solutions to long-term care needs.
    We have not met our recruitment and retention goals for 
medical and dental corps officers for the last 3 years. This 
situation is particularly stressful in war-time medical 
specialties. Currently, we have deployed 90 percent of our 
general surgeons, and 70 percent of our active duty 
psychiatrists in our inventory. From the Reserve component, 85 
percent of the anesthesiologists, and 50 percent of our oral 
surgeons have deployed.
    While we are very grateful for your efforts in support of 
expanded and increased accession and retention bonus--and these 
have made a difference--these incentives will take 
approximately 2 to 5 years to be reflected in our pipelines.
    Additionally, the stress on the force due to multiple 
deployments and individual augmentations has had a significant 
impact on morale across the healthcare communities. Personnel 
shortages are underscored by Navy Medical Department 
scholarships going unused, and the retention rate of 
professionals beyond their initial tour falling well below 
goal.
    By using experienced Navy medicine personnel to assist 
recruiters in identifying prospective recruits, we're 
developing relevant opportunities and enticements to improve 
retention. We are demonstrating to our people how they are 
valued as individuals, and how they can achieve a uniquely 
satisfying career in the Navy, and in Navy medicine.
    Navy medicine's research efforts are dedicated to enhancing 
the health, safety, and performance of the Navy-Marine Corps 
team. It is this research that has led to the development of 
the state-of-the-art armor, equipment and products that have 
improved our survivability rates, to the highest levels 
compared to all previous conflicts.
    In addition, our research facilities are a critical 
component, ready to respond to worldwide biological warfare 
attacks, and are making significant strides in tracking injury 
patterns in warfighters through the joint trauma registry. We 
are breaking new ground in the identification of pattern of 
injury resulting from exposure to blast.
    Navy medicine's medical research and development 
laboratories are playing an instrumental role in the worldwide 
monitoring of new, emerging infectious diseases, and the three 
Navy overseas laboratories have been critical in determining 
the efficacy of all anti-malarial drugs used by the Department 
of Defense to prevent and treat disease.

                           PREPARED STATEMENT

    Chairman Inouye, Senator Stevens, Senator Mikulski, thank 
you, again, for your support, and for providing me this 
opportunity to share with you Navy medicine's mission, what we 
are doing, and our plans for the upcoming year. It has been my 
pleasure to testify before you today, and I look forward to 
answering your questions.
    Senator Inouye. All right, thank you very much, Admiral.
    Thank you very much.
    [The statement follows:]
          Prepared Statement of Vice Admiral Adam M. Robinson
    Chairman Inouye, Ranking Member Stevens, distinguished members of 
the Committee, I am here to share with you my vision for Navy medicine 
in the upcoming fiscal year. You have been very supportive of our 
mission in the past, and I want to express my gratitude on behalf of 
all who work for Navy medicine--uniformed, civilian, contractor, 
volunteer personnel--who are committed to meeting and exceeding the 
health care needs of our beneficiaries.
    Navy medicine is at a particularly critical time in history as the 
Military Health System has come under increased scrutiny. Resource 
constraints are real, along with the increasing pressure to operate 
more efficiently while compromising neither mission nor health care 
quality. The budget for the Defense Health Program contains fiscal 
limits that continue to be a challenge. The demands for wounded warrior 
care continue to steadily increase due to military operations in Iraq 
and Afghanistan. Furthermore, Navy medicine must meet the requirement 
to maintain a peacetime mission of family and retiree health care, as 
well as provide Humanitarian Assistance/Disaster Relief as needed 
around the globe.
    The current rate of medical cost growth is adding increased demands 
on the defense budget and internal efficiencies are insufficient to 
stem the rising healthcare costs. Benefit adjustments should be 
considered to ensure the future of our high quality medical system and 
to sustain it for years to come.
                 force health protection and readiness
    Our mission is Force Health Protection. Navy medicine is capable of 
supporting the full range of operations from combat support for our 
warriors throughout the world to humanitarian assistance. As a result, 
is it vitally important that we maintain a fully ready force, and we 
achieve that by recruiting and retaining outstanding healthcare 
personnel and providing excellence in clinical care, graduate health 
education, and biomedical research, the core foundation of Navy 
medicine.
    Navy medicine must ensure that our forces are ready to go when 
called upon. We must remain fully committed to readiness in two 
dimensions: the medical readiness of our sailors and marines, and the 
readiness of our Navy medicine team to provide health service support 
across the full range of military operations. We place great emphasis 
on preventing injury and illness whenever possible. We are all 
constantly looking at improvements to mitigate whatever adversary, 
ailment, illness, or malady affects our warrior and/or their family 
members. We provide care worldwide, making Navy medicine capable of 
meeting our military's challenges, which are critical to the success of 
our warfighters.
    The Navy and Marine Corps team is working to improve a real-time, 
standardized process to report individual medical readiness. Navy 
medicine collaborates with the line to increase awareness of individual 
and command responsibilities for medical readiness--for it is as much 
an command responsibility as it is that of the individual.
        humanitarian assistance/disaster relief missions (ha/dr)
    Since 2004, the Navy Medical Department has served on the forefront 
of HA/DR missions which are part of the Navy's Core Elements of 
Maritime Power. Navy medicine physicians, nurses, dentists, ancillary 
healthcare professional officers, and hospital corpsmen have steamed to 
assist wherever there has been a need for health care. As a result, it 
has been said that Navy medicine is the heart of the U.S. Navy.
    HA/DR Missions create a synergy and opportunity for all elements of 
national power--diplomatic, informational, military, economic, joint, 
interagency, and cooperation with non-governmental organizations 
(NGOs). Most recently the USNS COMFORT (TAH-20) sent a strong message 
of U.S. compassion, support and commitment to the Caribbean and Central 
and South America during last summer's mission. Military personnel, as 
well as officers from the U.S. Public Health Service, trained and 
provided HA to the people of the partner nations and helped enhance 
security, stability and cooperative partnerships with the countries 
visited. NGOs participated in this deployment and brought value, 
expertise and additional capacity to the mission. According to 
President Tony Saca of El Salvador, ``This type of diplomacy really 
touched the heart and soul of the country and the region and is the 
most effective way to counter the false perception of what Cuban 
medical teams are doing in the region.''
    Last fall during the San Diego fires, the Navy engaged as an 
integral member of the community and provided assistance in several 
ways, including providing medical care to civilian evacuees. The Naval 
Medical Center in San Diego (NMCSD) accepted patients due to civilian 
hospital evacuations. In addition, NMCSD replenished medical supplies 
for community members who evacuated their homes without necessary 
medications. In addition, medical personnel from Naval Hospital Twenty-
Nine Palms and aboard ships in the area were helping civilian evacuees 
at evacuation centers across the county.
    It is important to note, that if not planned for appropriately this 
emerging part of our mission will prove difficult to sustain in future 
years. We must balance the requirements of sustaining the Global War on 
Terror with HA/DR requirements.
     patient and family centered care and wounded, ill and injured 
                             servicemembers
    Navy medicine's concept of care is always patient and family 
centered, and we will never lose our perspective in caring for our 
beneficiaries. Everyone is a unique human being in need of 
individualized, compassionate and professionally superior care. As you 
have heard, advances in battlefield medicine have improved 
survivability rates so the majority of the wounded we are caring for 
today will reach our CONUS facilities. This was not the case in past 
conflicts. These advances, leveraged together with Navy medicine's 
patient and family centered care, provide us with the opportunities to 
effectively care for these returning heroes and their families. In Navy 
medicine we empower our staff to do whatever necessary to deliver the 
highest quality, comprehensive health care.
    The Military Healthcare System is one of the most valued benefits 
our great Nation provides to service members and their families. Each 
service is committed to providing our wounded, ill and injured with the 
highest quality, state-of-the art medical care, from the war zone to 
the home front. The experience of this health care, as perceived by the 
patient and their family, is a key factor in determining health care 
quality and safety.
    For Navy medicine the progress a patient makes from initial care to 
rehabilitation, and in the support of life-long medical requirements is 
the driver of where a patient is clinically located in the continuum of 
care and how that patient is cared for. Where a particular patient is 
in the continuum of care is driven by the medical care needed instead 
of the administrative and personnel issues or demands. Medical and 
administrative processes are tailored to meet the needs of the 
individual patient and their family--whatever they may be. For the 
overwhelming majority of our patients, their priority is to locate 
their care as close to their homes as possible. We learned early on 
that families displaced from their normal environment and dealing with 
a multitude of stressors, are not as effective in supporting the 
patient and his or her recovery. Our focus is to get the family back to 
``normal'' as soon as possible, which means returning the patient and 
their family home to continue the healing process.
    In Navy medicine we have established a dedicated trauma service as 
well as a comprehensive multi-disciplinary care team which interfaces 
with all of the partners involved in the continuum of care. These 
partners include Navy and Marine line counterparts who decentralize 
care from a monolithic continuum with one person in charge to a 
dispersed network where patients and families return to their 
communities; once returned home they can engage with friends, families, 
traditions, peers and their communities in establishing their new life. 
To move patients closer to home requires a great deal of planning, 
interaction and coordination with providers, case workers and other 
related health care professionals to ensure care is a seamless 
continuum. We work together from the day of admission to help the 
patient and the family know we are focused on eventually moving the 
patient closer to home as soon as their medical needs allow. The 
patient's needs will dictate where they are, not the system's needs.
    Our single trauma service admits all OEF/OIF patients with one 
physician service as the point of contact for the patient and their 
family. Other providers, such as orthopedic surgery, oral-maxillofacial 
surgery, neurosurgery and psychiatry, among others, serve as 
consultants all of whom work on a single communications plan. In 
addition to providers, other key team members of the multi-disciplinary 
team include the service liaisons at the military treatment facility, 
the Veterans Affairs health care liaison and military services 
coordinator.
    Another key component of the care approach by Navy medicine takes 
into consideration family dynamics from the beginning. Families are 
considered as part of the care team, and we integrate their needs into 
the planning process. They are provided with emotional support by 
encouraging the sharing of experiences among other families (family-to-
family support) and through access to mental health services.
    Currently, Navy medicine is also paying particular attention to de-
stigmatizing psychological health services, the continuity of care 
between episodes, and the hand-off between the direct care system and 
the private sector. We are developing a process to continuously assess 
our patient and their families perspectives so that we may make 
improvements when and where necessary.
    Beginning in 2006, Navy medicine established Deployment Health 
Centers (DHCs) to serve as non-stigmatizing portals of entry in high 
fleet and Marine Corps concentration areas and to augment primary care 
services offered at the military treatment facilities or in garrison. 
Staffed by primary care providers and mental health teams, the centers 
are designed to provide care for marines and sailors who self-identify 
mental health concerns on the Post Deployment Health Assessment and 
Reassessment. The centers provide treatment for other service members 
as well. We now have 17 such clinics, up from 14 since last year. From 
2006 through January 2008, DHCs had over 46,400 visits, 28 percent of 
which were for mental health issues.
    Delays in seeking mental health services increase the risks of 
developing mental illness and exacerbating physiological symptoms. 
These delays can have a negative impact on a servicemember's career. As 
a result, we remain committed to reducing stigma as a barrier to 
ensuring servicemembers receive full and timely treatment following 
their return from deployment. Of particular interest is the recognition 
and treatment of mental health conditions such as PTSD. At the Navy's 
Bureau of Medicine and Surgery we established the position for a 
``Combat and Operational Stress Control Consultant'' (COSC). This 
individual, who reported on December 2006, is a combat experienced 
psychiatrist and preventive medicine/operational medicine specialist. 
Dedicated to addressing mental health stigma, training for combat 
stress control, and the development of non-stigmatizing care for 
returning deployers and support services for Navy caregivers, this 
individual also serves as the Director of Deployment Health. He and his 
staff oversee Post Deployment Reassessment (inclusive of Deployment 
Health Centers), Substance Abuse Prevention and Treatment, Traumatic 
Brain Injury diagnosis and treatment, and a newly created position for 
Psychological Health Outreach for Reserve Component Sailors.
    As you know, in June 2007 Secretary Gates received the 
recommendations from the congressionally mandated Department of Defense 
(DOD) Mental Health Task Force. Additionally, the Department's work on 
identifying key gaps in our understanding and treatment of TBI gained 
greater visibility and both DOD and the Department of Veterans Affairs 
began implementing measures to fill those gaps. Positive momentum has 
resulted from the task force's recommendations, the Department of 
Defense's work on TBI, and the additional funding from Congress. This 
collaboration provided an opportunity for the services to better focus 
and expand their capabilities in identifying and treating these two 
conditions.
    Since the late 1990s Navy medicine has been embedding mental health 
professionals with operational components of the Navy and the Marine 
Corps. Mental health assets aboard ships can help the crew deal with 
the stresses associated with those living isolated and unique 
conditions. Tight quarters, long work hours, and the fact that many of 
the staff may be away from home for the first time, presents a 
situation where the stresses of ``daily'' life may prove detrimental to 
a sailor's ability to cope so having a mental health professional who 
is easily accessible and going through many of the same challenges has 
increased operational and battle readiness aboard these platforms.
    For the Marines, Navy medicine division psychiatrists stationed 
with marines developed OSCAR Teams (Operational Stress Control and 
Readiness) which embed mental health professional teams as organic 
assets in operational units. Making these mental health assets organic 
to the unit minimizes stigma and provides an opportunity to prevent 
combat stress situations from deteriorating into disabling conditions. 
There is strong support for making these programs permanent and 
ensuring that they are resourced with the right amount of staff and 
funding.
    At the Navy's Bureau of Medicine and Surgery and Marine Corps 
headquarters, two positions for Combat and Operational Stress 
Consultants have been created. These individuals are dedicated to 
addressing mental health stigma, training for combat stress control, 
and the development of non-stigmatizing care for returning deployers 
and support services for Navy caregivers.
    In addition, we are developing and strengthening training programs 
for line leadership and our own caregivers. The goal is for combat 
stress identification and coping skills to be part of the curriculum at 
every stage of development of a sailor and/or marine. From the Navy's A 
Schools, to the Marine Corps Sergeant's course, and in officer 
indoctrination programs, we must ensure that dealing with combat stress 
becomes as common as dealing with any other medical issue.
    Recently Navy medicine received funding for creation of a Navy/
Marine Corps Combat and Operational Stress Control (COSC) Center at 
Naval Medical Center San Diego (NMCSD). The concept of operations for 
this first-of-its-kind capability is underway, as is the selection of 
an executive staff to lead the Center. The primary role of this Center 
is to identify best COSC practices, develop combat stress training and 
resiliency programs specifically geared to the broad and diverse power 
projection platforms and Naval Type Commands, establish provider 
``Caring for the Caregiver'' initiatives, and coordinate collaboration 
with other academic, clinical, and research activities. As the concept 
for a DOD Center of Excellence develops, we will integrate, as 
appropriate, the work of this center. The program also hopes to reflect 
recent advancements in the prevention and treatment of stress 
reactions, injuries, and disorders.
    We continue to make significant strides towards meeting the needs 
of military personnel with psychological health needs and TBI-related 
diagnoses, their families and their caregivers. We are committed in 
these efforts to improve the detection of mild-to-moderate TBI, 
especially those forms of TBI in personnel who are exposed to blast but 
do not suffer other demonstrable physical injuries. Servicemembers who 
return from deployment and have suffered such injuries may later 
manifest symptoms that do not have a readily identifiable cause, with 
potential negative effect on their military careers and quality of 
life.
    Our goal is to establish comprehensive and effective psychological 
health services throughout the Navy and Marine Corps. This effort 
requires seamless programmatic coordination across the existing line 
functions (e.g., Wounded Warrior Regiment, Safe Harbor) while working 
numerous fiscal, contracting, and hiring issues. Your patience and 
persistence are deeply appreciated as we work to achieve long-term 
solutions to provide the necessary care.
        recruitment and retention and graduate medical education
    We have not met our recruitment and retention goals for Medical and 
Dental Corps officers for the last 3 years. This situation is 
particularly stressful in wartime medical specialties. Currently, we 
have deployed 90 percent of our general surgery active duty medical 
corps officers, a specialty that is only manned at 87 percent. For 
psychiatrists, who are 94 percent manned, 72 percent of the active duty 
inventory has deployed. From the reserve component, 85 percent of the 
anesthesiologists and 50 percent of oral surgeons have deployed. While 
we are very grateful for your efforts in support of expanded and 
increased accession and retention bonuses, these incentives will take 
approximately 2,095 years to reflect in our pipeline.
    We in Navy medicine are increasing our efforts and energy in the 
recruitment and retention of medical personnel. We must demonstrate to 
our personnel how they are valued as individuals and they can achieve a 
uniquely satisfying career in the Navy. We are using experienced Navy 
medicine personnel to assist recruiters in identifying perspective 
recruits and developing relevant opportunities and enticements to 
improve retention.
    A challenge to meeting our recruitment and retention efforts is the 
impact of future increase in Marine Corps personnel. The Navy personnel 
needed in support of the increase will largely be medical officers and 
enlisted personnel. This situation, coupled with the stress on the 
force, needs to be addressed so that we can shape the force to meet the 
needs of the warfighter in the future.
    Also, the stress on the force due to multiple deployments and 
individual augmentation has had a significant impact on morale across 
the health care continuum. Personnel shortages are underscored by Navy 
medical department scholarships going unused and the retention rate of 
professionals beyond their initial tours falling well below goal.
    Graduate Medical and Health Education (GME/GHE) programs are a 
vital component of Navy medicine and of the Military Health System. 
These programs are an integral part of our training pipeline, and we 
are committed to sustaining these efforts to train future generations 
of health care providers. GME/GHE programs are required to fulfill our 
long-term goals and maintain the ever-changing health care needs of our 
beneficiaries. In addition, these programs are a critical part of our 
recruitment and retention efforts for new medical professionals and 
those involved in educating them.
                    research and development efforts
    Research is at the heart of nearly every major medical and 
pharmaceutical treatment advancement, and that is no different for Navy 
medicine. Our research efforts are dedicated to enhancing the health, 
safety, and performance of the Navy and Marine Corps team. It is this 
research that has led to the development of state-of-the art armor, 
equipment, and products that have improved our survivability rates to 
the lowest rates from any other conflict.
    Navy medicine research and development efforts cover a wide range 
of disciplines including biological defense, infectious diseases, 
combat casualty care, dental and biomedical research, aerospace 
medicine, undersea medicine and environmental health.
    The Naval Medical Research Center's Biological Defense Research 
Directorate (BDRD) is one of the few laboratories in the United States 
ready to detect over 20 biological warfare agents. In addition, the 
BDRD, located in Bethesda, MD, maintains four portable laboratories 
ready to deploy in 18 hours in response to worldwide biological warfare 
attacks.
    The Naval Health Research Center (NHRC) has a significant 
capability to track injury patterns in warfighters through the Joint 
Trauma Registry and is the leader in identifying patterns of injury 
resulting from exposure to blast. This ongoing assessment of injury 
patterns provides researchers and source sponsors key information in 
order to base decisions on programmatic issues. These decisions are 
used to develop preventative and treatment technologies to mitigate the 
effects of blast on the warfighter.
    Navy's medical research and development laboratories also play an 
instrumental role in the worldwide monitoring of new emerging 
infectious diseases, such as avian influenza, that threaten both 
deployed forces and the world. The three Navy overseas laboratories 
have also been critical in determining the efficacy of all anti-
malarial drugs used by the Department of Defense to prevent and treat 
disease. Our personnel at those facilities, specifically Jakarta and 
Lima, were participants in the timely and highly visible responses to 
natural disasters in Indonesia (Tsunami of December 2004 and Central 
Java Earthquake of 2006) and Peru (Earthquake in August 2007).
    Our research and development efforts are an integral part of Navy 
medicine's success and are aimed at providing solutions and producing 
results to further medical readiness for whatever lies ahead on the 
battlefield, at sea and at home.
    Chairman Inouye, Ranking Member Stevens, distinguished members of 
the Committee, thank you again for providing me this opportunity to 
share with you Navy medicine's mission, what we are doing and our plans 
for the upcoming year. It has been my pleasure to testify before you 
today and I look forward to answering any of your questions.

    Senator Inouye. And now, General Roudebush.
STATEMENT OF LIEUTENANT GENERAL JAMES G. ROUDEBUSH, 
            SURGEON GENERAL, DEPARTMENT OF THE AIR 
            FORCE
    General Roudebush. Thank you, sir.
    Mr. Chairman, Senator Stevens, Senator Mikulski, 
distinguished members of the subcommittee, it's truly my honor 
and privilege to be here today to talk with you about the Air 
Force Medical Service. But before I make any remarks, first I 
must thank you for your support. The Senate, and this 
subcommittee in particular, have been absolutely key in helping 
us work through some very turbulent times, in terms of fiscal 
challenges, personnel challenges, facility challenges--all the 
while meeting a very demanding operational mission. So first, I 
must say, thank you.
    Your Air Force is the Nation's guardian of America's force 
of first and last resort to guard and protect our Nation. To 
that end, we Air Force medics--and I use medics in a very broad 
sense--officer, enlisted, all-corps, total force, active Guard 
and Reserve, and our civilians, allies, and counterparts that 
come together to make up Air Force medicine.
    So, when I say we Air Force medics, I mean that in the very 
broadest and most inclusive sense. We, Air Force medics, work 
directly for our line leadership in addressing our Air Force's 
top priorities--win today's fight, taking care of our people, 
and prepare for tomorrow's challenges.
    The future strategic environment is complex and very 
uncertain. Be assured that your Air Force, and your Air Force 
Medical Service, are fully executing today's mission, and 
aggressively preparing for tomorrow's challenges. It's 
important to understand that every Air Force base at home 
station, and deployed, is an operational platform, and Air 
Force medicine supports warfighting capabilities at each of our 
bases.
    It begins with our Air Force military treatment facilities 
providing combatant commanders a fit and healthy force, capable 
of withstanding the physical and mental rigors associated with 
combat and other military missions. Our emphasis on fitness and 
prevention has led to the lowest disease and nonbattle injury 
rate in history.
    The daily delivery of healthcare in our medical treatment 
facilities is also essential to maintaining critical skills 
that guarantee our medical readiness capability, and our 
success. Our Air Force medics--working with our Army and our 
Navy counterparts, care for our families at home, we respond to 
our Nation's call supporting our warriors in deployed 
locations, and we provide humanitarian assistance and disaster 
response to both our friends and allies abroad, as well as our 
citizens at home.
    To execute these broad missions, the services--the Air 
Force, Navy and Army--must work interoperably and 
interdependently. Every day, together, we earn the trust of 
America's all-volunteer force--airmen, soldiers, sailors, 
marines and their families--and we hold that trust very dear.
    Today I'm here to address the health needs of our airmen 
and their families. The Air Force Medical Service is focused on 
the psychological needs of our airmen, and in reducing the 
effects of operational stress. We thank Congress for the fiscal 
year 2007 supplemental funding, which strengthened our 
psychological health, and traumatic brain injury (TBI) program 
research, surveillance, and treatment. It has directly improved 
access, coordination of care, and the transition of our 
patients to our allies and counterparts in the VA when that's 
appropriate.
    We're fully committed to meeting the health needs of our 
airmen and their families, and will continue to execute and 
refine these programs, again, working within the Air Force, but 
very closely with our Army, Navy, VA and private sector care 
allies and counterparts.
    In meeting this demanding mission, we must recruit the best 
and the brightest, prepare them for the mission, and retain 
them to support and lead the Air Force Medical Service in the 
years to come. The demanding operations tempo at home and 
deployed requires finding a balance between these demanding 
duties, personal recovery and family time.
    We are undertaking a number of initiatives to recapitalize 
and invest in our most precious resource--our people. Enhancing 
both professional and leadership development, ensuring 
predictability in deployments and offering financial incentives 
are all important ways we improve our overall retention, and 
thank you for your support in helping us do that.
    In closing, Mr. Chairman, I am humbled by, and intensely 
proud, of the daily accomplishments of the men and women of the 
United States Air Force Medical Service. The superior care 
routinely delivered by Air Force medics is a product of 
preeminent medical training, groundbreaking research, and a 
culture of personal and professional accountability, all 
fostered by the Air Force's core values.

                           PREPARED STATEMENT

    With your continued help, and the help of this 
subcommittee, the Air Force will continue our focus on the 
health of our warfighters and their families. Thank you for 
your enduring support, and I look forward to your questions.
    Thank you, sir.
    Senator Inouye. I 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, it is my honor 
and privilege to be here today to talk with you about the Air Force 
Medical Service. The Air Force Medical Service exists and operates 
within the Air Force culture of accountability wherein medics work 
directly for the line of the Air Force. Within this framework we 
support the expeditionary Air Force both at home and deployed.
    We align with the Air Force's top priorities: Win Today's Fight, 
Take Care of our People, and Prepare for Tomorrow's Challenges. We are 
the Nation's Guardian--America's force of first and last resort. We get 
there quickly and we bring everyone home. That's our pledge to our 
military and their families.
                           win today's fight
    It is important to understand that every Air Force base is an 
operational platform and Air Force medicine supports the war fighting 
capabilities at each one of our bases. Our home station military 
treatment facilities form the foundation from which the Air Force 
provides combatant commanders a fit and healthy force, capable of 
withstanding the physical and mental rigors associated with combat and 
other military missions. Our emphasis on fitness, disease prevention 
and surveillance has led to the lowest disease and non-battle injury 
rate in history.
    Unmistakably, it is the daily delivery of health care which allows 
us to maintain critical skills that guarantee our readiness capability 
and success. The superior care delivered daily by Air Force medics 
builds the competency and currency necessary to fulfill our deployed 
mission. Our care is the product of preeminent medical training 
programs, groundbreaking research, and a culture of personal and 
professional accountability fostered by the Air Force's core values.
    In support of our deployed forces, the Air Force Medical Service 
(AFMS) is central to the most effective joint casualty care and 
management system in military history. The effectiveness of forward 
stabilization followed by rapid Air Force aeromedical evacuation has 
been repeatedly proven. We have safely and rapidly moved more than 
48,000 patients from overseas theaters to stateside hospitals during 
Operations ENDURING FREEDOM and IRAQI FREEDOM. Today, the average 
patient arrives from the battlefield to Stateside care in 3 days. This 
is remarkable given the severity and complexity of the wounds our 
forces are sustaining. It certainly contributes to the lowest died of 
wounds rate in history.
                        total force integration
    Our Air Force Medical Service is a model for melding Guard, Reserve 
and civilians with active duty elements. Future challenges will mandate 
even greater interoperability, and success will be measured by our 
Total Force and joint performance.
    A story that clearly illustrates the success of our Total Force and 
joint enroute care is that of Army SGT Dan Powers, a squad leader with 
the 118th Military Police Company. He was stabbed in the head with a 
knife by an insurgent on the streets of Baghdad on July 3, 2007. Within 
30 minutes of the attack, he was flown via helicopter to the Air Force 
theater hospital at Balad Air Base, Iraq. Army neurosurgeons at the 
Balad Air Force theater hospital and in Washington DC reviewed his 
condition and determined that SGT Powers, once stabilized, needed to be 
transported and treated at the National Naval Medical Center, Bethesda, 
MD as soon as possible. The aeromedical evacuation system was activated 
and the miracle flight began. A C-17 aircrew from Charleston Air Force 
Base, SC, picked up SGT Powers with a seven-person Critical Care Air 
Transport Team and flew non-stop from Balad Air Base, to Andrews Air 
Force Base, MD. After a 13-hour flight, they landed at Andrews AFB 
where SGT Powers was safely rushed to the National Naval Medical Center 
for lifesaving surgery.
    As SGT Powers stated, ``the Air Force Mobility Command is the stuff 
they make movies out of . . . the Army, Navy, and Air Force moved the 
world to save one man's life.''
    We care for our families at home; we respond to our Nation's call 
supporting our warriors, and we provide humanitarian assistance to 
countries around the world. To execute these broad missions, the 
services--Air Force, Navy and Army--must work jointly, 
interoperatively, and interdependently. Our success depends on our 
partnerships with other Federal agencies, academic institutions, and 
industry. Our mission is vital. Everyday we must earn the trust of 
America's all-volunteer force--airmen, soldiers, sailors and marines, 
and their families. We hold that trust very dear.
                        take care of our people
    We are in the midst of a long war and continually assess and 
improve health services we provide to airmen, their families, and our 
joint brothers and sisters. We ensure high standards are met and 
sustained. Our Air Force chain of command fully understands their 
accountability for the health and welfare of our airmen and their 
families. When our warfighters are ill or injured, we provide a wrap-
around system of medical care and support for them and their families--
always with an eye towards rehabilitation and continued service.
Wounded Warrior Initiatives
    The Air Force is in lock-step with our sister services and Federal 
agencies to implement the recommendations from the President's 
Commission on the Care for America's Returning Wounded Warriors. The 
AFMS will deliver on all provisions set forth in the fiscal year 2008 
National Defense Authorization Act and provide our warfighters and 
their families help in getting through the challenges they face. I am 
proud today to outline some of those initiatives.
Care Management, Rehabilitation, Transition
    When a service member is ill or injured, the AFMS responds rapidly 
through a seamless system from initial field response, to stabilization 
care at expeditionary surgical units and theater hospitals, to in-the-
air critical care in the Aeromedical Evacuation system, and ultimately 
home to a military or Department of Veterans Affairs (VA) medical 
treatment facility (MTF). With specific regard to our airmen who are 
injured or ill, Air Force commanders, Family Liaison Officers, airmen 
and Family Readiness Center representatives, in lock step with Federal 
Recovery Coordinators, and medical case managers, together ensure 
``eyes-on'' for the airman and family throughout the care process. For 
injured or ill active duty airmen requiring follow-up medical care, 
they will receive it at their home station MTF. If no MTF is available, 
as is often the case for our Guard and Reserve airmen, the TRICARE 
network provides options for follow-on care with case managers at the 
major command level overseeing the care. If transition to care within 
the VA is the right thing for our airmen--Active, Guard, or Reserve--we 
work to make that transition as smooth and effective as possible. For 
those airmen medically separated, care is provided through the TRICARE 
Transitional Health Care Program and the VA health system. The Air 
Force Wounded Warrior Program, formerly known as Palace Hart, maintains 
contact and provides assistance to those wounded airmen who are 
separated from the Air Force for a minimum of 5 years.
    The AFMS provides timely medical evaluations for continued service 
and fair and equitable disability ratings for those members determined 
not to be fit for continued service. We will implement DOD policy 
guidance on these matters and all final recommendations from the pilot 
programs to improve the disability evaluation system. We have processes 
in place to ensure healthcare transitions are efficient and effective. 
Briefings are provided on VA benefits when individuals enter the 
Physical Evaluation Board process. Discharged members, still under 
active treatment, receive provider referral and transfer of their 
records. A key component of seamless transfer of care is a joint 
initiative by the VA and DOD, called the VA Benefits Delivery at 
Discharge (BDD) Program. Air Force MTFs provide the BDD Program advance 
notice of potential new service members and their health information 
through electronic transfer.
    The Air Force Medical Hold Program is very different from our 
sister services. In the Air Force, those undergoing disability 
evaluation stay in their units. We work closely with wing commanders to 
ensure that our personnel receive timely disposition. The key to 
success in this process is comprehensive case management. Outpatients 
are managed by the home unit and major command case managers. The Air 
Force does not use patient holding squadrons for Air Force Reserve 
personnel in medical hold status since the majority of reserve members 
live at home and utilize base and TRICARE medical services. If members 
are outside the commuting area for medical care, they are put on 
temporary duty orders and sent to military treatment facilities for 
consultations for as long as needed for prompt medical attention. We 
are teaming with our Air Force Personnel counterparts to initiate 
efforts to further reduce administrative time without downgrading the 
quality of medical care.
Psychological Health and Traumatic Brain Injury
    Psychological health means much more than just the delivery of 
traditional mental health care. It is a broad concept that covers the 
entire spectrum of well-being, prevention, treatment, health 
maintenance and resilience training. To that end, I have made it a 
priority to ensure that the AFMS focuses on these psychological needs 
of our airmen and identifies the effects of operational stress.
Post Traumatic Stress Disorder and Traumatic Brain Injury
    The incidence of Post Traumatic Stress Disorder (PTSD) is low in 
the Air Force, diagnosed in less than 1 percent of our deployers (at 6 
months post-deployment). For every airman affected, we provide the most 
current, effective, and empirically validated treatment for PTSD. We 
have trained our behavioral health personnel to recognize and treat 
PTSD in accordance with the VA/DOD PTSD Clinical Practice Guidelines. 
Using nationally recognized civilian and military experts, we trained 
more than 200 psychiatrists, psychologists, and social workers to equip 
every behavioral health provider with the latest research, assessment 
modalities, and treatment techniques. We hired an additional 32 mental 
health professionals for the locations with the highest operational 
tempo to ensure we had the personnel in place to care for our airmen 
and their families.
    We recognize that Traumatic Brain Injury may be the ``signature 
injury'' of the Iraq war and is becoming more prevalent among service 
members. Research in Traumatic Brain Injury (TBI) prevention, 
assessment, and treatment is ongoing and the Air Force is an active 
partner with the Defense and Veterans Brain Injury Center, the VA, the 
Center for Disease Control, industry and universities. To date, the Air 
Force has had a relatively low positive screening rate for TBI--
approximately 1 percent from Operation IRAQI FREEDOM (OIF) and 
Operation ENDURING FREEDOM (OEF)--but maintains our clear focus on this 
injury because of the impact it has on each individual and family 
affected.
Prevention
    Several years ago the AFMS shifted from a program of head-to-toe 
periodic physical examinations for all active duty members and moved to 
an annual focused process, the Preventive Health Assessment (PHA), that 
utilizes risk factors, exposures and health history to guide the annual 
assessment. Through the use of the PHA, we identify and manage 
personnel readiness and overall health status, to include preventive 
health needs.
    In addition, there are separate pre- and post-deployment health 
assessment/reassessment processes. Before deployment, our airmen are 
assessed to identify any health concerns and determine who is medically 
ready to deploy. The Post-Deployment Health Assessments are completed 
at the end of their deployment and again at 6 months post-deployment. 
Of note, questions are embedded in the post-deployment assessments to 
screen for Traumatic Brain Injury. These cyclic and focused processes 
allow us to fully assess the airmen's overall health and fitness. This 
allows commanders the ability to assess the overall fitness of the 
force.
           department of veterans affairs sharing initiatives
    Our work with the VA toward seamless care and transition for our 
military members is a high priority, particularly as we treat and 
follow our airmen redeploying from Operations OEF/OIF.
    An important lesson learned from the care of our returning warriors 
is the need for a seamless electronic patient health record. After 
assuming command and responsibility for the Bagram and Balad hospitals, 
the Air Force successfully deployed a joint electronic health record 
known as Theater Medical Information Program Block 1. This 
revolutionary in-theater patient record is now visible to stateside 
medical providers, as well as those within the battlefield. 
Additionally, clinicians can access these theater clinical data at 
every military and VA medical center worldwide using the joint 
Bidirectional Health Information Exchange. This serves to improve the 
overall delivery of healthcare home and abroad for wounded and ill 
service members.
    We are expanding our sharing opportunities with the VA, 
establishing a fifth joint venture at Keesler AFB Medical Center and 
the Biloxi VA Medical Center in Mississippi. This new Center of 
Excellence will optimize and enhance the care for DOD and VA patients 
in the area.
    Our joint venture at Elmendorf AFB, Alaska, is another Air Force/VA 
success story. In 2007, the 3rd Medical Group at Elmendorf increased 
their access by more than 200 percent for veterans in areas such as 
orthopedics and ophthalmology. This effort enhanced readiness training 
for 3rd Medical Group medics, and increased the surgery capacity by 218 
percent for the 3rd Medical Group and 239 percent for the VA. Sharing 
our medical capabilities not only makes fiscal sense and improves 
access to care for our patients; it helps to sustain our medics' 
clinical skills currency so we remain prepared for tomorrow.
                   prepare for tomorrow's challenges
Our Medics
    The demanding operations tempo at home and deployed locations also 
means we must take care of our Air Force medical personnel. This 
requires finding a balance between these extraordinarily demanding 
duties, time for personal recovery and growth, and time for family. We 
must recruit the best and brightest; prepare them for the mission and 
retain them to support and lead these important efforts in the months 
and years to come. We work closely with the Air Force Recruiting 
Service and the Director of Air Force Personnel to maximize the 
effectiveness of the Health Professions Scholarship Program (HPSP) and 
recruitment incentives. HPSP is our primary avenue of physician 
recruitment accounting for over 200 medical student graduates annually. 
Once we recruit the best, we need to retain them. The AFMS is 
undertaking a number of initiatives to recapitalize and invest in our 
workforce. Enhancing both professional and leadership development, 
ensuring predictability in deployments, and offering financial 
incentives, are all important ways in which we will improve our overall 
retention.
Graduate Medical Education
    Our in-house Graduate Medical Education (GME) programs offer 
substantial benefits and are a cornerstone for building and sustaining 
our AFMS. The Air Force has 35 residencies in 18 specialties, and 100 
percent of these are fully accredited compared to a national civilian 
average of 85 percent accreditation. This caliber of quality and 
commitment translates to a 95-98 percent first-time board pass rate for 
Air Force, Army and Navy program graduates which meets or exceeds the 
civilian national average for each of our specialties. Two of our GME 
programs, the Emergency Medicine and the Ophthalmology Residency 
Programs at Wilford Hall Medical Center TX, are rated among the top in 
the Nation.
Centers for Sustainment of Trauma and Readiness Skills
    Training our Expeditionary Airmen to be able to respond to any 
contingency is critically important. The Centers for Sustainment of 
Trauma and Readiness Skills (C-STARS) provides hands-on clinical 
sustainment training for our physicians, physician assistants, nurses, 
and medical technicians in the care of seriously injured patients. Our 
medics learn the latest trauma techniques and skills from leading 
medical teaching facilities, including the University of Maryland's R. 
Adams Cowley Shock Trauma Center in Baltimore, MD; the Cincinnati 
University Hospital Trauma Center; and the St. Louis University Trauma 
Center. These C-STARS sites offer an intense workload coupled with 
clinical experience that sharpens and refreshes our medics' trauma 
care. This training increases our knowledge and helps us care for the 
most critical injuries. We are developing plans to enhance training for 
our oral and plastic surgeons to better respond to facial trauma.
Medical Treatment Facility Recapitalization
    Our recent experience re-emphasizes that America expects us to take 
care of our injured and wounded in a quality environment, in facilities 
that are healthy and clean. I assure you that the Air Force is meeting 
that expectation. All 75 Air Force medical treatment facilities are 
regularly inspected (both scheduled and unannounced) by two nationally 
recognized inspection and accreditation organizations. The Joint 
Commission inspects and accredits our Air Force medical centers and 
hospitals, while the Accreditation Association for Ambulatory Health 
Care inspects and accredits our outpatient clinics. These inspections 
focus on the critical areas of quality of patient care, patient safety, 
and the environment of care. All Air Force medical facilities have 
passed inspection and are currently fully accredited.
Telehealth
    Telehealth applications are another important area of focus as we 
seek improvements and efficiencies in our delivery of healthcare. 
Telehealth moved into the forefront with the Air Force Radiology 
Network (RADNET) Project. This project provides Dynamic Workload 
Allocation by linking military radiologists via a global enterprise 
system. RADNET will provide access to studies across every radiology 
department throughout the AFMS on a continuous basis. Its goal is to 
maximize physician availability to address workload, regardless of 
location. Our partnership with the University of Pittsburgh Medical 
Center in this endeavor started over 6 years ago. Together we built 
telemedicine programs across the AFMS through the development of the 
Integrated Medical Information Technology System. This effort is 
providing teleradiology and telepathology to the AFMS. We are 
aggressively targeting deployment of this capability in fiscal year 
2009 to all Air Force sites.
    Also scheduled for fiscal year 2009 deployment is the Tele-Mental 
Health Project. This project will provide video teleconference units at 
every mental health clinic for live patient consultation. This will 
allow increased access to, and use of, mental health treatment to our 
beneficiary population. Virtual Reality equipment will also be 
installed at six Air Force sites as a pilot project to help treat 
patients with post traumatic stress disorder. This equipment will 
facilitate desensitization therapy in a controlled environment.
Benefit Adjustments
    Increased health care demand combined with the current rate of 
medical cost growth is increasing pressure on the defense budget, and 
internal efficiencies are insufficient to stem the rising costs. 
Healthcare entitlements need to be reviewed to ensure the future of our 
high quality medical system and to sustain if for years to come.
                               conclusion
    In closing, Mister Chairman, I am intensely proud of the daily 
accomplishments of the men and women of the United States Air Force 
Medical Service. Our future strategic environment is extremely complex, 
dynamic and uncertain, and demands that we not rest on our success. We 
are committed to staying on the leading edge and anticipating the 
future. With your help and the help of the committee, the Air Force 
Medical Service will continue to improve the health of our service 
members and their families. We will win today's fight, and be ready for 
tomorrow's challenges. Thank you for your enduring support.

    Senator Inouye. Before I proceed with my questions, I 
believe I speak for the subcommittee in thanking all of you, 
and the personnel you command for the service you render us. 
You make us very proud of what you're doing for us.
    If I may, I'd like to be a bit personal about this 
question. A few weeks ago, the men of my regiment got together 
to celebrate their 65th anniversary. And at that time one of 
the fellows piped up and said, ``You know, we're lucky, we were 
in an easy war.''
    By ``easy war'' he meant that the aftermath wasn't as 
stressful and demanding as today's war. Take my case, for 
example. It took me 9 hours, from 3 o'clock in the afternoon, 
to midnight, to be evacuated from the combat zone to the field 
hospital. Today, I suppose, I'd be picked up by helicopter, and 
I'd be in a field hospital within 30 minutes. And that alone 
has made one dramatic difference.
    Today when you look at photographs and go to Walter Reed, 
you will notice that double amputations are commonplace. In my 
regiment, there isn't a single surviving double amp. They 
either died of loss of blood, or shock, or something like that. 
But today, since, well, evacuation is so speedy, and the 
medical technology is so refined, they survive. In my day, 
whenever there's a huge battle, and stretchers are lined up in 
a tent, teams of doctors would go down the line and decide who 
to care for, and who will rest in peace. I was one of those 
selected to rest in peace, because the chaplain came by and 
said, ``Son, God loves you.'' And I had to tell him, ``You 
know, I'm not ready to see God, yet.'' And they changed my 
designation, and put me in surgery.
    That brings me to my question. I note that there's a 
proportionately greater number of those with brain injuries, 
with stress problems, psychiatric problems, than I can remember 
in World War II. Are we making a special effort?
    General Schoomaker. Sir, let me, if I could start by making 
a comment from the standpoint of the Army.
    First of all, I'd be very reluctant to compare the 
sacrifices and challenges facing your generation of soldiers or 
any generation of soldiers, sailors, airmen and marines in any 
war--I think those comparisons are very difficult, and probably 
not for people like me to make. I think we're all struck by the 
sacrifices and the courage that your generation demonstrated on 
the battlefield in defense of this country.
    I would venture to say that many of the challenges that 
your generation of soldiers faced, and marines and others, 
faced, continue to face all soldiers, in all conflicts. And one 
of the things that I think distinguishes this conflict is that 
we, as an Army, and I think we as a joint force are stepping up 
and acknowledging, really, what have been generational 
challenges to all combatants.
    The challenges of post-traumatic stress, which have 
attended every battlefield, probably, since the beginning of 
war, but have not been well documented, well acknowledged, and 
well understood--we're in an era of invention and discovery, 
and of appropriate training for resilience, screening for early 
emergence of symptoms and prevention of longstanding effects of 
combat exposure. In that respect, sir, I would say that we are 
making great headway.
    There's much to be gained, and much to be learned, yet, 
about the overlap between post-traumatic stress symptoms that 
attend a deployment, and especially in an active combat zone, 
and exposure to the horrors of war, and coexisting symptoms 
that may attend, for example, a concussive injury that is 
received as a consequence of blast.
    The second point I would make, is the one that you've made. 
We have made--as Admiral Robinson and Admiral--excuse me, 
General Roudebush have referred to--extraordinary strides in 
breaking what we thought was an unbreakable limit on survival 
of battlefield. In Afghanistan and Iraq today, and conceivably 
in every conflict that we're going to face in this era of 
persistent conflict with an adaptive enemy that uses blast very 
effectively--I've said in many fora that the signature weapon 
of this war is blast. The signature wounds are many, but the 
weapon is blast.
    We are encountering a constellation of injuries, and 
psychological challenges that are heretofore unprecedented in 
terms of survival. No, even civilian trauma center, sees the 
degree, and we know that because we bring civilian 
traumatologists to Landstuhl, and we take them into Baghdad. We 
take them into Balad, and we take them into Evensina, and we 
let them operate with us, and we let them observe what our 
soldiers and marines and sailors and airmen are exposed to. And 
they come away saying, ``We don't see this degree of trauma.'' 
And yet, at the same time, ``We don't see this survival.''
    And that is the consequences, as Jim Roudebush has said, of 
this enormous cooperation across the services, in our joint 
theater trauma team, and our registry and in real-time revision 
of our practices and our procedures and our devices that have 
kept soldiers from the point of injury to the VA hospitals or 
civilian network hospitals, or military hospitals back home, 
improving all along the way.
    So, yes, sir--we are making great strides--it's an era of 
discovery.
    Senator Inouye. Well, I'm glad we've recognized that 
there's such a thing as stress disorder. I can still remember, 
because I'm old enough to--when in the ancient war, World War 
II, a well-known general slapped a soldier because he was 
afraid, and after the Vietnam war, we looked down upon those 
who said, ``I've got stress disorder,'' that they were just 
moaning and squawking and lazy.
    But, I'm glad you realized the real thing, now I hope we 
can do something about it, because in that ancient war, at 
least we knew who'd be shooting us--they were in uniform. 
Today, there's no one in uniform on the other side. Somebody 
who may be the friendliest-looking fellow, may be the most 
violent enemy you have.

                        RECRUITING AND RETENTION

    So, my second question is, in light of the changes in 
medical service, are you having a terrible time in recruiting 
and retaining? Because I know the, on the outside world they're 
having the same thing, there are not enough nurses, there are 
not enough specialists--how about the Navy?
    Admiral Robinson. Senator Inouye, we are having difficulty 
in recruiting and retaining in that we are in the competitive 
market of the entire Nation, and we have a few things that the 
entire Nation doesn't have, and that is a volunteer force 
that's fighting a war. So, there are challenges that do present 
themselves from a medical recruitment and retention 
perspective.
    Second, the optempo that we have and the repeated trips 
into war zone or repeated trips into operational environments 
become a stressor, not only on the individual--which probably 
has a direct effect in the amount of psychological stress that 
occurs--but additionally it has a huge effect on the families.
    If you take generations of servicemembers in the past, most 
were unmarried. If you take our present generation of 
servicemembers, most are married. So, therefore, there is a new 
dynamic that has been introduced into the recruitment and into 
the retention calculus, which includes that family.
    So, there are lots of factors that are making it a little 
bit more difficult to attract people and bring them in. But I 
would say that we've made significant advances in the last 
several years on the Navy side, by making sure that we, medical 
professionals, are directly involved in going to medical 
schools, and going to professional organizations, and actually 
talking about what we do, and what we need, and what people can 
get from service to the country. Because, as an all-volunteer 
force, there are a lot fewer people today in the recruitment 
pool than in years past, but certainly the necessity of making 
sure that people understand what we need, and their obligations 
to the country, is huge.
    I think that we are slowly making turns, and I would also 
say that the retention and the bonus systems that you have 
applied for our medical officers--for our medical service Corps 
officers, our psychologists, our licensed clinical social 
workers, has made--our dentists, also, and our nurses--has made 
a tremendously positive impact in becoming more competitive in 
the job market.
    So, that's a mixed answer. I think there are some trends 
that are hopeful, but there are also challenges, particularly 
with families and with some of the new dynamics of optempo that 
we'll have to take into account.
    Senator Inouye. General--General Roudebush--do you believe 
that the personnel, in the medics--I'm talking about the 
family--doctors and physicians and nurses--do you believe that 
they are appropriately recognized by the people of the United 
States?
    To put it another way, is their morale high, or low?
    General Roudebush. Sir, the morale is good. I would share 
the concerns of General Schoomaker and Admiral Robinson, in 
that as we work to recruit the best and the brightest from a 
rather diminishing group of willing candidates in the United 
States, it is more challenging to bring these individuals on.
    But the things that we need to provide them, one, in terms 
of proper compensation, we have a special pays process and 
foundation that has not been changed drastically over the last 
10 to 12 years. In the last year or two, we have made a lot of 
progress--and thank you for helping us do that--in order to 
move that forward, and to make the compensation more 
competitive.
    But it goes beyond that. It goes to the working 
circumstances, the environment of care. As General Schoomaker 
pointed out, many of our facilities are aging. It is difficult, 
in some circumstances, to provide the quality of care that we 
need to because of aging infrastructure, but we are working 
through that.
    I will tell you that what underpins the morale most firmly, 
however, is the services that these individuals provide. Quite 
often, a deployment will be--it always is--a very challenging 
opportunity, but it's not uncommon for it to be a life-changing 
opportunity. And I'll talk to physicians or nurses or 
technicians at Balad or Kirkuk, or Bagram, and they will tell 
me, ``This is what I am trained to do. This is one of the most 
meaningful moments in my life.'' Being able to use their 
talents, use their skills, in a way that truly makes a 
difference--and come home and continue to do that. Because the 
care and the rehabilitation and the ongoing care of these men 
and women who go in harm's way, is a challenge. We are 
certainly working through that.
    But, the fact is, the morale is good. But, we need to pay 
attention to all of those factors, in terms of operations 
tempo, our facilities, our compensation system, and our 
graduate medical education in order to remain competitive and 
retain these folks. There is a high demand for our military 
medical professionals in the private sector. These are folks 
who come out with skills, a demonstrated sense of purpose, and 
ethics, and they are incredibly valuable, and are compensated 
appropriately in the private sector.
    So, it's a demanding environment, but sir, the bottom line 
is morale is good.
    Senator Inouye. Thank you very much.
    Senator Stevens.
    Senator Stevens. Thank you very much.

                    RECRUITMENT FROM MEDICAL SCHOOLS

    Admiral, you mentioned, the recruitment is fairly low, now, 
from medical schools. Do you have any idea what percentage of 
medical school graduates entered the military services?
    Admiral Robinson. Sir, I could not tell you the number of 
medical school graduates that enter military service.
    I can tell you, that in our HPSP--the Health Professions 
Scholarship Program--that we have--we have not met our goals 
for the last several years, as I mentioned in my opening 
statement, but we have increased the numbers, and we are 
probably at the--in the 60 to 70 percent range of making goal, 
and that seems to be trending upward. But total numbers of 
physicians coming out of medical school, coming into military 
services, is going to be a very, very low number. But I cannot 
give you that number. I will try to get it--unless someone else 
has it.
    General Roudebush. We have looked at that, in terms of the 
percentage of individuals in medical school classes that are 
willing to consider the military, and it's less than 10 
percent. It's probably more on the order of 7 or 8 percent. So, 
it's relatively low.
    Senator Stevens. Some time ago, I proposed that those 
people to receive a financial assistance from Federal taxpayers 
for graduate education, be compelled to provide service to some 
form of our Federal Government--not necessarily the medical 
side.
    But I'm disturbed to hear that, because I think the bulk of 
those people that are going through graduate schools today are 
receiving substantial Federal assistance. And it does seem to 
me that there's an obligation to serve, to deal with the great 
problems of those people who are in harm's way right now.
    Let me ask you this, General Roudebush. I'm sure you know, 
and you just gave the 3rd Medical Group at Elmendorf, I 
believe, we have a situation there where the Air Force is 
caring for the 4/25th Combat Brigade, and the combat team 
that's come back to our State--and doing very well. Is there 
any other place where we're taking care of the returning 
veterans of one service in the hospital of another service?
    General Roudebush. Oh, yes, sir. And I would begin with the 
wonderful care that our airmen receive at Walter Reed and 
Bethesda, in terms of care of their injuries, and as we 
transition and take care of soldiers and sailors at our 
facility--whether it's Elmendorf in Alaska or Wright-Patterson 
in Ohio, or Wilford Hall in Texas--we do see each other's 
soldiers, sailors, airmen and marines.
    I think it's important to note that one of the key values 
of our military healthcare system is that we have developed 
centers of excellence, and I'll let General Schoomaker and 
Admiral Robinson talk about that. But in terms of amputee care, 
there is no place better than Walter Reed, or Brook Army 
Medical Center, in terms of head injury care, there's no place 
better than Bethesda Naval Hospital.
    The Center of Excellence for Psychological Health and 
Traumatic Brain Injuries is a joint endeavor, and actually as 
we move toward the base realignment and closure (BRAC) 
implementation, these large platforms will, in fact, be joint.
    I have Air Force physicians, nurses, technicians, working 
at Walter Reed, for example. We certainly share the platform at 
Brooke Army, and we work very closely with our allies in Alaska 
to take care of the folks there in Anchorage, as well as in 
Fairbanks.
    So, it's a very collaborative environment that allows us to 
serve our servicemen of whatever service, close to their home, 
or in the best circumstances possible.
    Senator Stevens. Well, I would hope that there would be a 
better integration--particularly of knowledge of the expertise 
of particular areas, as you've mentioned, for dealing with some 
of these specific cases of people who are coming back who have 
a really different problem than the bulk of those who are 
returning. And I think that's true for those people who have 
been involved in units such as the Stryker units, where if they 
have any problems, they really have pretty severe problems. I 
would hope that there would be further integration.
    General Roudebush. Sir, I might add that the Air Force is 
very proud of our ability to both be critically centered in the 
saving of these lives, forward, in the joint theater trauma 
system, but then through the aeromedical evacuation system, our 
critical care, our medical transport teams, to bring these 
severely injured servicemen and women back home to their 
families and definitive care, where it's best applied. Whether 
it's at one of our military centers of excellence, or one of 
our VA polytrauma centers, which are superb in treating some 
very, very significant and very complex injuries.
    So, it really is an interdependent and interoperable system 
that's providing care that heretofore has never been seen.
    Thank you.
    Senator Stevens. General Schoomaker, and Admiral Robinson, 
I'm interested in the comment that General Roudebush just made, 
concerning Walter Reed and Bethesda. We have a BRAC deadline 
for completing the integration of these facilities now, and 
some of us are--I'm one of them--are not too happy to see a 
total integration of those two facilities--what is going on out 
there, and will they meet the deadline?
    General Schoomaker. Well, first of all, sir, let me just 
quickly echo what General Roudebush commented about, about the 
jointness of care. You know, the color and type of a uniform 
really makes no difference when it comes time to taking care of 
a warrior.
    Senator Stevens. It's not that--not that. I was concerned 
about whether or not there was access to these various 
entities, without regard to uniform.
    General Schoomaker. Oh, yes, sir, there's--I mean if you go 
to Landstuhl today, it's very hard to tell a Navy corpsman from 
an Air Force critical care doc, from an Army nurse----
    Senator Stevens. I'm not talking about them, I'm talking 
about people coming in.
    General Schoomaker. Exactly, sir. We are mixing the joint 
force to care for them, and we ecumenically care for the 
combatant, independent of what uniform they have. And I think 
one of the strengths as Admiral Robinson has mentioned, is that 
we are a disseminated system of direct care that can provide 
access to all of these.
    As far as the integration and co-location of facilities in 
the National Capital Region, integration of the National Naval 
Medical Center, Bethesda, and Walter Reed Army Medical Center 
has been ongoing, now, for a number of years. It's--full 
integration is very close, at this point. The Departments of 
Orthopedics and Rehabilitative Services, Departments of 
Obstetrics and Gynecology, medicine, surgery, these are all--
and neurosurgery--these are all integrated programs now. We 
have a single chain of clinical command and directorship for 
Navy and Air Force--excuse me, Army services between, and the 
National Naval Medical Center, Bethesda, and Walter Reed, and 
have been working on that for a number of years. When Admiral 
Robinson commanded Bethesda, and I commanded Walter Reed, we 
worked very closely in this.
    Co-location of the two facilities is what's going to be 
culminated in the final building of the Walter Reed National 
Military Medical Center, and the closing of Walter Reed, and 
the coalescence of the two facilities in one. But integration 
is ongoing, and it's very--being very aggressively pursued, and 
very successfully so, sir.
    Senator Stevens. And what's the use of the old Walter Reed 
going to be? What is the plan for that?
    General Schoomaker. Sir, that's not for me to say that. 
Under BRAC law, that's going to be turned over to other 
elements of the Federal Government, I understand the General 
Service Administration, Department of State have put a claim on 
that. But I don't have any notion of how it's going to be used.
    Senator Stevens. We have been looking at the conversion of 
medical to civilian activity as far as the treatment is 
concerned. Is there a plan in place for the conversion of these 
people over a period of time who are getting training and care, 
in your military medical facilities, is there a plan for, and 
do you follow a plan with regard to conversion over civilian 
treatment?
    General Schoomaker. Yes, sir. That's been ongoing from the 
beginning. Whether it's in the VA system, or whether it's in a 
network of private care, in partnership with our management 
care support contractors--all of the services--Admiral Robinson 
referred earlier to the Navy model of a more distributed, 
disseminated model that puts care closer to the home, and the 
home unit of the marine or the sailor. The Army uses a more 
centralized model, but still promotes getting the soldier and 
his or her family as close to home--or the parent unit--as 
possible, as close as possible and----
    Senator Stevens. Well, I'm taking too long. But my main 
concern is bringing these people--our people that have been 
assigned to Alaska, they're bringing back to Alaska, they're 
going to the Elmendorf hospital, regardless of what service 
they're in, and then there's a transition. Normally if they 
were at--in what we call the outside, the South 48--the 
transition would be to the VA. We don't have a VA facility.
    General Schoomaker. Yes, sir.
    Senator Stevens. We have to transition automatically to 
civilian operations for civilian care. And civilian care in our 
State is limited--just as you are competing for doctors, we're 
competing for doctors, and they're not there right now.
    General Schoomaker. Yes, sir.
    Senator Stevens. So, what is the plan for people in those 
circumstances--will they be moved back to Washington to 
somewhere else, if there's not a VA hospital?
    General Schoomaker. Exactly, sir. I mean, we try to target 
the care, especially for a persistent wound or injury or 
illness to where they can best receive that service--civilian, 
VA, or military direct care system, and in compliance with the 
needs and requirements of the family and the soldier. And 
that's a very, very individuated decision.

                          VETERANS HEALTHCARE

    Senator Stevens. Well, that worries me, because our State 
has the highest level of volunteers, per capita, in the 
country. And as they're coming back, they're going to the 
military hospital in Anchorage, the Air Force hospital. Some of 
them are going to Bassett up in Fairbanks, but not many. And 
once they're through that care, it looks like they're going to 
be shifted back outside, and their families are still in 
Alaska.
    I would hope that somehow we would work out some kind of a 
VA--a concept for Alaska--so they don't have to be moved back 
outside to go through VA, and then moved back into Alaska when 
they finally transition into civilian care. Most of these are 
very long-term care we're talking about.
    Admiral Robinson. Senator Stevens, one aspect that probably 
is also helpful in the continuum of care as a member, is 
transition from active duty, goes through a disability 
evaluation process--and it does depend on how that process goes 
in percent--that member and family often are then able to 
obtain TRICARE benefits which would be directly usable in any 
of the treatment facilities in Alaska, in the sense that 
TRICARE would then become one of the methods that could be 
utilized.
    It's not completely satisfactory--I understand your dilemma 
in Alaska--but it certainly is one of the other aspects of care 
of our returning warriors.
    Senator Stevens. Well, in our State that would be 
transition in many of the rural areas, Indian Health Service 
hospitals. I don't know whether you've ever worked out any 
arrangements with them, but I'd encourage you to do so.
    Thank you very much, I've taken too much time already.
    Senator Inouye. Senator Mikulski.
    Senator Mikulski. Thank you, Mr. Chairman, and gentlemen 
for the excellent testimony.
    All of us recall where just a very short time ago, this 
room was jam-packed for a hearing on military medicine because 
of the press accounts on the Walter Reed scandal. We want to 
thank you for what you've done to clean that up, and that's 
going to be, really, my line of questions.
    We want you to know, we're on your side. For those of us 
who've never worn a uniform, know that we feel that the best 
way to support our uniformed services, is not only in the 
battlefield, but with military medicine. And the opstempo that 
you face, the challenges of a war that's gone on for so long, 
the volume of injury, the new kinds of injury, and the old 
kinds of injury. And what we see is almost a 50-year war, in 
the sense of, not over there, but when we look at these men and 
women who've come back, some bear the permanent wounds of war, 
all will bear the permanent impact of war, and we need to know 
what that means--from stress to terrible injuries like 
amputation.
    So, what I want to follow in my line of questions today is, 
what did we do in response to Walter Reed, and I'd like to 
refer in my questions to the Dole-Shalala report, which I think 
was a definitive report, and gave us benchmarks and guidelines 
about where to go.
    I'd like to thank General Pollock, General Schoomaker, 
who--during the interim of change from one Surgeon General to 
the other, really stepped up to the plate and, I think we owe 
her a debt of gratitude, and we'll be talking to them about the 
nursing shortage later.
    But here's what Dole-Shalala said, ``We need to serve those 
who were injured, support their recovery and their 
rehabilitation, and simplify the complex system that frustrates 
soldiers and families.'' Their very first recommendation was, 
create a patient-centered recovery plan. And with that, I 
believe you've established something called the warrior 
transition units (WTUs)--that, in other words, it was not only 
the brilliant work done on the battlefield, at Lundsfeld and 
the hospital here--or even at Walter Reed itself--but it was 
what happened when they transitioned from acute care to 
outpatient care, that people began to fall between the cracks.
    Could you tell us what you've done to implement Dole-
Shalala, to create a patient-centered recovery plan? Where are 
we on the warrior transition units--do we have enough of them? 
Do we need more people? Do you need more money? What do we need 
to do to implement Dole-Shalala?
    General Schoomaker. Yes, ma'am, thanks for that question--
and you're absolutely right, we owe a great debt of gratitude 
to Major General Pollock, who stepped into the breach as the 
acting Surgeon General during that time, and really took the 
bull by the horns, as we were working at the operational level 
to make changes.
    Probably, in a nutshell, I would say that what the Army 
did, almost immediately, was to stand up a program we call the 
Army medical action plan. And a commission chartered by the 
Chief of Staff of the Army, the Secretary of the Army, and 
overseen very, very closely by the Vice Chief of Staff of the 
Army, Dick Cody.
    The Army medical action plan, overseen by Brigadier General 
Mike Tucker, who served as my Deputy Commander at the North 
Atlantic Regional Medical Command, and then later was elevated 
to an Assistant Surgeon General, the first Assistant Surgeon 
General for Warrior Care and Transition. The Army medical 
action plan began immediately to identify problems, to work 
closely with the Independent Review Group, chaired by former 
Secretaries of the Army----
    Senator Mikulski. Please, General, I have limited time.
    General Schoomaker. Yes, ma'am.
    Senator Mikulski. Tell me what we're doing for patients, 
rather than military bureaucracy and acknowledging the 
wonderful people who did it.
    General Schoomaker. Ma'am, the answer was intended to 
describe that, as Dole-Shalala stood up, we took every idea and 
every recommendation of Dole-Shalala on the fly, and applied 
that. And the Army today has created that patient-centered 
program that is described, is working very closely with the VA 
and the other services to provide the care that Dole-Shalala--
--
    Senator Mikulski. But how many do you have?
    General Schoomaker. I have 35 warrior transition units, we 
currently have 11,280 soldiers, warriors in transition that 
have been taken out of a variety of units in the Army with 
wounds, illnesses or injuries--many non-battle related--and are 
now cared for in a patient-centered focus around a triad of 
care. A squad leader at the small unit leader level, a nurse 
case manager, and a primary care physician.
    Senator Mikulski. General, let me go to the case managers, 
because in February 2007, besides the fragmented senior 
leadership--which obviously, from your description, has been 
corrected--there was a lack of integrated casework. There were 
no, really, primary care managers. The nurse case managers had 
been eliminated, in yet one other DOD reorganization plan years 
ago. There were no advocates, forgotten families, complaints 
fell on deaf ears--you know them, I don't need to give the 
laundry list.
    Can you tell us now where we are in the case management? 
And do you really have enough of these warrior units--I think 
the military action plan is a great way for implementing the 
Dole-Shalala recommendations. But, where are we on the care 
managers? What is the ratio? The nurse case managers, with the 
nursing shortage? Do you have enough? Is there an ombudsman in 
every unit?
    General Schoomaker. Yes, ma'am. It's very, very closely 
monitored--thanks for that question--it's very closely 
monitored----
    Senator Mikulski. Because it goes to your human capital 
needs.
    General Schoomaker. Yes, ma'am.
    Senator Mikulski. These are not meant to be, ``Are you 
doing your job?'' it's how do we all do our job?
    General Schoomaker. Well, I think what the Walter Reed 
experience taught was that we had drifted over the last two 
decades to a model of pure inpatient and outpatient medicine, 
and we'd forgotten much of what Senator Inouye's generation was 
exposed to, which is an intermediate rehabilitation capability 
that had transition from one to the other. We've recreated 
that. And we've partnered with the VA and with the private 
sector, now, to have a very comprehensive handoff--we call it a 
comprehensive care plan--that begins almost from the point of 
injury, and throughout the acute phase, the recovery phase, and 
the rehabilitation phase, even into the VA or the private 
sector, we have a system of administrative leaders, of 
clinicians, and of nurse case managers, working in close 
relationship with VA coordinators, as well, to ensure that 
we've got this warm handoff taking place.
    Senator Mikulski. Well, that's the plan, but let me go 
again. Do you have enough nurse case managers?
    General Schoomaker. Ma'am, we've managed--we manage that 
very closely, we monitor it, our ratios--our expected ratios of 
nurse case managers to warriors in transition is 1 to 18. We 
closely monitor that to ensure that we've--we are safe in all 
regards.
    I would have to say, as the population continues--as we 
identify more soldiers that are better cared for in the WTUs, 
we bring them in and bolster the----
    Senator Mikulski. And remember, these are not accusatory 
questions----
    General Schoomaker. No, ma'am.
    Senator Mikulski [continuing]. These are how do we get to 
make sure?
    General Schoomaker. And there's probably no group in that 
triad of care right now that is more challenging to recruit 
than our nurse case managers.
    Senator Mikulski. And we're going to come back to that.
    Does every unit have an ombudsman?
    General Schoomaker. We have 29 ombudsman across the 35 
units, some of them are regional in their focus, but they have 
access to an ombudsman in every warrior transition unit. And in 
the large ones, we have assigned one or two ombudsman directly.
    Senator Mikulski. And we asked that a hotline be 
established, so that if you had a problem----
    General Schoomaker. Yes, ma'am.
    Senator Mikulski [continuing]. You could dial 100, 1-800, 
Hi Army, I need help.
    General Schoomaker. We have a 1-800 line, I'd be happy to 
pass a card to you. We pass these cards out to every family 
member and soldier and members of the community. Any question 
about any aspect of anything, from pay to housing to nonmedical 
attendants, we've got a hotline that solves the problem. We've 
taken about 7,000 to 8,000 calls in the last year to this 
hotline.
    Senator Mikulski. Well, I just have one other area of 
questioning and come back, because this is really digging into 
it.
    Coming again back to Dole-Shalala in our own conversations, 
it says to restructure the disability systems, and we need to 
have a seamless effort between VA and DOD. One, the transition 
of the warfighter from military to VA, and that goes to the 
transition of care, and then this whole issue of reorganizing 
the benefit structure.
    Both you and, also our other Surgeons General, how do you 
think that's working? The feedback I get anecdotally in my own 
State is that it is enormously uneven, that the real problem--
one of the real problems here in implementing the 
recommendations from Dole-Shalala is that the connect between, 
I'll call it DOD medicine, and then VA--both particularly in 
the areas of disability benefits and handoff--can be 
disjointed.
    General Schoomaker. Ma'am, the current system of 
disability, the VA and DOD systems, was developed 50 to 60 
years ago, in an era in which, as Admiral Robinson said, our 
soldiers, sailors, airmen, marines were largely single, we did 
not have a TRICARE healthcare benefit, and we did not have the 
complex wounds that we see today.
    In 2008, what we're now faced with is a system of 
disability adjudication in the DOD that largely focuses on 
whether you're fit for duty or not, and then adjudicates 
disability based upon that single unfitting condition, even if 
you've got a variety of other injuries or problems, and even 
using the same tables of disability that the VA uses.
    The VA then turns to the same soldier and says, ``I will 
now assess disability based upon the whole person concept, and 
your employability and your quality of life.'' The military 
attaches to the disability adjudication for that single 
unfitting condition, whether or not you have access to lifetime 
benefits for TRICARE. And for a family who is seeking, and a 
soldier who is seeking disability at a threshold, 30 percent, 
that then gets them access to TRICARE, they see the military as 
being stingy for them, while the VA does not.
    Until we have a single system of disability adjudication, 
and a national debate about what service and injury or illness 
in-service warrants that soldier, sailor, airman, marine, we 
will not resolve the flashpoint injury--the problem of the 
physical disability evaluation system.
    Senator Mikulski. Well, there's an 18-month backlog in 
getting evaluated for VA disability. That is the subject of 
another hearing, General, and not your responsibility, but it 
is.
    But it goes to what Senator Stevens raised about the Alaska 
soldiers. What I hear from my own--a lot of my own military 
that have suffered injuries, is the reason they seek a 30 
percent or more disability, it's not for the money or 
commissary privileges, because they'll stay in TRICARE. And in 
TRICARE they feel that they have a medical home, and they know 
the rules of the game. And that medical home means they can 
have access to military facilities, where those academic 
centers of excellence or others in their own community, but 
they know they will have a home.
    When they worry that if they go to VA, the disability 
ascertainment is prolonged, there's enormous stress on them, 
you have to go to the VA facilities. They feel that they're 
going into a black hole that they don't know from which they're 
going to emerge.
    So, what they like about the military and TRICARE, is they 
feel it's been their one-stop shop, even as they might be 
transitioning to civilian life.
    And, what we worry about, then, because it's really been 
the Walter Reed scandal, and then these excellent commission 
reports that was to drive, pretty strongly, that there be this, 
really, seamless connection between DOD, military medicine, and 
the transition. So my question is, do you feel--in addition to 
the need for a national debate, and I agree--do you feel that 
this is really happening? Do you feel that there is this same 
sense of urgency when this was all over CNN?
    General Schoomaker. Ma'am, I think there's a great sense of 
urgency, and we have a pilot program right now in the National 
Capital area in which we're looking at a large number of 
soldiers, marines, and others to see if we can't smooth out and 
reduce the bureaucratic hurdles and hassles associated with the 
physical disability system in--under current law.
    But I want to say that I think we all recognize that we 
still have this 500-pound gorilla in the room, and that is the 
threshold of disability and a single adjudication of disability 
that access----
    Senator Mikulski. And who would make those decision?
    General Schoomaker. Ma'am, that has to--that is--that is in 
law, and without changing the law----
    Senator Mikulski. But who makes the recommendations to 
change the law?
    General Schoomaker. I think right now the Senior Oversight 
Committee that is meeting between the VA and the DOD and is in 
a position to help make----
    Senator Mikulski. But we're looking for the 
recommendations. Do we ask that of Secretary Gates, the 
Secretary of the VA, do we ask for a conversation with the 
President, how do we get these changes?
    General Schoomaker. I think that at the Secretary level is 
probably where it needs to begin.
    General Roudebush. Ma'am? I agree. I think it does get to 
the secretarial level and above, because what you're--you are 
doing is you are making a decision based on both medical and 
administrative pay and benefit issues that encompass the entire 
benefit for that individual. So I think it does rightfully 
accrue to the leadership positions, and I would echo General 
Schoomaker.
    At the Senior Oversight Committee, which is co-chaired by 
Deputy Secretary of Defense Mr. England, and Deputy VA 
Secretary, Mr. Mansfield, there is a sense of very important 
urgency to get this right, in order to be able to do that 
across the entire spectrum of activities to include medical.
    Senator Mikulski. Well, I've exceeded my time and we'll go 
to this.
    First of all, know that I believe real progress has been 
made. So, I believe that real progress has been made, and we 
thank all who were involved in that. I think there's still much 
to be done, because these military warriors--these warriors are 
going to be with us a long time and we have an obligation. And 
not only where there's been these severe injuries.
    Then there's this whole impact on the families. You said 
they were mostly single. Well, they also had a mother. When I 
visited these bases, it's either the spouse or the mother 
that's there. We viewed them as unpaid attendants, and if we 
get an opportunity for a second round, we'll be talking about 
the family. But, I think we're looking forward to regular 
reports and conversations on how to implement this, and we have 
to ask the Secretaries about this.
    And, Mr. Chairman, I think it might be the subject of 
another hearing, particularly also with our colleagues in VA.
    Anyway, thank you very much.
    Senator Inouye. Thank you.
    Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman.
    And thank you all for being here today, for your testimony, 
and for the work that you do for the men and women who serve 
our country. It's an honor for me to follow the angel on our 
subcommittee, and thank her for all of her work, as well as our 
chairman.
    We were here 1 year ago under a lot of stress and looking 
at a system that was literally broken. And we have made a lot 
of progress, not just at Walter Reed, but across the country, 
out in my State at Madigan and other facilities. I've been 
there, I've been on the ground, I know that we're making 
changes, but I also agree with Senator Mikulski, we still need 
a sense of urgency. There are big questions left remaining. It 
is about how we work our way through this, but also how we have 
the resources to do it. And it's making sure that we have the 
commitment from this administration and from Congress to back 
them up. I know the American people are there, that when we ask 
someone to serve our country, we have to be there to follow up 
with the money to take care of what we--what their needs are, 
and I think that's part of what the challenge is that we face.
    Senator Mikulski asked a number of questions about the 
whole process. Let me focus on a very real concern that I still 
have that really still needs a sense of urgency, and that is 
the invisible wounds of war, the psychological needs of our 
soldiers when they come home. I know I've talked to soldiers 
and airmen and, of all of our components who feel like they're 
a left behind because the American people can't see their 
physical wounds of war.
    And we still have tremendous challenges in front of us. The 
MHAT 5, that was recently released, illustrated the 
psychological stress that our deployed servicemembers are 
under. I was concerned because this study only focused on the 
active duty. We have a large Reserve component, and 
particularly the National Guard that has really unique 
concerns. They've been deployed and redeployed, and it seems to 
me that there are no near-term plans to discontinue the use of 
our Reserve component. So I wanted to ask you, do you think 
it's important to evaluate their overall health, as well?
    General Schoomaker. Yes ma'am, I think MHAT 5, the Mental 
Health Advisory Team 5th iteration, fifth year, really focused 
on two active component brigades only because of the force mix 
that was in-theater at the time, Afghanistan and Iraq. In past 
MHATs, they've also studied Reserve component brigades.
    And this is one Army, ma'am, we are as concerned about the 
mental health challenges for the National Guard and Reserve as 
we are for our active component. In fact, as is pointed out by 
their leadership and by their State's representatives, they 
frequently have to go back into parts of America, as Senator 
Stevens has said, where we don't have access to the direct----
    Senator Murray. That's correct.
    General Schoomaker [continuing]. System, the VA system is 
even sometimes not readily available.
    Senator Murray. Do you intend to do an evaluation?
    General Schoomaker. Yes, ma'am, we're following that very 
closely, we're working with the Reserve component to look at 
the best solutions for those soldiers as they----
    Senator Murray. I would like to be kept up to date on what 
your--what your evaluations are and your recommendations from 
those.
    General Schoomaker. And, ma'am, you need to understand, 
too, they're held to the same standard that--upon return and 
reintegration, 90 to 180 days after being redeployed, they have 
to go through a post-deployment health reassessment that 
screens for the symptoms of post-traumatic stress.
    Senator Murray. Right. I am told that in the first part of 
the war, the ratio of servicemember to psychological healthcare 
provider in-theater was close to 800 to 1. We've been working 
on this and trying to improve it, but it's back up to 740 to 1 
and rising. What is being done to reverse that trend?
    General Schoomaker. Ma'am, we've always stayed below what 
our target was, which was better than one behavioral health 
specialist to 1,000 soldiers.
    We've--our biggest problem, I would have to say--and we've 
revised this on the fly--is the distribution of our soldiers. 
Many of our soldiers, especially in Afghanistan and other parts 
of Iraq, work in very distributed teams that are not accessible 
to our forward-operating bases and places where we have a 
density of--of mental health workers.
    What we've done is to try to redistribute mental health 
workers. We work closely with the Air Force at Bagram, for 
example, which has got the lead on much of the healthcare in 
the Bagram area, to get care out to the individuals.
    We're also----

                        MENTAL HEALTH PROVIDERS

    Senator Murray. Is the--is there a challenge in filling the 
billets for healthcare, mental health?
    General Schoomaker. Oh, yes, ma'am. Our behavioral health 
specialists, psychologists, social workers, psychiatrists are 
some of the most frequently deployed.
    Senator Murray. Is that true across the services?
    General Roudebush. Yes, ma'am, it is.
    Admiral Robinson. Yes, it is.
    General Roudebush [continuing]. We have Air Force providers 
in support of Army units and other distributed units. So it's a 
very joint approach to that. And I would emphasize that it also 
goes beyond, although it focuses appropriately on the mental 
health and behavioral health professionals, we are sure that 
our other providers--both our critical care and our primary 
care providers--are also trained in detecting and treating 
issues relative to behavioral or mental health concerns, and to 
be able to trigger and get the individual to more definitive 
care, if required.
    So, it's a broader system than just the mental health 
professionals, but obviously that's a key and critical part of 
it.
    Senator Murray. I think it's one that we do need to focus 
on. And interestingly, I have a member of my staff who is a 
psychiatrist and he tried to volunteer his time to help 
servicemembers and their families who have TBI and PTSD, and 
was told that he couldn't volunteer. And I know, if he's one 
psychiatrist who's willing to do that, there are others. Any 
idea how someone can volunteer?
    General Schoomaker. Actually, the American Psychiatric 
Association has come forward with an offer of individual 
volunteers. What we try to do is provide that knowledge to 
patients.
    Our problem is, we cannot certify thousands of voluntary 
psychologists or psychiatrists, under our system, but we can 
certainly give our patients----
    Senator Murray. But if they are certified----
    General Schoomaker [continuing]. Access to the----
    Senator Murray [continuing]. Psychiatrists, is there a way 
for them to provide a service, at a time when we need----
    General Schoomaker. We can get back to your staff and talk 
to you.
    Senator Murray. I would like to know that. I mean, I'm sure 
there are other people in the country today----
    General Schoomaker. Yes, ma'am.
    Senator Murray [continuing]. Who feel very strongly----
    General Schoomaker. The APA has been forthcoming.
    Senator Murray [continuing]. About supporting our soldiers 
when they come home. They are certified and it seems to me 
that, you know, we ought to be using them.
    General Roudebush. Yes, ma'am, in fact we do some of that 
through the auspices of the Red Cross, we do have medical 
professionals who volunteer, both home and we've had 
individuals at forward locations, at Landstuhl, for example, in 
that regard, so I really appreciate your interest in that.
    Senator Murray. Okay.

                                SUICIDES

    Let me ask specifically about suicides. Because the suicide 
rate is very disturbing--as it should be--to all of us. And I 
know the military says that personal and family problems 
contribute to the increase, but it's also apparent that there 
are other significant contributors--increased lengths of 
deployment, repeated deployments, decreased dwell times--I 
think we all have to agree have had a huge impact on the 
psychological health of the men and women who are serving us.
    I know that there are several initiatives in the military 
to reduce the stigma of seeking mental health, and to providing 
professional mental health care. I'd like to ask you all how 
you see the efficacy of those initiatives today?
    General Roudebush. Ma'am, I can speak to the Air Force 
Suicide Prevention Program, which was initiated in 1996, which 
is a broad-spectrum, community-based program which focuses on 
both the individual de-stigmatizing the act or the request for 
getting help, but also leverages all of the capabilities--
whether it's mental health, family support----
    Senator Murray. Do you see it working?
    General Roudebush. Our suicide rate is 28 percent lower now 
than it was in 1996 when this was implemented. And the program 
has been reviewed by the fact and outcome-based entities within 
the United States, and has been found one of the few that 
truly, substantively works.
    Senator Murray. Admiral.
    Admiral Robinson. I think there are a couple of factors 
that are very important in the suicide rate. First of all, it 
is the number of exposures to stress, the number of exposures 
to the types of things that will create destabilizing, 
psychological events in one's life. And so, therefore, you need 
to look at who's, in fact, going forward, fighting, and being 
exposed to that repeatedly, as you're looking at the total 
psychiatric, psychological health and emotion health of an 
individual, and their family.
    The second factor is, there has to be embedded--and I think 
that I will emphasize embedded--mental health professionals--
not always psychiatrists, but social workers, psychiatric nurse 
practitioners, psychologists, psych technicians--that are with 
the units so that the stigmatization and other things become 
much less because that person, those team of people, become a 
lot less.
    Senator Murray. And you have that?
    Admiral Robinson. We have OSCAR units, we have seven. We 
think we need 31, so to your question of numbers--yes, we do 
not have enough, we need more, and it is exceptionally 
difficult. And then if you take into consideration that those 
psychologists, psychiatrists and mental health professionals 
are deploying at about the same rate as my general surgeons, 
you will see that trying to get people to stay under those 
types of circumstances becomes problematic. So, those are 
issues that need to be considered.
    And third, there has to be training and teaching that 
occurs at all levels--it has to be from the recruit to the war 
college, it has to be the lowest level, and it has to have line 
leadership that is involved with it. It is not a medical issue, 
per se, it is actually a line and a leadership issue. Medical 
takes the lead on the education, line takes the lead on the 
implementation, and utilizing it, and getting it out to the 
people that need it.
    So, those factors, I think, when you consider them, will 
reduce some of the issues with suicide, and with psychological 
issues----
    Senator Murray. But I'm hearing you say we still don't have 
enough of that, across-the-board professionals on the ground, 
and that's a concern.
    General Roudebush. That is correct. We do not have enough.
    Senator Murray. General.
    General Schoomaker. We are greatly concerned about--the 
Army is greatly concerned about the trends in suicide, and we 
are looking very carefully at this. We have a general officers 
steering committee that has met several times, and is 
recommending expansive changes to the leadership of the Army.
    I go back to what Admiral Robinson just said--suicide 
prevention ultimately is a commander's responsibility, and it 
revolves around small unit leadership, NCO and officer 
leadership. We in the medics are in support--along with the 
chaplains and others--and we are looking at a comprehensive 
program within the Army of education and reaching out to change 
the behaviors of small unit leaders and fellow soldiers, to 
identify the behaviors that will predict this impulsive act, 
frequently around the rupture of a relationship--either with 
the Army, or with a loved one--that seems to trigger this 
within the Army.
    Senator Murray. Do you know what the wait time is for a 
soldier to see a mental health professional?
    General Schoomaker. In an urgent situation, there is no 
wait time, ma'am.
    Senator Murray. How do you know if it's urgent?
    General Schoomaker. I mean, if it's identified as an urgent 
issue----
    Senator Murray. Sometimes, somebody just comes to a door 
and says, ``I need some help.'' If somebody just comes to the 
door and says, ``I want to talk to somebody,'' what's the wait 
time, do you know?
    General Schoomaker. Again, if it in any way relates to 
suicidal behavior, ideation, or fear of----
    Senator Murray. I'm not asking from an aggressive point of 
view, I--because our job is to provide the resources, so that 
you all can provide the people out on the ground. And my 
question in asking about the wait time is, that's critical 
knowledge for us to know whether we're providing enough 
resources for people.
    General Schoomaker. I think I would have to answer that it 
would be highly variable based upon the community. In some 
communities it may be as long as a week or 10 days. In other 
communities, it may be nearly instantaneous.
    And it really is a function--in Fort Drum, New York, for 
example, where we're constrained to get the mental health 
resources that are needed, it might be a little more 
difficulty. In the National Capital Region, or in San Antonio, 
it might be a completely different matter.
    Senator Murray. Okay, well, that is disconcerting to hear. 
And obviously we need to, I think, make sure we are dealing 
with those invisible wounds of the war, and providing the 
personnel and the support and all of the right processes.
    I have a number of other questions that I'll submit for the 
record, but thank you very much, Mr. Chairman.
    Thank you, to all of you.
    Senator Inouye. Thank you very much.
    Senator Feinstein.
    Senator Feinstein. Thank you very much, Mr. Chairman.
    Good morning, gentlemen.

                            DEPLOYMENT TIME

    Now that troop deployment time has been reduced from 15 
months to 13 months, I wanted to ask you for your reflection--
from a medical point of view--on the length of a deployment, as 
it relates to health, and particularly stress. It seems to me 
that the unpredictability of the kind of war that this is for 
an individual, makes long deployments very difficult. And I 
wonder if there is any medical recommendation as to what the 
deployment should be--and by should be, I mean, a deployment 
that makes sense, that gives the individual the best, optimum 
time, without some of the adversities that long deployments 
seem to bring about. Is there any medical advice as to what 
that length should be? General Schoomaker.
    General Schoomaker. Ma'am, that's a difficult question--
there's actually three variables, I think. The length of the 
deployment, the frequency of redeployment, and the dwell time 
between deployments. All three variables are critical.
    Senator Feinstein. But how would you--what would you say 
would be a model system which would minimize health impacts?
    General Schoomaker. It would be a system that probably 
reduces deployment length to the 6 to 9 month range. It would 
include a dwell time that exceeds 1\1/2\ years, or resets 
around 1\1/2\ years, at best, in the minimum, and reduces 
redeployment, obviously, to the minimum. And I think all of 
those things are focuses of the Army leadership.
    Senator Feinstein. Thank you.
    General Schoomaker. The MHAT studies, ma'am, have 
documented, in terms of stress--self-reported stress--what the 
effects of the longer deployments have done.
    Senator Feinstein. Admiral.
    Admiral Robinson. Yes, Senator Feinstein.
    The last thing General Schoomaker said about the studies--
there's no question that repeated exposures to stress, repeated 
exposure to traumatic situations, will increase emotional and 
psychological health issues. The inability to get proper dwell 
time, to come back and to recalibrate, has a devastating 
effect.
    I think what General Schoomaker outlined is very 
reasonable, I think the marine model of, probably, 6-, 7-month 
timeframe is optimum, ideal. And if that could occur within a 
dwell time that would exceed that amount, and come back to 
recalibrate, to reset, as it were, would be very good.
    Senator Feinstein. General, would you like to comment?
    General Roudebush. Yes, ma'am. Of course, in the Air Force, 
our deployment times have traditionally been shorter--we've 
moved from a 120-day, for example, Air Expeditionary Force 
(AEF) rotation, but depending on the availability of a 
capability, the deployment time may be longer than that, maybe 
180 days, maybe 1 year.
    I agree with my colleagues that the 6 months, plus or 
minus, is probably a goal to approach, however, there are 
operational issues. If you're on the ground, building 
relationships, 6 months may be inadequate to really build the 
kind of relationships and become mission effective. So, there 
are going to be those times when perhaps operationally, the 
deployment would appropriately be longer.
    But, I can tell you that my leadership pays very close 
attention to the rotational dwell time. The policy looks to 
optimize that for the weapons system that we're utilizing. We 
are also working to assure to take care of the families, as 
well. With an all-volunteer force, the individual chooses to 
join, but literally, the family chooses to stay.
    Senator Feinstein. Right.
    General Roudebush. So, it's important that we consider all 
of those factors as we look at our rotational and deployment 
policies.
    Senator Feinstein. You mentioned--if I just might follow-up 
with the General for a minute--you mentioned, dependent upon 
the weapons that are used--are you saying the more 
technologically developed those weapons are, the shorter the 
time should be?
    General Roudebush. No, ma'am. We have weapons systems that 
are very highly, technologically capable, but are in limited 
quantities, and high demand. So, those systems tend to stay 
deployed for longer.
    Senator Feinstein. I see, I see.
    General Roudebush. We also have individuals, for example, 
operating Predators who live in Las Vegas, drive to Creech Air 
Force Base, Nevada every day, perform that critical mission, 
and then come home. But those folks require care, as well, 
because psychologically, and from a mission operations tempo, 
that's a very demanding mission. And you have to be able to 
balance a family life with an operational life, that, for some 
of our airmen, is a very demanding issue.
    This war has created scenarios that we need to pay very 
close attention to.
    Senator Feinstein. General, you wish to----
    General Schoomaker. Ma'am, I just wanted to make sure--I 
want to qualify my comments earlier. You asked me for a medical 
assessment----
    Senator Feinstein. That's correct.
    General Schoomaker. Not an operational assessment.
    Senator Feinstein. That's correct.
    General Schoomaker. There are obviously operational 
imperatives that dictate length of deployments and redeployment 
and dwell times between. But, from the standpoint of what we 
empirically observe are the stresses upon individuals and 
families, the model that I depicted probably begins to approach 
what we think is sustainable.
    And we have models, for example, in the special operations 
community, special operations soldiers, airmen, SEALS, will 
deploy multiple times--eight, nine times--but for a shorter 
duration, with longer dwell times, that allow them to reset and 
prepare for the next deployment.
    Senator Feinstein. Do you think operations like that, the 
shorter deployment, the longer dwell time, is really the 
formula that we should seek for the future?
    General Schoomaker. Ma'am, I think that's really a mixture 
of operational and other considerations, that I'm really not 
prepared to answer.
    Senator Feinstein. I think, because one of the things that 
comes into this, this war has gone on for so long, and could 
conceivably continue on. And the kinds of injuries require 
long-term care. I'm thinking, particularly, because battlefield 
medicine is so good today--fortunately--that people who would 
have died from traumatic brain injury are saved, and they go 
on.

                             VETERANS CARE

    But what I'm finding in areas, is that they really need 
more than the system out there gives them to sustain their 
relationships and their lives over a substantial period of 
time. And one of the things that I've just been thinking about, 
because when I visit the VA--particularly in Los Angeles, the 
big campus on Wilshire Boulevard, it's over 300 acres--the 
thought occurs, if this could be a kind of residential 
community where families that really need help, because 
somebody is damaged to the point that they can't really operate 
really well, receives the kind of nurturing that's going to be 
necessary for the rest of their life.
    I think on a young family, this is a very hard thing to 
come to grips with. And I don't know if you all kind of at the 
top of the medical infrastructure has given it much thought. 
But, if you have, I'd sure like to know your thinking on that, 
whether it makes sense for us, as part of the VA, then, to 
build some real--some communities for families, where they can 
come and live. If the wife needs to work, she can work, but if 
the husband has a brain injury that's really going to suspend 
his effectiveness for the rest of his life, they get some 
additional care, on site.
    Admiral Robinson. Senator Feinstein, I think that approach 
is very good. I have given this thought from a surgeon's 
perspective--I mean a clinical surgeon, not Surgeon General, 
also from a commander, and not the Surgeon General perspective. 
Military medicine has traditionally been acute care medicine, 
we are a victim of our own success, now. You're absolutely 
right, TBI and many other injuries that we have now, we have 
only because we have such an incredibly wonderful survivability 
rate.
    Systematic rehabilitative care, has been traditionally the 
purview of VA. We now have a morphing of that, because we now 
have the acute care, active duty, or the military side, that 
has gotten involved in systematic rehab care. We also have had, 
through the years, between Vietnam and this war, disconnects--
those disconnects between DOD, between military medicine and VA 
are much, much, much, much less now. But there was a ramp-up, 
and there were learning curves, there were issues. They are not 
over.
    And the issue, then, becomes, because the issue that I 
think about a lot, is the sustainment of the care----
    Senator Feinstein. Yes.
    Admiral Robinson. Senator Mikulski said the 50-year war, 
that is absolutely correct. Because we know that many of the 
individuals that we have coming back are going to need a 
lifetime of care.
    So the goal is--how do we get to a sustainment of the care 
needed by the members and families, that we now have? And that 
is a huge problem, and burden, on us from a military 
perspective, because you are a soldier for life, you are an 
airman for life, you are a sailor for life, you are a marine 
for life, you are a Coastie for life--we have an obligation to 
care for you. The key is, how? And again, systematic 
rehabilitative care has traditionally been the VA.
    Your thoughts as to a possibility of how, seem very 
innovative and creative and, I think, should be explored. But 
we need to even take a deeper look as to how we're going to 
meld the DOD, the direct care, and the VA, the systematic 
rehabilitative care.
    Senator Feinstein. Thank you, Admiral.
    General.
    General Schoomaker. The Admiral has echoed my thoughts. I 
know that what you are discussing is of great interest and 
focus of Secretary Peake, and the VA. And I think we're in an 
unprecedented era of urgency about cooperating between the 
military services and the VA. We have very, very good relations 
and exchange of thoughts, ideas, people and the like.
    I would--this may be a good point to insert--there have 
been several truly miraculous events, if any war has a good 
side. One, we've talked about this unprecedented survival of 
wounds. The fact that we have an Air Force medical system that, 
in cooperation with the Army and the Navy, has evacuated now 
50,000 patients and strategic evacuation has not lost a single 
patient. Is running intensive care units (ICUs) in the air, and 
has not lost a single patient.
    But the other thing that's important here, is that in the 
first year, our system returns to duty two-thirds of the 
wounded, ill and injured soldiers. So, it's not a one-way 
street into rehabilitation and disability. It's a process of 
renewing the force, and retaining--in the Army alone--up to two 
brigades worth of voluntary soldiers, who want to remain in 
uniform. And that's one of our key goals.
    Senator Feinstein. Right, right.
    Well, I've been thinking--I've been out there twice now, 
and looked at it--it's, we've got 300 acres in the heart of Los 
Angeles, with neighbors around them not wanting commercial 
office high-rises. And the opportunity to do something truly 
innovative, right in the middle, with a first-rate hospital 
there, all of the amenities that you need to provide the kind 
of living circumstance for families--because there's enough 
property to do it--I think is really exciting. And I think 
we've got to start to think that way.
    I mean, I know of families where there has been traumatic 
brain injury, and they go back to a very rural community where 
they're isolated. And it's very difficult for them. Because 
they can't get the daily help they need to sustain that family.
    So, if you gentlemen wanted to take an interest in that, 
I'd be happy to show you around the L.A. VA facility, because I 
think something truly innovative ought to be done there for 
veterans.
    Well, right.
    General Roudebush. Ma'am, your point is very well taken, 
and as we look at the continuum from the care within the active 
duty construct to include both rehabilitation and return to 
duty, the transition to the VA, where that's appropriate. But, 
for many of our guardsmen and reservists that live in 
communities that are not near a VA, I think we also need to be 
thinking beyond how we approach that continuum of care, and we 
don't have the answer yet.
    But that is a concern, and something that I think we need 
to look at within our Nation in the more rural areas, where 
many of our reservists and guardsmen live--how we care for 
them, how we care for their families, and how we approach this.
    But I would offer one thought as we look at how we position 
ourselves very well to take care of those men and women who are 
ill or injured as a result of this conflict. With your help in 
this subcommittee, it also keeps us looking over the horizon, 
to look at what the next conflict may be, or the next set of 
challenges, to be sure that we're appropriately positioned, 
resourced, trained and equipped to meet that challenge, as 
well.
    So, it is a daunting task, and one that I know my work with 
the staff and with the members of this subcommittee--we very 
correctly focus on today's fight, but we also look over the 
horizon to see what might be next, to assure that we're able to 
meet that mission, as well. And it may be rather different than 
the fight we're fighting today.
    Senator Feinstein. Exactly.
    Thank you very much.
    Thank you, Mr. Chairman.
    Senator Inouye. Thank you very much.
    In about 35 minutes, the Appropriations Committee will be 
meeting to consider the President's supplemental appropriations 
request. It's a very important hearing, and therefore, if we 
have further questions to ask, may we submit them to you? For 
your consideration and response?
    I thank you very much.
    Our next panel, Major General Gale Pollock, Chief of the 
U.S. Army Nurse Corps, Rear Admiral Christine M. Bruzek-Kohler, 
Director of the Navy Nurse Corps, Major General Melissa A. 
Rank, Assistant Air Force Surgeon General for Nursing Services.
    May I first call upon General Pollock?
STATEMENT OF MAJOR GENERAL GALE POLLOCK, CHIEF, ARMY 
            NURSE CORPS, UNITED STATES ARMY
    General Pollock. Of course.
    Mr. Chairman, Senator Stevens, Senators Mikulski, Murray, 
and Feinstein, thank you very much for joining us today, and 
it's a pleasure to appear before you today representing the 
Army Nurse Corps--107 years of Army strong.
    Through the unwavering support of this subcommittee, we're 
able to serve soldiers--past and present--their families, and 
the strategic needs of this great Nation.
    The total Army nursing force encompasses the officers and 
enlisted personnel on active duty in the Army National Guard 
and in the U.S. Army Reserve. We are a truly integrated and 
interdependent nursing care team. In that spirit, it has been 
my distinct pleasure to serve with Major General Deb Wheeling, 
of the Army National Guard, and Colonel Etta Johnson of the 
U.S. Army Reserve, who have been my senior advisors for their 
respective components over the past year.
    I would also be remiss if I failed to highlight the 
exceptional work of Colonel Barbara Bruno, my Deputy Corps 
Chief. Without her total support and attention, I would not 
have been able to move the Army Nurse Corps forward over the 
last 4 years. She will retire this summer, and I wanted you 
each to know of her dedication and support of the Army Nurse 
Corps and our Nation.
    Despite long and repeated deployments to combat zones, Army 
nurses remain highly motivated and dedicated to both duty and 
one another. They serve in Iraq, Afghanistan, and along every 
route that wounded warriors travel to get home.
    They're serving across Asia, Europe, and Central and South 
America, preparing and protecting our force. They're serving in 
every time zone, and at home, caring for those who need us.
    Since 2003, we have activated Reserve component Army Nurse 
Corps officers, re-aligned active duty Nurse Corps officers, 
and recruited civilian registered nurses, to serve as nurse 
case managers to support the continuity of healthcare for our 
wounded warriors. Nurse case managers also help the soldiers 
and their families navigate the complex healthcare system 
within military hospitals, our civilian TRICARE network, and 
the transition to the Department of Veterans Affairs.
    Recognizing the critical role of the nurse case manager in 
support of our wounded warriors, we now have 181 military and 
216 civilian nurse case manager positions authorized for the 
warrior transition units. These authorizations establish a 
staffing ratio of 1 to 18 at our medications centers, and 1 to 
36 at smaller medical activities.
    Not only does this support our wounded warrior healthcare 
mission today, the establishment of authorized, documented 
positions ensures that we maintain a robust nurse case 
management program supporting our healthcare beneficiaries in 
the future, whether we are at peace or in conflict.
    To ensure that our nurse case managers have the knowledge 
and skills necessary for this essential role, we standardize 
nurse case management training, using the military healthcare 
system, and the U.S. Army Medical Center and School, distance 
learning programs. Our next step is establishing a civilian 
university-based nurse case manager program for our military 
and civilian nurse case managers.
    Recognizing the significant behavioral health issues 
associated with deployment and combat, we are reshaping the 
advanced practice psychiatric nurse role, from that of a 
clinical specialist, to a psychiatric mental health nurse 
practitioner role. In collaboration with USUHS and our sister 
services, we now have a new psychiatric mental health nurse 
practitioner program, scheduled to begin in May 2008. Nurses 
graduating from the program will function as independent 
behavioral health providers, with prescriptive authority and 
practice both in our fixed healthcare facilities, and in 
deployed combat stress units.
    The Army Nurse Corps is also instituting an internship 
program scheduled to begin later this spring. This program 
bridges the gap between academia and practice for officers who 
are new to the profession. The anticipated outcome is better 
educated, and trained, medical surgical staff nurses, 
functioning independently.
    Army Nurse Corps studies focus on the continuum of military 
healthcare needs, from pre- and post-deployment health, to 
nursing-specific practices necessary to best care for the 
warriors in theater. Today, we have 33 doctorally prepared 
researchers working around the world. In addition to four well-
respected, and well-established research cells at our regional 
medical centers, we're establishing five new cells at our other 
medical centers.
    And finally, we have one doctorally prepared nurse 
researcher, two Army public health nurses, and one medical 
surgical nurse deployed to Iraq as part of the deployed combat 
casualty research team, conducting both nursing and medical 
research activities in-theater.
    The competitive market conditions and current operational 
demands continue to challenge us as we strive to ensure we have 
the proper manning to accomplish the mission. The Army Nurse 
Corps used incentives to assist in improving both recruitment 
and retention of Army Nurses. We have a Professional Nurse 
Education Program, the Army Enlisted Commissioning Program, the 
Army Nurse Candidate Program, the Funded Nurse Education 
Program, incentive specialty pay, nurse anesthesia specialty 
pay, nurse accession bonuses, critical skill retention bonuses, 
and a health professional loan repayment program.
    We will continue to refine our retention strategies. A 
recent review of personnel records by the Department of the 
Army indicated that the Army Nurse Corps had the highest 
attrition of any officer branch in the Army. Ongoing research 
indicates that Army nurses leave the service, primarily because 
of less than optimal relationships with their supervisors, the 
length of deployments, and inadequate compensation.
    I'm pleased to inform you that we now offer a Registered 
Nurse Incentive Specialty Pay Program, that recognizes the 
professional education and certification of Army nurses. 
Numerous studies have demonstrated the link between certified 
nurses and improved patient outcomes. These include higher 
patient satisfaction, decreased adverse events and errors, the 
improved ability to detect early signs or symptoms of patient 
complications, and the initiation of early intervention. 
Certified nurses also report increased personal and 
professional satisfaction, and improved multidisciplinary 
collaboration.
    For our Reserve component nurses, the issue is primarily 
the imbalance of professionally educated officers in the 
company grades. Many Reserve component nurses do not have a 
bachelor's degree. Only 50 percent are educationally qualified 
for promotion. This creates a concern for the future force 
structure for the senior ranks of the Reserve components. We're 
grateful that the Chief of the Army Reserves is focusing 
recruiting incentives on those nurses who already have a BSN, 
and funding the specialized training and assistance programs, 
to allow both new accessions and existing Army Reserve nurses 
without a BSN, to complete those degrees.
    The Army Nurse Corps continues adapting to the new 
realities of persistent conflict, but remains firm on providing 
the leadership and scholarship required to advance the role of 
professional nursing. We will maintain the focus on sustaining 
readiness, clinical competencies, and sound educational 
preparation, with the same commitment to serve those 
servicemembers who defend our Nation now, that we have 
demonstrated for the past 107 years.
    I appreciate this opportunity to highlight our 
accomplishments, and discuss the issues we face.

                           PREPARED STATEMENT

    Thank you very much for your support of the Army Nurse 
Corps and of me, over the 4 years in which I've had this 
position.
    Thank you.
    Senator Inouye. Thank you very much, General Pollock.
    [The statement follows:]
          Prepared Statement of Major General Gale S. Pollock
    Mr. Chairman, Senator Stevens, members of the committee: it is a 
pleasure to appear before you today representing the Army Nurse Corps. 
Today, the Army Nurse Corps is 107 years Army Strong. Through the 
unwavering support of this committee, we are able to serve soldiers, 
past and present, their families, and the strategic needs of this great 
Nation. The Total Army Nursing Force encompasses the officers and 
enlisted personnel on Active Duty, in the Army National Guard, and in 
the U.S. Army Reserve. We are a truly integrated and interdependent 
nursing care team. In that spirit, it has been my distinct pleasure to 
serve with Major General Deborah Wheeling of the Army National Guard, 
and Colonel Etta Johnson of the U.S. Army Reserve, who have been my 
senior advisors for their respective components over the past year.
    The Secretary and the Chief of Staff of the Army have set four core 
objectives for the Army: maintain the quality and viability of an all-
volunteer force; prepare the force by training and equipping soldiers 
and units to maintain a high level of readiness for the current 
operations in Iraq and Afghanistan; reset our soldiers, units, and 
equipment for future deployments and other contingencies; and transform 
the Army to meet the demands of the combatant commanders in a changing 
security environment. Each of the respective components of the Army 
Nursing Force is actively engaged in working the ways and means to 
these strategic ends. In so doing, we are achieving our vision of a 
quality transforming force through the advancement of professional 
nursing practice, and we are maintaining our superiority in research, 
educational innovation, and effective healthcare delivery.
                               deployment
    Army Nursing remains an operational capability fully engaged in the 
support of the Nation's soldiers, sailors, airmen, Coast Guardsmen, and 
marines--both at home and abroad. The Army Nurse Corps also operates as 
a strategic force with the capability to win hearts and minds through 
the provision of vital healthcare and humanitarian aid. This is a 
significant challenge in our various operational environments. Today, 
this group of nurses is the best trained in the history of operational 
nursing. Despite long and repeated deployments to combat zones, Army 
nurses remain highly motivated and dedicated to both duty and each 
other. They serve in Iraq, Afghanistan, and along every route Wounded 
Warriors must travel to get home. They serve across Asia, Europe, and 
Central and South America preparing and protecting the force. They 
serve in every time zone, and at home caring for Wounded Warriors on 
the long road to recovery.
    There are currently three forward deployed hospitals serving in 
Iraq--the 31st, the 325th and the 86th Combat Support Hospitals. The 
115th Combat Support Hospital is deploying to Iraq to conduct a relief 
in place with the 31st after a long 15-month deployment. The nurses 
serving in these units make an incredible difference in the lives of 
our Warriors and the Iraqi people.
    Army nurses make no distinction among their patients; they provide 
all patients the highest quality care. On February 1, 2008, a 10-year-
old Iraqi girl was brought to the 86th Combat Support Hospital (CSH) 
after sustaining 50 percent total body burns from a fire in her home. 
The fire left her with massive disfigurement from the waist down and a 
progressive infection. During the 10 days she remained at the 86th CSH, 
the nursing staff of the Intensive Care Unit and Intermediate Care Ward 
put tremendous effort into the care of both the young girl and her 
mother. She was transferred to Shriners Hospital for Children in Boston 
for extensive care of her burns on February 10th. As a testament to the 
quality of care this young girl received in Iraq, Shriners Hospital 
commented that the young girl arrived in far better condition than they 
had expected given the severity of injuries she had sustained. They 
said that the care provided by the 86th clearly saved her life, and she 
survived because of the extraordinary efforts made by the team. The 
young Iraqi girl and her mother have expressed endless thanks for the 
team's work and compassion; because of their excellent care, a mother 
continues to smile upon her only daughter.
             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 healthcare 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.
    The role of the Nurse Practitioner (NP) in the Army Medical 
Department continues to adapt and evolve to meet dynamic mission 
requirements. NPs continue to provide excellent healthcare and 
leadership, whether serving on the home front or deployed in support of 
the global war on terror. The following experiences highlight some of 
the important contributions made by Army NPs in 2007.
    Warrior Transition Units (WTUs) were developed at many 
installations across the Army Medical Department to enhance the 
excellent care provided to soldiers returning from deployments. Colonel 
Richard Ricciardi, Lieutenant Colonel Reyn Mosier and Lieutenant 
Colonel Mary Cunico are three NPs who were instrumental in training 32 
active duty and reserve nurses from across the country as case 
managers. These three individuals helped establish the first WTU at 
Walter Reed Army Medical Center in a compressed timeframe. Lieutenant 
Colonel Cunico managed the design, development and remodeling of the 
Warrior Clinic and now serves as the Officer in Charge providing care 
to over 700 wounded, recovering and rehabilitating military personnel.
    Lieutenant Colonel Jean Edwards is a primary care provider for the 
WTU at Vicenza, Italy, which was launched in June 2007. Her success 
includes new clinical skills in the areas of caring for skin grafts, 
the removal of bullets and shrapnel fragments, and the preparation of 
narrative summaries for medical boards.
    Lieutenant Colonel Kathleen M. Herberger served as a staff officer 
on the President's Commission on Care for America's Returning Wounded 
Warriors. She was selected as the nurse representative on the staff due 
to her experience as a Family Nurse Practitioner. While on the 
commission, she was assigned as the Care Management Analyst. Lieutenant 
Colonel Herberger served on the Continuum of Care Subcommittee and as 
the clinical consultant for the Information Management and Technology 
Subcommittee. She provided research and analysis on issues related to 
Continuum of Care and the clinical care pathway that is necessary for 
the severely Wounded Warrior. The team visited over 23 sites to gather 
information from soldiers, their families, and healthcare providers on 
the challenges presented by the severely wounded. Lieutenant Colonel 
Herberger evaluated and recommended ways to ensure access to high 
quality care and analyzed the effectiveness of the processes through 
which we deliver healthcare services and benefits. She provided 
research information, and developed the background paper used to 
formulate the recommendations for the Federal Recovery Coordinator 
concept for the severely wounded.
    Three Nurse Practitioners added to the success of the 7th Special 
Force's Group (Airborne) mission in support of Operation Enduring 
Freedom. Lieutenant Colonel Tamara LaFrancois, and Majors Jennifer 
Glidewell and Stacy Weina provided excellent care in very austere 
conditions at Fire Base Clinics and on Medical Civil Action Program 
(MEDCAP) missions in over 30 locations in Afghanistan. Using female 
providers to care for female local nationals and children opened up an 
entirely new perspective for the Special Operations Community. Helping 
Special Operations Forces (SOF) units with important non-kinetic 
missions by reaching a population of women who are not normally 
accessible not only allowed the local women to obtain healthcare for 
the first time, but enhanced the SOF unit's ability to develop good 
rapport with the local national population in their areas of operation. 
It led to many High Value Individuals who had important information 
being turned over by the locals and even joining forces with Coalition 
troops in fighting terrorism. This mission was so successful that a 
request for four NPs in fiscal year 2008 was submitted.
    Major Amal Chatila from Fort Bragg was the first NP to be assigned 
to a Civil Affairs unit. She was requested based on her outstanding 
work in reestablishing the medical infrastructure in Iraq and her 
excellent care of Iraqi nationals on two separate deployments. Major 
Maria Ostrander is currently assigned in Iraq as a Civil Affairs 
Officer and works with the Baghdad Provincial Reconstruction Team as a 
Health Advisor for the State Department.
    Efforts in providing medical care to the battle injured or those 
located far-forward is an ongoing concern for the military. In a war 
where there is no designated frontline, any setting can be the scene of 
a combat engagement. Some of these locations are situated where medical 
assets are readily available, but there are many distant locations 
where soldiers are isolated from general logistics, including 
healthcare assets. Placing advanced healthcare practitioners in Forward 
Operating Bases (FOB) plays a significant role in conserving the 
fighting strength of our soldiers. The forward healthcare element in 
this case consisted of one NP and one medic, along with a comprehensive 
range of pharmaceuticals and medical equipment. The construction of a 
new Aid Station took approximately 3 days, although the team was 
functional almost immediately upon their arrival at the FOB. By placing 
healthcare teams far forward in areas prone to injury or illness, we 
can obviate the risk of sending ill or injured soldiers to distant 
locations on dangerous roads for non-urgent/non-emergent treatment of 
disease and non-battle injury. By putting prevention into practice, we 
improved and maintained our soldiers' health throughout their 
deployment.
    In collaboration with senior Army Family Nurse Practitioners 
(FNPs), physician colleagues in family practice and various 
specialties, and the staff of the Uniformed Services University of the 
Health Sciences (USHUS), a FNP Residency Program was developed which 
provides a standardized program plan, required and optional rotations, 
rotation guides, and program evaluation tools. This residency program 
was developed in response to a long-standing request by FNPs and 
nursing leaders for a standardized NP residency program. The residency 
program was based on the recommendation of the National Council of 
State Boards of Nursing's ``Vision Paper 2006,'' a 10-year plan for 
standardizing core curriculum, licensure, certification, and scope of 
practice for Advanced Practice Registered Nurses and a requirement for 
a residency program after completion of education at the master's level 
or above. The intent of the FNP Residency Program is to provide a 
structured role transition for the newly graduated FNP working within 
the Army healthcare system and a refresher program option for the FNP 
returning to clinical practice after a lapse of greater than 3 years. 
This program allows FNPs to be introduced to the Medical Treatment 
Facility staff, policies, and services in their newly acquired provider 
role. It facilitates orientation, as well as privileged practice in 
specialty and ancillary areas, and acquaints the FNP with the staff 
members and procedures for those specialty clinics with which the FNP 
consults.
    Since 2003, we have activated reserve component Army Nurse Corps 
officers, realigned active duty Army Nurse Corps officers and recruited 
civilian registered nurses to serve as Nurse Case Managers to support 
the continuity of healthcare for our Wounded Warriors. These dedicated 
nurses have provided great support to our soldiers through their 
efforts to individualize care to the soldier. Nurse Case Managers also 
help soldiers and their families navigate the sometimes complex 
healthcare system within military hospitals, our civilian TRICARE 
network, and the transition to the Department of Veterans Affairs (VA). 
Recognizing the critical role of the Nurse Case Manager in supporting 
our Wounded Warriors, we now have 181 military and 216 civilian nurse 
case manager positions authorized for the Warrior Transition Units. 
These authorizations establish a staffing ratio of 1:18 at our medical 
centers and 1:36 at our medical activities. Not only does this support 
our Wounded Warrior healthcare mission today, the establishment of 
authorized, documented positions ensures that we maintain a robust 
Nurse Case Manager program supporting our healthcare beneficiaries in 
the future, whether in peacetime or during conflicts.
    To ensure that our Nurse Case Managers have the knowledge and 
skills necessary for this essential role, we have standardized Nurse 
Case Management training using the Military Healthcare System and U.S. 
Army Medical Department Center and School (AMEDDC&S) distance learning 
programs. Our next step is to establish a civilian university-based 
Nurse Case Manager program for our military and civilian nurse case 
managers.
    Within the Army Nurse Corps, we established a process that takes 
lessons learned from our support of the war effort to help shape Corps 
programs. Recognizing the significant behavioral health issues 
associated with deployment and combat, we are reshaping the Advanced 
Practice Psychiatric Nurse role from the previous clinical specialist 
to a Psychiatric Mental Health Nurse Practitioner role. In 
collaboration with the USUHS and our sister services, we now have a new 
Psychiatric Mental Health Nurse Practitioner program scheduled to begin 
in May 2008. Our Army Nurse Corps psychiatric nurse consultant, Colonel 
Kathy Gaylord, and our first faculty member, Major Robert Arnold, were 
actively engaged in the program development. This program provides an 
advanced practice degree and incorporates military unique behavioral 
healthcare issues into the curriculum. Nurses graduating from the 
program will function as independent behavioral health providers with 
prescriptive authority and practice both in our fixed healthcare 
facilities and in deployed combat stress units.
    Late last year, the AMEDDC&S opened a new $11.1 million, 55,000 
square foot building, named in honor of Brigadier General Lillian 
Dunlap, who was the 14th Chief of the Army Nurse Corps. The new 
academic building houses 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 the U.S. 
Army Graduate Program in Anesthesia Nursing Branch. The Department of 
Nursing Science, Army Medical Department Center and School is 
responsible for nearly all specialty-producing courses for the Army 
Nurse Corps. In addition, we provide leadership courses for nurses, and 
three enlisted programs. I would like to share the highlights of our 
program.
    The U.S. Army Graduate Program in Anesthesia Nursing is rated 
number two in the Nation by U.S. News and World Report. This program 
trains an average of 35 Army, 5 Air Force and 3 VA Certified Registered 
Nurse Anesthetists (CRNAs) per year. Students score, on average, 37 
points above the national average on the certification exam. The first-
time pass rate for the certification exam is nearly 100 percent. These 
students' performance exceeds civilian community scores relative to 
trauma, regional blocks, and central line placement. The program 
faculty members are in constant communication with the field, 
especially the deployed CRNAs, to rapidly incorporate changes into this 
program to meet the needs of the Warriors we serve. Simulation 
enhancements in this program allow students to be more comfortable with 
various techniques, and therefore better prepared to function in the 
clinical Phase 2 clinical training environment. The faculty and student 
program of research investigate the effects of various complementary 
and alternative medication preparations on anesthesia--the only well-
established program of research of this kind in the country.
    The Licensed Practical Nurse (LPN) Program is highly successful in 
producing LPNs who can function in a variety of assignments, to include 
critical care in fixed facilities or deployed environments, a specialty 
not taught in most civilian LPN programs. This program produces 550-600 
active and reserve component LPNs per year, with a first-time pass rate 
on the National Certification Licensure Exam of 94.4 percent compared 
to the national average of 88 percent. Half of the students serve in 
the reserve component, thus, we are also producing excellent LPNs that 
benefit the civilian community.
    The Critical Care Nursing Course trains a total of 70 nurses 
annually, and the Emergency Nursing Course trains 15. These courses 
provide Army nurses with the knowledge, experience, and certifications 
necessary to function independently in these specialties following 
several months of structured internship. Graduation requirements 
include certifications in trauma, advanced life support, pediatric life 
support and burn care. We are working toward incorporating flight 
nursing concepts in these courses. The OB/GYN Course produces 30 
trained professionals per year, who can function as post-partum and 
labor and delivery nurses. The Psychiatric Nursing Course produces an 
average of 8 specialists in psychiatry per year who are encouraged to 
advance to graduate level education in this much needed specialty. The 
Perioperative Nursing Course trains an average of 48 perioperative 
specialists per year. This particular specialty program is in its final 
stages of institutionalization at the AMEDDC&S and will include an 
option that allows students to become Registered Nurse First Assists 
(RNFA). Approximately 10 Army nurses have been through the RNFA 
Program.
    The Department of Nursing Science also manages the nursing 
components of the officer leadership courses. To improve readiness we 
have added the Trauma Nursing Core Course and Acute Burn Life Support 
Courses and their respective certifications to these courses. Because 
our nurses are preparing patients for medical evacuation (MEDEVAC) 
flights, we have incorporated such content into these programs to 
better prepare patients for flight. The two nursing-specific leadership 
courses, the Head Nurse Course and Advanced Nurse Leadership Course, 
train approximately 400 nurse managers and supervisors per year.
    The Department of Nursing Science manages the 150 students 
currently in the Army Enlisted Commissioning Program. Through close 
monitoring, we can identify potential problem students early in their 
academic programs and have substantially decreased the extensions in 
the program. The Army Nurse Corps is instituting an internship program 
scheduled to begin in spring 2008. This program, like many in the 
civilian sector, will bridge the gap between academia and practice for 
officers who are new to the profession. The anticipated outcome of this 
initiative is better educated and trained medical surgical staff nurses 
who can function independently.
    Finally, the Dialysis Technician Program trains 7-8 dialysis 
technicians each year to perform hemodialysis, hemofiltration, and 
other similar procedures in our facilities. Additionally, we train 
about 400 surgical technicians each year, and we are currently 
investigating national program certification for this specialty.
                         leadership in research
    The TriService Nursing Research Program (TSNRP), established in 
1992, provides military nurse researchers funding to advance research 
based health care improvements for the warfighters and their 
beneficiaries. 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 theater.
    The Army Nurse Corps has a long and proud history in military 
nursing research established more than 50 years ago. Nurse researchers 
continue to contribute to the scientific body of knowledge in military-
unique ways to advance the science of nursing practice. Today we have 
33 doctoral-prepared nurse researchers working around the world. There 
are four well established nursing research cells at Walter Reed Army 
Medical Center, Brooke Army Medical Center, Madigan Army Medical 
Center, and Tripler Army Medical Center. Five additional research cells 
are being established at Womack Army Medical Center, Eisenhower Army 
Medical Center, Darnell Army Medical Center, William Beaumont Army 
Medical Center, and Landstuhl Regional Medical Center.
    The focus of these research cells is to conduct funded research 
studies to advance nursing science and to conduct small clinical 
evaluation studies to answer process improvement questions. They also 
assist Hospital Commanders and Deputy Commanders for Nursing analyze 
and interpret data, resulting in improved patient care and business 
processes. These research cells are instrumental in assisting staff 
members and students in developing and implementing evidence based 
nursing practice.
    Additionally, the Nurse Corps currently has one doctoral-prepared 
nurse researcher, two Army Public Health Nurses, and one medical-
surgical nurse deployed to Iraq as part of the Deployed Combat Casualty 
Research Team who conduct both nursing and medical research activities 
in theater. The ongoing nursing studies in theater cover a broad range 
of acute and critical care nursing issues, to include pain management 
practices at the Combat Support Hospital, hand hygiene in austere 
environments, ventilator-acquired pneumonia prevention, use of 
neuromuscular blocking agents during air transport, women's health, 
sleep disturbance, compassion fatigue, and providing palliative care in 
the combat environment.
    Thanks to the initiative and motivation of the nursing staff, 
Evidence-Based Practice is in full swing at Tripler Army Medical 
Center. In 2007, the nursing staff at Tripler completed 12 evidence-
based practice projects that changed nursing practices to prevent 
ventilator-acquired pneumonia, improve the management of diabetic 
patients, and screen patients with depression for cardiovascular 
disease. Other successful projects included preparing children for 
surgery, improving postpartum education for new parents, and providing 
depression screening to family members of deployed soldiers. They 
initiated a competency training program for nurses preparing to deploy 
in support of Operation Iraqi Freedom and Operation Enduring Freedom. 
The robust evidence-based practice initiative at Tripler has improved 
nursing care to a variety of patients, including soldiers and family 
members, and enhanced the professional practice of nursing at Tripler. 
These evidence-based practice initiatives were spearheaded by 
Lieutenant Colonel Debra Mark and Lieutenant Colonel Mary Hardy, 
Tripler Army Medical Center Nursing Research Service and supported by 
the TriService Nursing Research Program.
    Two evidence-based practice guidelines, Pressure Ulcer and Enteral 
Feedings, have been implemented at WRAMC and post-implementation data 
is being collected and analyzed. A third guideline, Deep Vein 
Thrombosis and Pulmonary Embolism Risk Assessment has been piloted and 
is ready for hospital-wide implementation at WRAMC. A fourth guideline 
regarding medication administration is currently in the initial stages 
of protocol development and funding acquisition. Once complete, the 
evidenced-based practice guidelines will be posted to the TriService 
Nursing Research Program's website for implementation across all 
Medical Treatment Facilities within the Department of Defense.
    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 multi-discipline, 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's collaboration with Government and non-Government 
organizations around the world has helped streamline care where it was 
otherwise fragmented, and has introduced innovations in the delivery of 
care. I would like to share with you some examples of these innovations 
and collaborative partnerships.
    Tripler Army Medical Center is in the process of implementing a new 
nursing care delivery model called Relationship Based Care under the 
guidance of Lieutenant Colonel Anna Corulli. This model of care's core 
principals are: patient and family centered care; registered nurse led 
teams with clearly defined boundaries for all nursing staff based on 
licensure, education, experience, and standards of practice; and 
primary nursing to promote continuity of care and ensure patient 
assignments are made to align the patient's needs with the competencies 
of the registered nurse. This is a resource driven model that 
necessitates a pro-active mindset regarding staffing, scheduling, skill 
mix and professional nurse development.
    The Relationship Based Care program has resulted in improved 
communication among engaged nursing staff members who are part of the 
problem resolution process on the nursing ward/unit. The program has 
restored the personal relationship between the nursing staff and the 
patients, and among the individual nursing unit staff members; it has 
also promoted continuity of care and patient education. The model 
asserts the baccalaureate-trained Registered Nurse as team leader 
cognizant of the competencies and functions other members of the 
nursing care team bring to successful and safe patient outcomes.
    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 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.
    Professional partnerships are a vital way in which to promote 
professionalism and collaboration. The Army Nurse Corps is engaged in 
these partnerships across the country and around the world. Colonel 
Patricia Nishimoto, (Ret.), Colonel Princess Facen, and Major Corina 
Barrow, in collaboration with Dr. ReNel Davis, Associate Professor of 
Nursing at Hawaii Pacific University (HPU) and Director of the 
Transcultural Nursing Center at HPU, planned and organized the very 
first Transcultural Nursing Conference for the State of Hawaii in 
Honolulu in April 2007. The Transcultural Nursing Advisory Board is 
currently planning the next conference.
    The University of Hawaii (UH) at Manoa School of Nursing and Dental 
Hygiene is in the planning stage of a formal partnership with Tripler 
Army Medical Center to establish resource sharing potential for faculty 
and student clinical practicum venues to strengthen the nursing 
profession in both the academic and clinical areas. In a first step 
toward this partnership, Lieutenant Colonel Patricia Wilhelm recently 
served as an acting UH faculty member to teach a pediatric clinical at 
Kapiolani Medical Center, filling a critical need for clinical faculty. 
The second major focus is to expand the graduate program by matching UH 
graduate students with Tripler's masters-prepared nursing staff serving 
in clinical faculty roles.
    In December 2005, U.S. Army and Air Force nurses assessed military 
nursing in Vietnam and recommended short and long-term plans for the 
development of professional military nursing in Vietnam. A delegation 
from Vietnam then visited the U.S. in April 2007 to review bachelor's 
level curricula at the University of Hawaii, nursing education and 
practice at Tripler Army Medical Center, and Army Nurse Corps training 
at the AMEDDC&S. Allowing several months for the Vietnam team to 
incorporate changes in their administrative, clinical, and educational 
processes and curriculum, the next step is for four U.S. Army Nurse 
Corps officers and one UH faculty member to follow up with 2 weeks in 
Hanoi, Vietnam, in September 2008. They will help Vietnam educators 
develop a bachelor-level curriculum for Vietnam Army Nurses, as well as 
troubleshoot, clarify, and problem-solve with hospital-based military 
nurses and the Vietnam Military Medical Department team. This exchange 
will enhance a positive U.S. influence and presence in Vietnam, improve 
readiness and interoperability in the Asia-Pacific region, and create 
competent coalition partners.
    Colonel Debbie Lomax-Franklin and Colonel Nancy K. Gilmore-Lee have 
established a first ever Memorandum of Agreement with the Joseph M. 
Still Burn Center in Augusta, Georgia, to provide intensive burn care 
training to Army Nurse Corps officers throughout the region who are 
preparing to deploy. The Still Burn Center is the largest burn 
treatment center in the Southeast, serving Georgia, South Carolina, 
Florida, and Mississippi. This civil-military partnership has vastly 
improved the readiness of Army Nurse Corps officers and contributed to 
the quality of care delivered in theater.
                        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.
    We access officers for the Active Component through a variety of 
programs, including the Senior Reserve Officers' Training Corps (ROTC), 
the Army Medical Department Enlisted Commissioning Program, the Army 
Nurse Candidate Program, and direct accession recruiting. However we 
must develop a range of recruiting options to ensure we remain 
competitive to diverse applicants. We have a number of programs to 
achieve this end. The Army Nurse Corps utilized the following 
incentives to assist in improving both recruitment and retention of 
Army Nurses: the Professional Nurse Education Program, the Army 
Enlisted Commissioning Program, the Army Nurse Candidate Program, the 
Funded Nurse Education Program, Incentive Specialty Pay, Nurse 
Anesthetist Specialty Pay, Nurse Accession Bonus, Critical Skills 
Retention Bonus, and Health Professional Loan Repayment Program.
    The first of these is the Professional Nurse Education Program. In 
an effort to minimize the impact of faculty shortages, the Army Nurse 
Corps is piloting a strategy to leverage its resources on this 
important issue. This pilot program serves as a retention tool, as well 
as provides an additional skill set for the Officer. Six mid-grade Army 
Nurses with clinical master's or doctoral degrees have been detailed to 
a baccalaureate nursing program to serve as clinical faculty for 2 
years. The University of Maryland is the pilot site for this program. 
The presence of these officers in the Bachelor of Science in Nursing 
programs serves as an excellent marketing tool for Army Nursing. The 
University of Maryland was able to expand its undergraduate nursing 
program by 151 additional seats. In addition, the University is 
developing a clinical placement site at Kimbrough Ambulatory Care 
Center located at Fort Meade, Maryland.
    The Army Enlisted Commissioning Program allows enlisted soldiers 
who can complete a Bachelor of Science in Nursing (BSN) degree within 
24 months to do so while remaining on active duty. This program has 
provided a successful mechanism to retain soldiers, while ensuring a 
continuous pool of nurses for the Army. The number of seats available 
was increased from 75 to 100 per year for fiscal year 2008. 153 
students are enrolled in the program; 52 students graduated in fiscal 
year 2007; and 26 students have graduated to date in fiscal year 2008.
    The Army Nurse Candidate Program targets nursing students who are 
not eligible to participate in ROTC. It provides incentives to nursing 
students to serve as Army Nurses upon graduation from a BSN program. A 
bonus of $5,000 is paid upon enrollment, and another $5,000 is paid at 
either the start of the second year, or upon graduation for those 
enrolled for only 1 year. It also provides a stipend of $1,000 for each 
month of full-time enrollment. Individuals incur a 4- or 5-year active 
duty service obligation (ADSO) in exchange for participation in this 
program. For fiscal year 2008, 15 graduates accessed onto active duty 
took advantage of this incentive.
    The Funded Nurse Education Program (FNEP) provides an additional 
accession source for the Army Nurse Corps. It gives active duty Army 
officers serving in other branches the opportunity to obtain, at a 
minimum, a BSN or higher level nursing degree and continue to serve as 
Army Nurse Corps officers. For both fiscal year's 2008 and 2009, 25 new 
starts were funded. Six individuals started nursing school in fiscal 
year 2008 under FNEP, and a recent FNEP board filled all 25 seats for 
starts in the fall of 2008.
    The Active Duty Health Professional Loan Repayment Program is 
offered as an accession incentive. As participants in this program, 
nurses can receive up to $38,300 annually for 3 years to repay nursing 
school loans. In fiscal year 2008, 28 direct accession Nurse Corps 
officers were brought into the Army under this program.
    The Accession Bonus remains attractive to direct accessions. In 
fiscal year 2008, 19 officers accepted an accession bonus of $25,000 
and were accessed into the ANC in exchange for a 4-year ADSO, and 9 
officers accepted an accession bonus of $15,000 and were accessed into 
the ANC in exchange for a 3-year ADSO. A combination of the Accession 
Bonus and Active Duty Health Professional Loan Repayment Program is 
also offered in exchange for a 6-year ADSO. In fiscal year 2008, 20 
officers accepted these combined incentives and were accessed into the 
ANC.
    We continue to scrutinize retention closely and we work constantly 
to refine our retention strategies. 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 their supervisors and 
hospital leadership and the length of deployments. Those who stay do so 
because of our outstanding educational opportunities, the satisfaction 
that comes with working with soldiers and their families, and 
retirement benefits.
    We are pleased to note that we offer a Registered Nurse Incentive 
Specialty Pay (RN ISP) program that recognizes the professional 
education and certification of Army Nurses. This program, approved in 
August of 2007, is now fully implemented. The RN ISP offers eligible 
officers a payment schedule of $5,000 for a 1-year ADSO, $10,000 a year 
for a 2-year ADSO, $15,000 a year for a 3-year ADSO, and $20,000 a year 
for a 4-year ADSO. In order to be eligible for the active duty RN ISP, 
Registered Nurses must complete both post baccalaureate training and be 
certified in their primary clinical specialty. Certification is the 
formal recognition of the specialized knowledge, skills and experience 
demonstrated by achievement of standards identified by nursing 
specialties to promote optimal health outcomes. However, the real value 
of certification is in the numerous positive outcomes for our patients.
    Numerous studies have demonstrated the link between certified 
nurses and improved patient outcomes. These include higher patient 
satisfaction, decreased adverse events and errors, the improved ability 
to detect early signs or symptoms of patient complications, and 
initiate early interventions. Certified nurses also reported increased 
personal and professional satisfaction and improved multidisciplinary 
collaboration.
    The following clinical nursing specialties are eligible for the RN 
ISP: Perioperative Nursing (66E), Critical Care Nursing (66H8A), 
Emergency Nursing (66HM5), Obstetrics/Gynecological (OB/GYN) Nursing 
(66G), Psychiatric/Mental Health Nursing (66C), Medical-Surgical 
Nursing (66H), Community/Public Health Nursing (66B), Nurse Midwife 
(66G8D), and Nurse Practitioners (66P). Although only implemented in 
August 2007, the RN incentive specialty pay proved to be an excellent 
retention tool.
    The total nursing population eligible for this incentive is 
currently 669 personnel. To date, 577 nurses have applied for incentive 
specialty pay which amounts to approximately 74 percent of the eligible 
population. Out of this population, the majority opted for the 4-year 
RN ISP.
    Nurse anesthetists can also receive special pay in the amount of 
$40,000. Of the 170 nurse anesthetists that were eligible for this 
specialty pay, there were 161 on active duty that took advantage of 
this incentive. Nevertheless, 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. The U.S. Army's Graduate Program in Anesthesia Nursing has 
been rated as the second best in the Nation; however, we have not 
filled all of our available training seats for the past several years. 
Additionally, many of these outstanding officers opt 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 slow departures in the mid-career range. This coming 
June, we 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.
    The Army is also concerned with retention of company grade 
officers, and recently announced the implementation of a Critical 
Skills Retention Bonus (CSRB) for regular Army captains, including Army 
nurses. This is a temporary program to increase retention among 
officers with specific skills and experiences. Qualified officers 
received a one time payment of $20,000 for a 3-year ADSO and 288 Army 
Nurse Corps officers have taken advantage of the CSRB to date.
    For Reserve Component (RC) nurses, the issue is primarily the 
imbalance of professionally educated officers in the company grades. 
Many RC nurses do not have a BSN degree. As a result, only 50 percent 
have been educationally qualified for promotion to major over the past 
few years. This creates a concern for the future force structure of the 
senior ranks of the RC in the years to come. For this reason, we are 
grateful that the Chief, Army Reserve is focusing recruiting incentives 
on those nurses who already have a BSN degree and funding the 
Specialized Training and Assistance Program to allow both new 
accessions and existing Army Reserve nurses without a BSN to complete 
their degrees. 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.
    The AMEDD student loan repayment program for current and new 
civilian nurse recruits has had an outstanding impact on recruiting and 
retaining civilian nurses. Over 185 civilian nurses have already 
elected to participate in the loan repayment program in exchange for a 
3-year service obligation. The program has been so successful that the 
AMEDD will continue the education loan repayment program. We must 
sustain such initiatives in the future if we are to maintain a quality 
nursing work force.
    More than ever, the Army Nurse Corps is focused on providing 
service members, retirees, and their families the absolute highest 
quality care they need and deserve. We continue adapting to the new 
realities of this protracted 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 107 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 now call upon Rear Admiral Christine 
M. Bruzek-Kohler.
STATEMENT OF REAR ADMIRAL CHRISTINE M. BRUZEK-KOHLER, 
            DIRECTOR, UNITED STATES NAVY NURSE CORPS
    Admiral Bruzek-Kohler. Thank you, good morning, Chairman 
Inouye, Ranking Member Stevens, Senator Mikulski, and 
distinguished members of the subcommittee.
    As the 21st Director of the Navy Nurse Corps, I am honored 
to offer testimony in this, the centennial anniversary of the 
Navy Nurse Corps. My written statement has been submitted for 
the record, and I'd just like to highlight a few key issues.
    Senator Inouye. Without objection.
    Admiral Bruzek-Kohler. In the past, the stigma of seeking 
medical attention for mental health issues hindered 
servicemembers from getting the full complement of care that 
they needed. The treatment of post-traumatic stress and 
traumatic brain injury are at the forefront of our caring 
initiatives. We have added a psychiatric mental health clinical 
nurse specialist to the Comprehensive Combat and Complex 
Casualty Care Program, and anticipate assignment of psychiatric 
mental health nurse practitioners with the marines in the 
operational stress control and readiness teams. These assets 
will expedite delivery of mental health services to our 
warriors.
    Today's Navy nurses, especially those who have served for 
less than 7 years, know firsthand of the injuries and illnesses 
borne from war. This is the only world of Navy nursing they 
have known. This ``normal'' world of caring is oftentimes a 
heavy cross to bear. Our Care of the Caregiver Program assists 
staff with challenging patient care situations by offering 
attentive listeners in the form of psychiatric mental health 
nurses who make rounds of the nursing personnel to assess for 
indications of increased stress. Another caring initiative, 
Operation Welcome Home, founded by a Navy nurse, and widely 
recognized at the Expeditionary Combat Readiness Center, has 
ensured that over 5,000 soldiers, sailors, airmen and marines 
return from operational deployments, and receive a ``Hero's 
Welcome Home''.
    For a second consecutive year, I am proud to share with you 
that the Navy Nurse Corps has met its active duty direct 
accession goal. Our nurses' diligent work and engagement in 
local recruiting initiatives have contributed to these positive 
results.
    But while I boast of this accomplishment, I fully realize 
that my losses continue to exceed my gains. These losses, and 
the continued challenge we face in meeting our Reserve 
component recruiting goals, mean fewer Navy nurses to meet an 
ever-growing healthcare requirement.
    The Registered Nurse Incentive Special Pay Program is a new 
retention initiative designed to incentivize military nurses to 
remain at the bedside providing direct patient care. Wartime 
relevant undermanned specialties with inventories of less than 
90 percent are eligible for this specialty pay.
    Additionally, we have deployed innovative approaches to 
retain nurses. For the first time since 1975, Navy nurses 
within their initial tour of duty may apply for a master's 
degree in nursing via the Duty Under Instruction Program. The 
Government Service Accelerated Promotion Program has also been 
successful in retaining our Federal civilian registered nurses 
and reducing RN vacancy rates.
    We are proud of the partnerships we have established in 
enhancing the education of our nurses. At the Uniformed 
Services University, our Nurse Corps Anesthesia Program, ranked 
third in the Nation among 108 accredited programs by the U.S. 
News & World Report, will merge with the Graduate School of 
Nursing to form one Federal program. We have also contributed 
faculty to the university's newly developed psychiatric mental 
health nurse practitioner track.
    Tri-service nursing research is critically important to the 
mission of the Navy Nurse Corps, and I am committed to its 
sustainment. Our nurses are engaged in research endeavors that 
promote health, improve readiness and return our warriors to 
wellness.
    Aligned with the Chief of Naval Operations maritime 
strategy, Navy nurses supported global humanitarian missions 
aboard USNS Mercy and Comfort, and will be critical crewmembers 
in future operations. The versatile role of advanced practice 
nurses, especially family and pediatric nurse practitioners, 
make them particularly well-suited for these missions. Other 
specialties such as obstetrics and pediatrics deployed 
infrequently in the past are now critical to the support of 
missions focused on the care of women and children. Navy nurses 
serve in operational roles in worldwide medical facilities in 
Africa, Europe, Southwest and Southeast Asia, the Middle East, 
and also aboard various naval ships. Among our ``firsts'' in 
operational billets, a Navy nurse is now assigned to Fleet 
Forces Command in Norfolk, Virginia.
    One of my family nurse practitioners served for 1 year as 
the medical officer of a provincial reconstruction team in 
Afghanistan where he provided care to civilians, Afghan 
military and police, as well as coalition forces. In this role 
he participated in over 100 ground assault convoys facing both 
direct and indirect fire. This depicts only one example of the 
challenging environments in which Navy nurses deliver care 
daily.
    In the past year, I have had the opportunity to see my 
nurses at work in military treatment facilities ashore and 
afloat. They are indeed a different type of nurse than those I 
have seen in the past. They are seasoned by war, confident, 
proficient and innovative and fully recognize why it is they 
wear this uniform. It is said that the eyes are the mirror to 
the soul, and the eyes of my nurses yield more than words can 
ever impart. They truly love what they do, and they want to be 
no place other than where they are, caring for America's 
heroes.

                           PREPARED STATEMENT

    I appreciate the opportunity to share some of the 
accomplishments of my nurses, and I look forward to continuing 
our work together as I carry on as Director of the Navy Nurse 
Corps.
    Thank you.
    Senator Inouye. I thank you very much, Admiral.
    [The statement follows:]
     Prepared Statement of Rear Admiral Christine M. Bruzek-Kohler
                            opening remarks
    Chairman Inouye, Ranking Member Stevens and distinguished members 
of the subcommittee, I am Rear Admiral (upper half) Christine Bruzek-
Kohler, the 21st Director of the Navy Nurse Corps and privileged to 
serve as the first Director at this rank. I am particularly honored to 
offer this years' testimony in this, the centennial anniversary of the 
Navy Nurse Corps. It has indeed been a century hallmarked by courageous 
service in a time-honored profession, rich in tradition and unsurpassed 
in its commitment to caring.
    Today I will highlight the awe-inspiring accomplishments of a Navy 
Nurse Corps that is 4,000 nurses strong. Just like our nursing 
ancestors, today's Active and Reserve Component nurses continue to 
answer the call of duty whether it be at the bedside of a patient in a 
Stateside military treatment facility, aboard an aircraft carrier 
transiting the Pacific, in a joint-humanitarian mission on one of our 
hospital ships, in an Intensive Care Unit (ICU) at Landsthul Regional 
Medical Center, or in the throes of conflict in Iraq. Navy nurses stand 
shoulder to shoulder, supporting one another in selfless service to 
this great Nation.
    We are a Nation in a continuing war and the true mission of the 
Navy Nurse Corps both today, and in 1908 when we were first established 
by Congress, has remained unchanged: caring for our warriors as they go 
into harm's way. Nurses play an invaluable role in Navy medicine. We 
are relied upon for our clinical expertise and are recognized for our 
impressive ability to collaborate with a host of other healthcare 
disciplines in caring for our warriors, their families and the retired 
community.
    In the past year, nurses at the National Naval Medical Center 
(NNMC) have treated, cared for, cried with, laughed and at times 
mourned for, over 500 casualties from Operation Iraqi Freedom and 
Operation Enduring Freedom. The professionalism and humanity of this 
profoundly talented and dedicated nursing team, as well as all my 
nurses throughout Navy medicine, have made all the difference in the 
world to the wounded warriors and their families.
                              warrior care
    The Comprehensive Combat and Complex Casualty Care (C5) Program at 
the Naval Medical Center San Diego (NMCSD) was developed in 2006 to 
provide the highest quality of care for wounded warriors and their 
families. It now includes the addition of a psychiatric clinical nurse 
specialist and a Family/Emergency Room Nurse Practitioner. The nurse 
practitioner serves as the C5 medical holding company's primary care 
manager. The psychiatric clinical nurse specialist works in 
collaboration with one of the command chaplains. Together, they 
facilitate bi-weekly support groups for Operation Iraqi Freedom/
Operation Enduring Freedom vets who are undergoing medical treatment at 
NMCSD. The focus of these groups is to facilitate discussions related 
to challenges and experiences servicemembers face and future outlooks 
for them.
    The Balboa Warrior Athletic Program (BWAP) encompasses mastery of 
previous skills patients engaged in prior to sustaining a life-altering 
injury. Cooking classes, swimming, water and snow skiing outings, yoga 
clinics, strength, and conditioning training, have culminated in an 
unintended, yet positive consequence as these warriors begin to 
willingly disclose Post Traumatic Stress Disorder (PTSD) issues, 
medical challenges, and the effects of war on their current lifestyle.
    Project Odyssey was initiated in November 2007 by the Wounded 
Warrior Project at NMCSD. This 3-day program focuses on self-
development, knowledge and challenges recently returning warriors face 
from their PTSD using sports and outdoor recreational opportunities. 
The goal of this program is to reestablish structure and routine, 
enforce team work and decrease isolation among returning warriors.
    At Naval Medical Center Portsmouth (NMCP), Wounded Warrior 
Berthing, also known as the ``Patriot Inn,'' was developed in August 
2007. It provides easily accessible accommodations, monitoring, and 
close proximity to necessary recovery resources for active duty 
ambulatory patients in varying stages of their health continuum within 
NMCP. The Patriot Inn staffing now include a case manager, recreation 
therapist, and clinical psychologist. A future construction plan 
includes reconfiguration of an existing site on the compound to 
increase capacity.
                         nurse case management
    Case managers are members of multi-disciplinary teams and integral 
in the coordination of care for our servicemembers as they transition 
from military treatment facility to a VA facility closer to home, or 
another civilian or military treatment facility. Our case managers work 
in conjunction with the staff of the Wounded Warrior Programs, Navy 
Safe Harbor, and United States Marine Corps (USMC) Wounded Warrior 
Regiments. They have been assigned to the Traumatic Brain Injury (TBI) 
and PTSD patient populations specifically to ensure continuity of care 
and point of contact for ongoing coordination of services and support 
for C5 patients at NMCSD.
    Efficacy of case managers' efforts may be best reflected in the 
following examples from some of our commands. A staff nurse assigned to 
the Camp Geiger Branch Medical Clinic serves as a case manager for the 
injured marines in the Medical Rehabilitation Platoon (MRP) at the 
School of Infantry-East. The number of marines in this platoon was 
maintained at 70-80 members over the past year with half of them 
returning to duty or training within 30 days. The nurse was able to 
expedite primary and specialty care appointments, ensure clear lines of 
communication with the Marine Corps leadership through weekly meetings 
and met with all the MRP marines on a regular basis to review and 
update their plan of care. Utilization of a case manager for the MRP 
improved compliance with the required care regimen and decreased the 
overall length of stay for marines in MRP.
    Nurses in other military treatment facilities have also become 
active in case management. At Naval Healthcare New England, the nurses 
work in conjunction with Army points of contact to coordinate care for 
soldiers' recovery at home. Two case managers at Naval Health Clinic 
Corpus Christi co-manage cases with Brook Army Medical Center for the 
Wounded Warrior Program, coordinating care for Fort Worth enrolled 
Soldier/Warriors in the Transition Program. Nurses assigned to Naval 
Hospital (NH) Great Lakes work collaboratively with the North Chicago 
VA Medical Center in tracking their wounded warrior population. Nurse 
case managers in the Pacific Rim (Hawaii) are following 120 patients to 
ensure they receive continuity of care throughout the Military 
Healthcare System.
                 psychiatric and mental health nursing
    Mental health care is a national concern, and we, in the Navy and 
Navy Nurse Corps, recognize our tremendous responsibility and 
accountability to ensure our patients receive the best possible mental 
health care. With this responsibility comes the realization that we 
have an ever increasing need for psychiatric mental health nurse 
practitioners and clinical nurse specialists. A pilot program of 
embedded staff with the Marines, the Operational Stress Control and 
Readiness (OSCAR) teams, is composed of Navy psychologists or 
psychiatrists, psychiatric technicians, chaplains or social workers. 
The goal of the pilot program is to establish permanently staffed teams 
that train and deploy with each regiment group. Psychiatric Mental 
Health nurse practitioners are being considered as potential providers 
for this requirement.
    The requirement to fill OSCAR teams, combined with the increased 
Marine medical requirement and the growing need for dependent care, 
pose a significant impact to an already overburdened community of 
mental health nurses. I am presently undertaking a full review of the 
manning requirements for mental health nursing to ensure that Navy 
medicine has the right number and level of expertise in concentrated 
areas of patient mental health care needs.
                          family-centered care
    Our mission involves not only the care of the active duty member, 
but also their family, their dependents, and America's veterans who 
have proudly served this country. Such care is not delivered in a 
single episodic encounter, but provided over a lifetime in a myriad of 
locations here and abroad.
    Obstetrical (OB) service continues to be one of our largest product 
lines. It can be challenging to find enough experienced labor and 
delivery nursing staff during peak periods. In some of our regions, 
this has required an increase in resource sharing agreements to 
supplement our military staff. As needed, our regional medical 
commanders utilize active duty nurses from low volume labor and 
delivery units to provide temporary additional duty at treatment 
facilities that are experiencing peak numbers of births.
    In some of our pediatric departments, nurses manage the well-baby 
clinics and see mothers and babies within days after discharge to 
provide post-partum depression screening and education. Babies receive 
a physical exam, weight and bilirubin check. Thus the couplet is 
assessed independently, and as a unit, further reinforcing the Surgeon 
General's concept of family-centered care.
    Naval Hospital Bremerton (NHB) offers the Centering Pregnancy model 
of group prenatal care which brings women together to empower them to 
control their bodies, their families and their pregnancies. Facilitated 
by a nurse practitioner, Centering Pregnancy was initially a Tri-
Service funded research project conducted by NHB and the 1st Medical 
Group Langley with data collection concluding in 2007. The application 
of this model on military family readiness and military health care 
systems showed greater satisfaction and participation in care with the 
Centering Program, reduction in waiting time to see providers and 
participants had significantly less expression of guilt or shame about 
depression. Navy medicine is currently assessing ways to expand this 
program.
    Four of our nurses (military and civilian) recently had an article 
published in Critical Care Nursing Clinics of North America. It spoke 
poignantly of lessons learned in caring for wounded warriors. It 
depicted the sacrifice and dedication required in coordinating 
sophisticated and multi-disciplinary care for these patients and their 
families. This further elucidates how family-centered care makes a 
tremendous difference for the recovery of the injured by including care 
of the family and their involvement in the overall care of the wounded 
warrior.
    Lastly there is the care of the family by Navy nurses that no one 
sees: the lieutenant junior grade who travels to New York on his day 
off to attend the funeral of one of his patients and is immediately 
recognized by the family and invited to their home for dinner after the 
service; the nurse who held the hand of a blind and injured soldier, 
crying and praying with him on a night in which he is unable to wake 
himself from flashbacks and nightmares--who attributes the soldier's 
perseverance through the highs and lows of his recovery as a source of 
inspiration to her; the soldier who sustained TBI and an amputation of 
one of his legs and can recall nothing of his prolonged 
hospitalization, but his father remembers and escorts his son on a 
visit to the ward so the staff can witness his healing and hear tales 
of his snowboarding adventures in Colorado; the soldier who lost both 
of his legs and suffered multiple life threatening injuries and was in 
complete isolation until the nursing staff was able to assist him in 
safely holding his new baby daughter without worry of transferring 
infections to her. It is indeed this type of selfless and compassionate 
care that has been embraced by my nurses in the integral role they play 
in both patient and family-centered services.
                         care of the caregiver
    Today's Navy nurses, especially those who have served for less than 
7 years, know firsthand the injuries and illnesses borne from war. This 
is the only world of Navy nursing they have known. This is their 
``normal'' world of caring. And this new ``normal'' may oftentimes be a 
heavy cross to bear. At NNMC, our psychiatric mental health nurses and 
others with mental health nursing experience make rounds of the nursing 
staff and pulse for indications of increased staff stress. They then 
provide to the identified staff, education on ``Care for the 
Caregiver.'' They are available to help staff with challenging patient 
care scenarios (increased patient acuity, intense patient/family grief, 
and staff grief) and offer themselves as attentive, non-judgmental 
listeners through whom the staff may vent.
    In addition to the classes on `Compassion Fatigue' offered by 
command chaplains to our nurses and hospital corpsmen, some commands 
host provider support groups where health professionals meet and 
discuss particularly emotional or challenging patient cases in which 
they are or have been involved. Aboard the USNS Comfort, Psychiatric 
Mental Health Nurses and Technicians were located at the deckplate in 
the Medical Intensive Care Unit, Ward and Sick Call to help members 
that might not report to sick call with their complaints of stress.
    In many of the most stressful deployed locations, our senior nurses 
are acutely attuned to the psychological and physical well-being of the 
junior nurses in their charge. They ensure that staffing is sufficient 
to facilitate rotations through high stress environments. Nurses are 
encouraged to utilize available resources such as chaplains and 
psychologists for guidance and support in their deployed roles and 
responsibilities.
    Our deploying nurses have been asked to hold positions requiring 
new skill sets often in a joint or Tri-Service operational setting. As 
individual augmentees, they deploy without the familiarity of their 
Navy unit, which oftentimes may pose greater stress and create special 
challenges. Our nurses who fulfill these missions require special 
attention throughout the course and completion of these unique 
deployments. I have asked our nurses to reach out to their colleagues 
and pay special attention to their homecomings and re-entries to their 
parent commands and they have done exactly that.
    At U.S. Naval Hospital Okinawa, nurses ensure that deploying staff 
members and their families are sponsored and assisted as needed 
throughout the member's deployment. A grassroots organization, 
Operation Welcome Home, was founded by a Navy nurse in March 2006 with 
the goal that all members returning from deployment in theater receive 
a ``Hero's Welcome Home''. To date over 5,000 sailors, soldiers, airmen 
and marines have been greeted at Baltimore Washington International 
Airport (BWI) by enthusiastic crowds who indeed care for them as 
caregivers.
                             force shaping
    In January 2008, Navy Nurse Corps Active Component manning was 94.5 
percent and our Reserve Component manning was nearly the same at 94.4 
percent. Our total force is 4,043 strong. For the second consecutive 
year, I am proud to share with you that the Navy Nurse Corps has met 
its active duty direct accession goal. Yet as I boast of this 
accomplishment, I fully realize that my losses each year continue to 
exceed my gains, by approximately 20-30 nurses per year. These losses, 
and the continued challenge we face in meeting our recruiting goals in 
the Reserve Component, culminate in fewer nurses to meet an ever-
growing healthcare requirement.
                               recruiting
    So what has made the difference in our recruiting success? Our 
nurses' diligent work and engagement in local recruiting initiatives 
have yielded positive results. We are ahead of our recruiting efforts 
this year, more than where we were at this same time last year. The top 
three programs working in our favor toward this successful goal 
achievement include the increases in Nurse Accession Bonus (NAB) now at 
$20,000 for a 3-year commitment and $30,000 for a 4-year commitment; 
Health Professions Loan Repayment Program (HPLRP) amounts up to $38,300 
for a 2-year consecutive obligated service; and the Nurse Candidate 
Program (NCP), offered only at non-ROTC Colleges and Universities, 
which is tailored for students who need financial assistance while in 
school. NCP students receive a $10,000 sign-on bonus and $1,000 monthly 
stipend. Other contributors to our success include location of our duty 
stations and the opportunity to participate in humanitarian missions.
    We created a Recruiting and Retention cell at the Bureau of 
Medicine and Surgery (BUMED) with a representative identified from each 
professional corps. These officers act as liaisons between Navy 
Recruiting Command (CNRC), Naval Recruiting Districts (NRD), Recruiters 
and the MTFs and travel to and or provide corps/demographic specific 
personnel to attend local/national nursing conferences or collegiate 
recruiting events. In collaboration with the Office of Diversity, our 
Nurse Corps Recruitment liaison officer coordinates with military 
treatment facilities to have ethnically diverse Navy personnel attend 
national conferences and recruiting events targeting ethnic minorities.
    The Nurse Corps Recruitment liaison officer has created a speaker's 
bureau of junior and mid-grade Nurse Corps officers throughout the 
country and they are reaching out to colleges, high schools, middle and 
elementary schools. Our nurses realize that each time they talk about 
the Navy and Navy nursing they serve as an emissary for our Corps and 
the nursing profession. Unique platforms such as USNS Comfort and Mercy 
are phenomenal recruiting venues. Officers provide ship tours to area 
colleges and civilian organizations (Schools of Public Health, Medicine 
and Nursing from Johns Hopkins University, Montgomery College School of 
Nursing, Boy Scouts of America, United States Coast Guard Auxiliaries), 
hospitals, recruiting centers, and sponsor speakers' bureau 
representatives from the ships to present at local civic and health 
groups about the rewards and lessons learned of serving on a 
humanitarian mission.
    NMCP participated in Schools of Nursing Transition Assistance 
curricula for future Nurse Corps Officers by offering a 120-hour 
preceptor guided clinical externship. NMCP also developed the 
Coordination of Nursing mentorship experience which offers ``Job 
Shadowing'' of a Nurse for both enlisted staff and high school students 
who are considering the nursing profession as a career. U.S. Naval 
Hospital Yokosuka encourages seamen and corpsmen from area ships to 
``shadow'' nurses to see if a career in the Nurse Corps is for them.
    Our Reserve Component recruiting shortfalls particularly impact 
their ability to provide nursing augmentation in some of our critical 
wartime specialties. In addition to reserve accession bonuses and the 
stipend program, our reserve affairs officer has initiated telephone 
calls to Active Component nurses who are leaving active duty and shares 
information with them related to opportunities that exist in the Ready 
Reserve.
                               retention
    Naval Hospital Camp Pendleton (NHCP) has cross-trained their nurses 
for utilization during periods of austere manning secondary to 
increased op-tempo and deployments. Last year, several Outside 
Continental United States (OCONUS) military treatment facilities 
received ten Junior Nurse Corps (NC) officers who attended our new 
Perinatal Pipeline training program, designed for medical-surgical 
nurses who expect to work in Labor and Delivery or the Newborn Nursery 
at OCONUS military treatment facilities. This program has increased 
clinical quality for these commands and increased the knowledge and 
preparation of these junior NC officers. This year we will expand the 
training to geographically remote Continental United States (CONUS) 
facilities as well.
    The Officer Career Development Board developed at Naval Hospital 
Oak Harbor for officers in the grade of lieutenant and below provides 
for career progression opportunities as both an officer and nurse 
professional. The board also offers guidance and mentoring for optimal 
career development.
    The Registered Nurse Incentive Special Pay (RN-ISP) program is a 
new retention initiative begun in February 2008. This program is 
designed to encourage military nurses to continue their education, 
acquire national specialty certification, and remain at the bedside 
providing direct care to wounded sailors, marines, soldiers and airmen. 
In the Navy Nurse Corps, we selected critical wartime specialties 
manned at less than 90 percent for this incentive special pay. The 
specialties and their respective manning levels are perioperative 
nursing (86 percent), critical care nursing (62 percent), pediatric 
nurse practitioner (82 percent) and family nurse practitioner (82 
percent). Since the program has only recently been implemented, there 
is not sufficient data to determine its efficacy in retaining nurses.
    Among Navy nursing's retention tools are the Certified Registered 
Nurse Anesthesia (CRNA) Incentive Special Pay, Board Certification Pay 
for Nurse Practitioners, and the new Registered Nurse Incentive Special 
Pay. Service obligations are incurred in proportion to the amount of 
special pay received in the Certified Registered Nurse Anesthesia 
Incentive Special Pay and the Registered Nurse Incentive Special Pay. A 
recent increase in the Certified Registered Nurse Anesthesia Incentive 
Special Pay has encouraged many Navy CRNAs to stay on active duty.
    The fiscal year 2008 Nurse Corps Health Professional Loan Repayment 
Program (HPLRP) was awarded to 42 nurses with an averaged debt load of 
$27,361. The selected officers' years of commissioned service spanned 3 
to 10 years and most will incur service obligations through 2010. 
Selected nurses were in the grades of Lieutenant Junior Grade to 
Lieutenant Commander and the majority of the loans incurred were from 
their baccalaureate education.
    Military treatment facility nurses are actively involved in 
partnering with local universities to recruit NC officers, and they are 
serving as mentors with area Medical Enlisted Commissioning Program 
(MECP) students. Our facilities also serve as clinical rotation sites 
for many Schools of Nursing (SONs). NC officers serve both as affiliate 
faculty at Universities across the country and as clinical preceptors 
to students. Naval Health Clinic Cherry Point nurses act as preceptors 
to high school students in Certified Nursing Assistant programs.
    We are challenged to retain nurses due to on-going deployment 
cycles, Individual Augmentee roles, intensive patient care 
requirements, and low inventories of critical war time specialties. The 
fiscal year 2007 Nurse Corps continuation rate after 5 years, which is 
the average minimum obligation, is 67 percent. Our 5-year historical 
average is 69 percent. Thus, further consideration must be given to 
initiatives that mitigate mid-grade Nurse Corps attritions.
    In February 2007 the Accelerated Promotions Program for Civilian 
Registered Nurses was approved by the Chief, Bureau of Medicine and 
Surgery for implementation throughout Navy medicine. NHCP joined NMCSD 
in adjusting their nursing salaries for the first time in over 15 
years, increasing the Navy's ability to compete for experienced nurses 
in the local community.
    At NNMC, the Government Service (GS) accelerated promotion program 
has been tremendously successful and will be expanded. It helped reduce 
the Registered Nurse (RN) vacancy rate from 13 percent to <4 percent 
and increased continuing education training opportunities for all 
nurses. GS nurses hired under the accelerated promotion plan are 
integrated into the Nurse Intern Program, enhancing their transition 
into a military nursing milieu.
                   readiness and clinical proficiency
    In order to meet nursing requirements at home and in forward 
deployed settings, nurses must maintain clinical proficiency and 
competence. Our readiness and clinical proficiency team recently 
launched core competencies for medical/surgical, psychiatric, critical 
care and emergency nursing. These will be integral in standardizing 
nursing competency assessments throughout Navy medicine and, once 
initiated in a nurses' orientation to a clinical specialty, would then 
follow the nurse across the career continuum, thus eliminating rework 
of subsequent competency packets at each duty station.
    An off-shoot from this group was the Tri-Service Nursing Procedures 
Standardization workgroup, which identified a web-based nursing 
procedure manual for acquisition and utilization in all military 
treatment facilities. This tri-service proposal was briefed and 
approved by my fellow Service Corps Chiefs at the Federal Nursing 
Service Council meeting. Navy members are now engaged in identifying 
contract vehicle and consolidated funding sources.
                              operational
    The Navy Nurse Corps continues to be one of the largest deploying 
groups among all professional corps (Medical, Dental and Medical 
Service Corps) in Navy medicine. From January 2006 to March 2008, 232 
Active and Reserve Component Navy nurses have deployed.
    Our nurses served admirably in operational roles in Kuwait, Iraq, 
Djibouti, Afghanistan, Bahrain, Qatar, Indonesia, Thailand, Southeast 
Asia, Pakistan, Guantanamo Bay, Cuba, Germany and aboard both hospital 
ships USNS Mercy and Comfort and on many other grey-hulls. They are 
part of Provincial Reconstruction Teams (PRTs), Flight Surgery Teams, 
participate in the Sea Trial of the Expeditionary Resuscitative Surgery 
System (ERSS) and perform patient movement via Enroute Care at or near 
combat operations.
    The nurses who perform Enroute Care have clinical experience in 
either critical care or emergency room nursing and prior to deployment 
attend specialized training at Naval Operational Medical Institute in 
Pensacola, Florida or Fort Rucker, Alabama. Their training includes 
physiologic changes of patients at various altitudes, airframe and 
equipment familiarization.
    The nursing ``footprint'' is still essential and evident at 
Expeditionary Medical Facility (EMF) Kuwait. In a 6-month period (July 
2007-December 2007), a total of 3,564 casualties were received and 
treated. Other activities supported by Navy nurses at EMF Kuwait 
include the coordinated, joint support of immunizations for Japanese, 
British and Korean troops and a Kuwait-staged mass-casualty/interagency 
drill and Advanced Cardiac Life Support programs with the American 
Embassy in Kuwait.
    At Landstuhl Regional Medical Center, 98 Navy Reserve Component 
nurses work alongside their colleagues from the Army and Air Force. 
During the past 2 years, Navy nurses from this contingent have also 
worked in the warrior management center and made great strides in the 
provision of optimal care to the wounded as they transit on flights 
from Landstuhl Regional Medical Center to military treatment facilities 
in the CONUS.
    The top five deploying specialties in the Navy Nurse Corps include 
medical/surgical, perioperative, emergency/trauma, critical care and 
CRNAs. By the summer of 2007, 25 percent of all Active Duty CRNAs were 
deployed, from recent graduates with 1 year of experience to seasoned 
officers at the rank of captain. The CRNA community has held roles in 
every aspect of Operational Medicine: humanitarian missions, special 
warfare operations, routine ship trials and movements, deployments with 
the Marines. and as multiservice and international security force PRTs.
    Though not identified among the ``top five deploying specialties'', 
our Family Nurse Practitioner (FNP) community is one in which 60 
percent of current billets have associated deployment platforms. FNPs 
are integral to Family Practice residency training programs, continuing 
to provide access and deliver health care wherever they are assigned. 
Solidly grounded in disease prevention and health promotion, the FNP 
brings these tenets of nursing care to every patient encounter--
positively impacting population health in our communities and reducing 
the disease burden and associated costs of chronic disease management. 
A study undertaken by the Center for Naval Analysis in 2007 will 
provide a comprehensive assessment of the emerging roles of the FNP, as 
well as the Pediatric Nurse Practitioner communities.
    The preparation of our forward deployed nurses could not be as 
effectively accomplished without the support of Navy Individual 
Augmentee Combat Training (NIACT). Prior to deploying, personnel are 
sent to NIACT at Fort Jackson, South Carolina, where the training 
consists of combat, survival, convoy, weapons handling and firing, and 
land navigation. Nurses also wear the entire ensemble of Kevlar and 
Interceptor Body Armor (IBA) daily which in one nurse's words 
``sensitizes you to the hardships of wearing the gear everyday, every 
hour as those in Iraq do. I felt prepared when I arrived to 
Expeditionary Medical Facility Kuwait.''
    Proactive nursing leaders have front-loaded staff training with 
operational relevant topics. At Naval Hospital Great Lakes, Tactical 
Combat Casualty Care Course was taught to 98 staff members for 
deployment readiness. At NMCSD and NHCP nursing leaders are directing 
staff attendance at other war-fighting support programs such as Fleet 
Hospital training, Combat Casualty Care Course, Enroute Care Training, 
Military Contingency Medicine/Bushmaster Course offered at the 
Uniformed Services University of the Health Sciences, Joint Forces 
Combat Trauma Management Course, and Naval Expeditionary Medical 
Training Institute.
    The Navy Trauma Training Course, developed in 2002 and hosted in 
conjunction with Los Angeles County/University of Southern California, 
continues to be an integral training platform for forward deploying 
nurses. Since the course inception, 241 nurses have received this 
training prior to reporting to their operational billet. This course, 
in which 39 Navy nurses were trained in 2007, combines didactic, 
simulation labs and clinical rotations in the main operating room, ICUs 
and the emergency department.
                        humanitarian assistance
    My precepts for Navy nursing align with the Chief of Naval 
Operations' Maritime Strategic Plan. Based upon successes of past 
global humanitarian missions in which Navy nurses were embarked aboard 
USNS MERCY and COMFORT, we will be critical crewmembers once again in 
upcoming dual missions planned for 2008.
    The USNS COMFORT (T-AH 20) was deployed from June 2007-October 2007 
to participate in a humanitarian training mission for the ``Partnership 
for the Americas''; visiting 12 countries and seeing 98,650 patients in 
the Caribbean and South America including Belize, Guatemala, Panama, 
Nicaragua, El Salvador, Ecuador, Peru, Columbia, Haiti, Trinidad/
Tobago, Guyana and Surinam. The COMFORT and its teams of multiservice 
healthcare professionals, military, reserve, civilians and Non-
Government Organizations (NGOs) from various fields of study (Nursing, 
Public Health, Dentistry, Pediatrics, Infection Control, etc) provided 
a total of 1,197 classes to 28,673 students in 12 countries during the 
Partnership for the Americas cruise. Many of our nurses would later 
remark that while the days were long, the interactions with patients 
and feeling of having truly made a difference in someone's life would 
be lasting memories.
    Even while deployed at sea on humanitarian missions, the necessity 
for discharge planning programs became quite evident. Two Nurse Corps 
officers with experience in community/public health and case management 
were provided with two other hospital personnel familiar with MEDEVAC 
procedures to coordinate plans for the development and implementation 
of a new nursing discharge planning team on the COMFORT. Utilizing a 
multidisciplinary approach, the team integrated services of 11 
divisions and capitalized on host nation assets which included private 
physicians, Ministries of Health and NGOs to assure post-operative 
follow up care for over 2,200 patients in their homelands. This team 
initiated over 20 process improvements that streamlined admission to 
discharge care for 7,500 inpatients.
    The USNS MERCY (T-AH 19) is slated for its next humanitarian 
mission, ``Pacific Partnership,'' visiting regions of the Western 
Pacific and Southeast Asia in 2008. Augmenting crew members are 
expected to include joint, multinational and interagency personnel. In 
preparation for this mission, the senior nurse on board the ship has 
attended the Joint Operations Medical Managers Course and Military 
Medical Humanitarian Assistance Course.
    Navy nursing's altruistic spirit and readiness to help were 
demonstrated in our own country during the horrific wildfires that 
ravaged Southern California coastlines in October 2007. Amidst 
evacuating their own families and ensuring their safety was preserved, 
Nurse Corps officers were rallying to support the needs of their 
command and any impending requirement to augment civilian health care 
delivery services that were severely taxed during this massive natural 
disaster.
    During the subsequent evacuation of many civilian healthcare 
facilities due to imminent danger posed by the smoke and fire, 28 
patients from a local skilled nursing facility were relocated to NMCSD 
on a rapidly deployed contingency ward jointly staffed by NMCSD and 
Naval Hospital Twenty-nine Palms personnel. The nursing staff 
impressively responded to this call for assistance and conducted 
expeditious patient assessments to determine patient acuity and how to 
best meet patient needs.
    An additional ten patients were evacuated to NMCSD from Pomerado 
Hospital and were safely absorbed into the Medical/Surgical wards and 
the ICU. During and after this state emergency, 12 Nurse Corps officers 
from this hospital volunteered at the local stadium which became a 
temporary shelter, providing aid and assistance to hundreds of 
dislocated and homeless San Diego citizens.
    During this same wild fire disaster, the Nurse Corps officer 
department head at Camp Pendleton evacuated the 52 Area Branch Clinics 
(School of Infantry) in less than 90 minutes. A temporary clinic was 
established and 24-hour medical coverage was available to wildfire 
evacuees which included approximately 400 patients. This officer 
further embedded a medical contingent of eight hospital corpsmen and 
one independent duty corpsman to ensure continuous medical support was 
available to 4,000 marines that were evacuated from their barracks and 
were living in a field environment.
    The Nurse Corps officer department head from the 31 Area Branch 
Clinic (Weapons Training Area) evacuated his clinic and relocated his 
staff to another base clinic and provided round- the-clock medical care 
to 1,000 evacuees in the Del Mar area of Marine Corps Base Camp 
Pendleton.
                     education program and policies
    Continuation of a Navy nurses' professional development via 
advanced educational preparation is necessary to better serve our 
beneficiary population, fortify their respective communities of 
practice and for promotion. My education program and policy team works 
to identify educational opportunities to Navy Nurses, expand the 
utilization of dual certified advanced practice nurses and formulate a 
mentorship program for entry-level nurses who are accessioned via the 
Nurse Candidate Program, Medical Enlisted Commissioning Program and the 
Reserve Officer Training Corps.
    This year marks the first time since 1975 that nurses within their 
first tour of duty may apply for a master's degree in nursing via the 
Duty under Instruction (DUINS) out-service training program. Our long-
term goal for this initiative is to increase service retention at 
critical junctures in a young officer's career and facilitate earlier 
entry into specialty communities of their choice. Over 70 new graduates 
with Masters of Science in Nursing will be assigned to new duty 
stations in 2008.
                               mentorship
    The role that Navy Nurses hold as mentors to our corpsmen and 
junior officers also serves to bolster recruiting efforts in our 
pipeline programs for enlisted members through the Medical Enlisted 
Commissioning Program (MECP) and the Seaman to Admiral Program (STA-21) 
and supports the retention of subordinate colleagues who perhaps once 
pondered a career outside of Naval service.
    Navy nurses enthusiastically embrace their role as mentors and 
activities involving such are pervasive throughout our treatment 
facilities. At NMCSD, 12 Nurse Corps option ROTC midshipmen spent 4 
weeks in clinical rotation on medical/surgical wards. These ``fledgling 
nurses'' became proficient with venipuncture and had exposure to 
operational nursing roles at NHCP and aboard USNS MERCY.
    NMCP promotes active mentoring roles with local MECP candidates. 
Navy Nurses assigned here also visit local job fairs as hosted by 
regional SONs and provide candid answers to queries from nursing 
students who are interested in service to their country.
                collaborative/joint training initiatives
    Many commands, perhaps not routinely affiliated with SONs, serve as 
practicum sites for students. At BUMED, senior nurse executives are 
preceptors for college juniors or seniors as they study nursing 
leadership. At U.S. Naval Hospital Naples, Italian nursing students are 
mentored by Navy nurses as they compare and contrast the medical 
systems of the two countries.
    The Navy Nurse Corps Anesthesia Program, ranked third in the Nation 
among 108 accredited Certified Registered Nurse Anesthesia programs by 
U.S. News and World Report, will unite with the Uniformed Services 
University of the Health Sciences (USUHS) Graduate School of Nursing 
nurse anesthesia program to form one Federal Nursing anesthesia 
program. The first class matriculates in May 2008.
    Additional partnerships with USUHS include the provision of a 
Psychiatric Mental Health Nurse Practitioner as faculty member to the 
newly developed Psychiatric Mental Health Nurse Practitioner Program. 
This nurse will join other colleagues from the Armed services who serve 
on faculty at the Graduate School of Nursing.
    Home to a robust, state-of-the-art ICU, NNMC became a training site 
for our Air Force nursing colleagues who require rigorous exposure to 
critically ill patients in preparation for their role on Critical Care 
Air Transport Teams. Internationally recognized as a site of clinical 
excellence, each year the Greek Navy sends three active duty nurses to 
Bethesda for training in critical care, medical/surgical and oncology 
nursing.
    Since July 2006, NMCP, in collaboration with Langley Air Force Base 
(AFB), has provided a comprehensive Perinatal Training Course for Air 
Force, Navy and civilian service RNs. Current Perinatal Training 
Programs provided at NMCP include a 6-week perinatal training 
consisting of a 2-week didactic curriculum at Langley Air Force Base 
and a 4-week clinical practicum with assigned preceptor. Collaboration 
among Perinatal Training Program Managers from NMCP and Langley AFB, 
Navy Medicine Manpower Personnel Training and Education Command and the 
BUMED Women's Health Specialty Leader led to proposed curriculum 
changes that will align with NMCSD's new program. NMCSD hosted and 
developed the Navy's 1st Perinatal Pipeline Training Program for Navy 
Nurses in receipt of orders for assignment to maternal-infant care 
units in overseas military treatment facilities.
    In December 2007, two senior Nurse Corps officers from NMCSD 
participated in a project with the University of Zambia to develop a 
Masters degree in Community and Public Health Nursing with an emphasis 
on infectious disease (HIV/AIDS) surveillance, prevention, care and 
treatment. These officers will be returning to Zambia in the summer of 
2008, where they will continue to assist the University with the 
development of this program as well as a Physician Assistants 
equivalent school, lab technology and medical assistant schools.
    Despite their geographic remoteness, our OCONUS military treatment 
facilities are very actively engaged in activities with U.S. facilities 
and host nation communities. Naval Hospital Guam participated in a 
nationwide exercise conducted simultaneously in multiple states in 
which various disaster scenarios were enacted, requiring involvement of 
both military and civilian resources to achieve a safe and successful 
outcome. U.S. Naval Hospital Yokosuka offers annual training for Sexual 
Assault Nurse Examiner, Trauma Nurse Casualty Care, Perinatal 
Orientation and Education Program, Neonatal Orientation and Education 
Program and Neonatal Resuscitative program for tri-service and Japanese 
military Self-Defense Force participation. U.S. Naval Hospital Okinawa 
supports local nursing education via a clinical intercultural nursing 
experience hosted semi-annually with the Hokobu Nursing School.
                                research
    The Tri-Service Nursing Research Program (TSNRP) is critically 
important to the mission of the Navy Nurse Corps and I am committed to 
its sustainment. Our nurses are engaged in research endeavors that 
promote health, improve readiness and return our warriors to wellness. 
An ongoing study conducted by a Navy Nurse, ``Evidence-Based Practice 
Center Grant (2002) Study'' provided training to nurses and funded 
initiatives from multiple military treatment facilities to translate 
evidence to practice. Another study entitled, ``Clinical Knowledge 
Development of Nurses in an Operational Environment (2003)'', uses 
information gleaned from interviews with nurses from Army, Navy, Air 
Force and Public Health Service who had deployed either in theatre or 
to natural disaster areas and identified subsequent knowledge necessary 
to this setting. ``The STARS Project: Strategies to Assist Navy Recruit 
Success (2001)'' culminated in BOOT STRAP Intervention which changed 
the policy of how Commanders approached recruits. The number of 
recruits separated from the Navy before completing basic training was 
reduced from a high of nearly 30 percent to <15 percent. A Navy nurse 
directed study on ``The Lived Experience of Nurses Stationed Aboard 
Aircraft Carriers (2000)'' changed policy about assigning new Ensigns 
to aircraft carriers.
    In addition to TSNRP endeavors, our doctorally prepared Navy nurses 
assigned throughout our military treatment facilities have actively 
engaged many nurses in a plethora of robust research initiatives that 
include areas of maternal/neonatal care, pediatrics, anesthesia, 
critical care and military populations deployed on ships. One of the 
graduates of the Navy Nurse Corps Anesthesia Program competed against 
both medical and nursing colleagues and won the 2007 Navy-wide Academic 
Research Competition staff category for his study.
                              publications
    Navy nurses are prolific authors whose works encompass all 
specialty areas of nursing and have appeared in nationally recognized 
publications as follows: Critical Care Nursing Clinics of North 
America; AORN Journal; Nursing Spectrum; Advance for Nurse 
Practitioners; Journal of Nursing Education; The Nurse Practitioners 
Journal; Journal of Wound, Ostomy & Continence; Journal of Pediatric 
Healthcare; Journal of Obstetric, Gynecologic and Neonatal Nursing; 
Dimensions of Critical Care Nursing; Military Medicine.
                        educational partnerships
    While all of our nurses do not teach every day in traditional brick 
and mortar SONs, they are still teachers in their service as clinical 
preceptors and as guest faculty/lecturers to our corpsmen, military and 
Government service nurses. They are also role models and recruiters to 
civilian nursing students who seek an opportunity to gain a lifetime of 
personal satisfaction in service to humanity and our Nation.
    One of our nurses teaches in an undergraduate nursing program at 
Hawaii Pacific University and another has precepted over 850 clinical 
hours for nurse practitioner students. Medical/surgical nurses are 
precepting civilian nursing and graduate students from Georgetown, 
Johns Hopkins, University of Guam, University of North Florida and the 
University of California at San Diego in our treatment facilities 
located in proximity to their SONs.
    Staff Nurse Anesthetists (CRNAs) assigned to the NNMC serve as 
clinical and didactic instructors for student nurses from the Nurse 
Corps Nurse Anesthesia programs at Georgetown University and USUHS.
    At Naval Hospital Beaufort, the nurse anesthesia staff established 
a memorandum of understanding (MOU) with the Medical University of 
South Carolina, College of Health Professions, and Anesthesia for 
Nurses program in September 2006. The first student arrived in December 
2006 and Navy Nurse Anesthetists have precepted 14 students to date. 
The MOU critically supports this region's anesthesia program and hands-
on training for nurse anesthetists. A senior Navy CRNA was selected 
Clinical Instructor of the Year for 2007 and was honored at the 
graduation ceremony in Charleston last May.
    Because of the size and scope of clinical specialties found at our 
medical centers at Bethesda, Portsmouth and San Diego, they have 
multiple MOUs with surrounding colleges and universities to provide 
clinical rotations for nurses in various educational programs from 
licensed practical/vocational nursing (including Army LPNs at the 
Bethesda site), Bachelor of Science in Nursing, Master of Science in 
Nursing, to Nurse Practitioner and Certified Nurse Anesthetist 
Programs.
    Our mid-sized MTFs are also actively engaged in training America's 
future nurses. Naval Hospital Twenty-nine Palms has developed a MOU 
with the California Educational Institute to serve as a clinical 
rotation site in support of developing the LPN to RN Bridge Program, 
while simultaneously maintaining current agreement with Copper Mountain 
College LPN and RN Nursing programs. Naval Hospital Great Lakes 
provides clinical sites for Family Nurse Practitioner clinical training 
and offers classes in Basic Life Support, Advanced Cardiac Life 
Support, Pediatric Advanced Life Support, and Neonatal Resuscitation 
Program to staff from the North Chicago VA Medical Center.
    It is not only the nurses of America that Navy nurses willingly 
teach, but also our own novice accessions. The Nurse Internship 
Program, available at each of our medical centers is a structured 
didactic and clinical curriculum involving a variety of nursing 
specialties which uses mentorship to transition the graduate nurse from 
the role of student to staff nurse. In 2007, we have cumulatively 
trained over 250 nurses. This program is also availed to our new 
civilian graduate nurse employees.
                               leadership
    The goals of the Nurse Corps leadership team include development 
and mentoring of future Nurse Corps leaders using identifiable 
leadership competencies across their career continuum.
    This year we celebrated two firsts: A Nurse Corps officer as the 
first Navy nurse assigned to a Fleet Forces Command role and another as 
the first to command a surgical company in Iraq. In September 2007, the 
first Nurse Corps Officer was assigned to U.S. Fleet Forces Command to 
provide analysis and recommendations on all professional and technical 
matters relating to nursing policy and practice throughout the fleet. 
As a senior staff officer, she also provides recommendation for health 
services support programs and policies related to health protection 
initiatives.
    CDR Maureen Pennington was awarded the Bronze Star in April 2007, 
for her role as the first Nurse Corps officer to serve as Commanding 
Officer of Charlie Surgical Company, Combat Logistics, 1st MLG, 1st 
MEF. CDR Pennington oversaw treatment of over 1,700 casualties. Despite 
increased numbers of patients with blast wounds from Improvised 
Explosive Devices, she and her team maintained an unprecedented 98 
percent combat wounded survival rate. In October 2007, she was 
recognized by California's First Lady with the Minerva Award, which 
honors women who have ``changed the State of the Nation with their 
courage, strength and wisdom.''
    Navy nurses are members and leaders not only at their military 
treatment facilities, but also in their community civic groups, non-
profit organizations, local, State and national civilian nursing 
associations and Federal nursing organizations. A Senior CRNA served 
for the 5th consecutive year on the Board of Directors for the Virginia 
Association of Nurse Anesthetists and served on the Public Relations 
Committee for the AANA National organization. Other Navy nurses hold 
the following leadership roles: President-elect of Sigma Theta Tau at 
The Catholic University of America, Director-Federal Nurses Association 
and Board of Directors-American Association of Critical Care Nurses. 
Our junior nurses have embraced a sense of community volunteerism and 
often work off-hours to support local area homeless shelters by 
preparing and serving meals, collecting and distributing clothing and 
assisting with facility renovations.
                              productivity
    The Nurse Corps Productivity Team developed a tri-service business 
strategy for inpatient and ambulatory care patient acuity assessment 
and staff scheduling system. The team which now includes the Tri-
Service Patient Acuity Staff Scheduling Working Group has met with 
Health Affairs and individual service representatives and are meeting 
with their respective Chief Information Officers to garner support as 
team activities move forward.
    Naval Hospital Beaufort's nurse-managed clinics decreased the 
pneumonia rate by 45 percent, GABHS (Group A & B Hemolytic 
Streptococcus) strep throat by 51 percent, febrile response syndrome by 
27 percent, and MRSA (Methicillin-Resistant Staphylococcus aureus) by 
26 percent through preventive medicine interventions with USMC recruit 
populations. Nurses at Naval Hospital Camp Lejeune assigned to Camp 
Geiger Branch Medical Clinic at the School of Infantry-East engaged in 
a collaborative effort with the Medical Clinic at Parris Island Recruit 
Depot to improve tracking and documentation of health care provided for 
recruits from accession to training. In a 6-month period these efforts 
culminated in significant cost savings by eliminating unnecessary 
duplication of lab work and immunizations.
    Nurse-run clinics established in four barracks at the Recruit 
Training Command (RTC) in Great Lakes facilitated triage and medical 
care of 200 recruits per day. The availability of these clinics 
decreased wait time in the main clinic from 3 hours to 20 minutes, 
recaptured 13,000 hours of previously lost recruit training time, 
provided for daily nursing rounds in ship compartments to monitor the 
status of Sick in Quarters/Limited Duty Recruits, and generated 
substantial cost avoidance for the RTC.
    Navy nurses at NMCSD were pivotal in developing an innovative model 
for tele-health nursing using the Armed Forces Health Longitudinal 
Technical Application (AHLTA) computer system. This project was 
developed with the goal of becoming a reliable system to provide 
documentation of patient calls which will improve continuity of care, 
while capturing nursing workload and improving nursing documentation. 
This project received the Access Award at the Healthcare Innovations 
Program Awards at the 2008 Military Health System Conference.
    Naval Health Clinic Hawaii collaborated with Hickam Air Force 
Base's 15th Medical Group on an evidenced-based practice project in 
caring for adult patients with Diabetes Mellitus (DM), showing an 
increase patient compliance as evidenced by their improving HbA1C and 
LDL values.
                             communication
    The overarching goal of the Nurse Corps Communication team is to 
develop two-way communication plans to optimize dissemination of 
official information that is easily accessible, current and understood. 
This has been accomplished via monthly ``Nurse Corps Live'' video tele-
conferences on a variety of topics relevant to our nursing communities, 
monthly electronic publication of ``Nurse Corps News'' newsletter which 
offers a venue to share information, events and articles with all 
nurses and the Nurse Corps webpage. The webpage serves as a portal to 
the Navy Nurse Corps detailers, policy and practice guidelines, 
advanced education offerings, career planning and messages from the 
Director of the Navy Nurse Corps. In the future, communication team 
members will be conducting surveys on webpage users to determine new 
requirements to improve accessibility and better meet user needs.
                            closing remarks
    The practice of nursing has changed over the last 100 years with 
research and technology, but the basic tenets of the profession are 
unchanged and timeless. We volunteered to wear the uniform, to practice 
our profession in a different environment and through this we have 
unlocked the secrets to our humanity and what is most important about 
caring for those willing to make the supreme sacrifice. Thanks to the 
generations of Navy nurses who moved us forward through other wars, we 
have a solid foundation upon which to meet the challenge of tomorrow. 
Our junior officers are our future and based on the passion and 
competence I see daily, our future looks bright indeed. We exist 
because we were and ARE mission essential. They needed us then; they 
need us now. We can be proud of what we have done and should be 
inspired and humbled by what we have left to do in the next 100 years.
    I appreciate the opportunity to share with you the remarkable 
accomplishments of my nurses. I look forward to continuing our work 
together as I carry on as Director and lead Navy nursing into its next 
century of excellence.

    Senator Inouye. And now may I recognize Major General 
Melissa Rank. General Rank.
STATEMENT OF MAJOR GENERAL MELISSA A. RANK, ASSISTANT 
            AIR FORCE SURGEON GENERAL NURSING SERVICES 
            AND ASSISTANT AIR FORCE SURGEON GENERAL 
            MEDICAL FORCE DEVELOPMENT
    General Rank. Mr. Chairman, and distinguished subcommittee 
members. It is an honor and great privilege to again represent 
your Air Force nursing team. The total nursing force is 
comprised of active duty, Guard, and Reserve officers, enlisted 
and civilian personnel.
    I am honored to have served with Brigadier General Jan 
Young, Air National Guard, Colonel Laura Talbot, Air Force 
Reserves, and Chief Master Sergeant David Lewis, Aerospace 
Medical Service, Career Field Manager.
    I look forward to serving with my new Reserve Mobilization 
Assistant, Colonel Anne Manly, and Chief Master Sergeant Joseph 
Potts, the newly appointed Aerospace Medical Career Field 
Manager. Together we represent a powerful total nursing force, 
directly supporting the Air Force's Secretary and Chief of 
Staff's top priorities.
    Whether at war or home station, our medics are providing 
world-class care. I offer this amazing act of heroism by one of 
our independent duty medical technicians, Staff Sergeant Jason 
Weiss.
    He's assigned to the 36th Rescue Flight, Fairchild Air 
Force Base, Washington. He and his fiance, Holly, were to be 
married on December 4, but he could not be there. Instead, his 
team was busy rescuing three injured, and nearly frozen, hikers 
trapped in an avalanche. Sergeant Weiss had to get the hikers 
to the extraction point before the chopper ran out of fuel. 
There would be no second chance.
    Low crawling, near exhaustion, Sergeant Weiss dragged the 
patient through 80 yards of waist-deep snow, to lifesaving 
treatment. Sergeant Weiss was married 4 days later, and Holly 
explained, ``He does such amazing things, that I have to share 
him.''
    The total nursing force is the backbone of deployed Air 
Force medical operational capability. A heightened demand has 
been placed upon us for advanced, highly complex clinical 
skills, and we are meeting the challenge.
    The 332nd Expeditionary Medical Group in Balad Air Base, 
Iraq continues to meet the mission with incredible success. 
This Air Force theater hospital is the hub for Operation Iraqi 
Freedom polytrauma and burn cases, and sustains a 98 percent 
survival rate, the best in history.
    From the moment a patient arrives into the Balad Air Base 
emergency room, until they reach definitive care at Landstuhl 
or stateside, an Air Force nurse and technician provide 24/7 
expert, compassionate care.
    On my recent trip to Balad Air Base and Bagram Air Base, 
Afghanistan members of our total nursing force related that 
their deployment has been the most personally and 
professionally rewarding experience of their lives.
    I was particularly moved by the story of Major Linda 
Stanley from the 31st Medical Group in Aviano, Italy. 
Paraphrasing her journal, ``I took care of a patient tonight, 
and I know I will never forget him. He had been on patrol, and 
lost his foot to an improvised explosive device (IED). For some 
reason, his bloody boot symbolizes all of the trauma patients 
that I'm taking care of--the vision of his boot, the sound of 
painful cries, and the smell of death are my senses side of 
war. I find life in these senses, and it reminds me of what is 
truly important in my own life. I am still glad that I 
deployed, and I hope I will always remember these feelings.''
    These are the heart-wrenching realities of war, and my team 
is committed to addressing the unique combat stress of 
caregivers. Our initiative is called R3--readiness, resilience, 
and rejuvenation. Our nursing team needs a high level of 
personal and professional readiness, an inner resilience, and 
the ability to rejuvenate after returning from deployment.
    As we develop our R3 programs, we will leverage our unique 
military nursing experience and commitment to care for 
ourselves and each other. Lieutenant Colonel Susan Jano, 
nursing supervisor at Balad Air Base, described it best, ``We 
saw mass casualties that training never quite prepared us for. 
We reached deeper into ourselves than we ever thought possible, 
and we cared for one another because we were all we had. 
Together, we made a difference.''
    We also are making a difference in Afghanistan, where the 
humanitarian mission is particularly robust. Zach was a child 
who had been hit by a bus. When he arrived at the Bagram 
emergency room, he had no pulse, his temperature was 91 
degrees, and he had astounding major abdominal injuries. 
Amazingly, after receiving extensive operations and nursing 
care, he went home with his family in just 30 days.
    The rewards of these efforts are highlighted by Major Daisy 
Castricone, currently deployed to Bagram Air Base, when she 
stated, ``You can see the appreciation and the love in their 
eyes for what we do, and you can feel the sincerity in the 
handshake--it's like electricity.''
    Thanks to the efforts of the 332nd Expeditionary Medical 
Group, and Expeditionary Civil Engineering Squadron, a piece of 
our nursing history will be preserved. On April 1, 2008 Trauma 
Bay 2, and a portion of the tent from the old Balad Air Base 
theater hospital were shipped to the National Museum of Health 
and Medicine, here in Washington, DC. Major Jody Ocker, 
Emergency Department Nurse Manager, related, ``Every medic had 
their own personal experience. As a team, we had a profound 
collective experience. In these tents, we witnessed tragedy 
beyond comprehension, and rose to challenges unimagined. We 
sweated, cried, and laughed together, most importantly, we 
saved lives.''

                           PREPARED STATEMENT

    Mr. Chairman, and distinguished members, the preservation 
of the theater hospital's trauma bay is a testament to the 
Department of Defense nurses, and medics, who have held the 
hands of wounded warriors, said goodbye to the fallen, and 
offered their blood, sweat and tears to save our Nation's sons 
and daughters. United, we will win today's fight, provide 
world-class care, and prepare for tomorrow's challenges.
    Thank you, sir, for your continued support.
    Senator Inouye. I thank you very much, General Rank.
    [The statement follows:]
          Prepared Statement of Major General Melissa A. Rank
    Mr. Chairman and distinguished members of the Committee, it is an 
honor and gives me great pleasure to again represent your Air Force 
Nursing team. As we vigorously execute our mission at home and abroad, 
Air Force nurses and enlisted medical technicians are meeting the 
increasing challenges with notable professionalism and distinction. The 
Total Nursing Force is comprised of officer, enlisted, and civilian 
nursing personnel with Active Duty, Air National Guard (ANG), and Air 
Force Reserve Command (AFRC) components. Serving alongside Brigadier 
General Jan Young of the ANG and Colonel Laura Talbot of the AFRC has 
been my distinct pleasure. I look forward to serving with Colonel Anne 
Manly who was recently appointed in the AFRC Corps Chief position 
replacing Colonel Laura Talbot. Together we are a powerful total force 
nursing team directly supporting the Secretary and the Chief of Staff 
of the Air Force's top priorities to Win Today's Fight, Take Care of 
our Airmen, and Prepare for Tomorrow's Challenges.
                         expeditionary nursing
    Air Force Nursing is an operational capability and Air Force 
Nursing Services remain at the forefront in support of the warfighter. 
A heightened demand has been placed upon military nursing for highly 
complex clinical skills and our total nursing force is meeting this 
challenge. Every member of the Total Nursing Force team has told me 
that their deployments, caring for America's most precious sons and 
daughters, has been the most professionally rewarding experience of 
their lives. For instance, Captain Shelly Garceau is an emergency room 
nurse at the 332nd Expeditionary Medical Group (EMDG) in Balad Air 
Base, Iraq, one of the busiest trauma centers in the world. The 
emergency room treats 23 patients a day on average, 11 of which are 
trauma cases. In a 24-hour cycle, the facility's operating room staff 
typically handles more than a dozen cases and performs more than 60 
procedures. In the past year, nursing was critical to the successful 
treatment of over 10,000 injuries. The hospital currently holds a 98 
percent survivability rate for wounded Americans who arrive at the 
332nd EMDG. Colonel Norman Forbes, 332nd EMDG Chief Nurse, states, ``In 
a four-month period, the facility's statistics match or exceed 
activities at the R. Adams Cowley Shock Trauma Center in Baltimore, 
where many of our staff nurses were trained.''
    Behind every case and helping every patient who arrives at their 
doorstep, is the nursing staff of the 332nd EMDG. From the moment a 
wounded soldier arrives at the hospital to the time the patient lands 
in Germany or is medically evacuated to the United States, a nurse and 
technician are there to care for the wounded patient. The pride that 
erupts from the members of this medical group is felt and seen when you 
look at even just one situation: Two Marines were transferred out of 
the Balad Air Base emergency room with partial thickness burns to the 
face as a result of an explosion; Captain Garceau (332nd EMDG) stated, 
``That guy couldn't even see me. He wouldn't be able to show you who I 
am if he saw me. But he'd recognize my voice. And when he said thank 
you to me, it was like nothing else. There's nothing like the `thank-
you's' you get here--nothing at all.''
    Bringing wounded warriors home is mission #1 for our fixed-wing 
aeromedical evacuation (AE) system. AE is a unique and significant part 
of our Nation's renowned mobility resources. Its mission is to rapidly 
evacuate patients under the supervision of qualified AE crewmembers by 
fixed-wing aircraft during peace, humanitarian, noncombatant evacuation 
operations, and joint/combined contingency operations. The Air Force 
Reserve Component owns approximately 88 percent of the total AE force 
structure, with the remaining 12 percent distributed among four active 
duty AE squadrons. During November 6-7, 2007, active duty and reserve 
subject matter experts met to hold a capabilities review and risk 
assessment on the AE system. As a result of this meeting, the Air Force 
AE patient care information management and in-transit visibility 
modernization plan evolved. The recommendations for a new electronic 
patient medical record and the ability for combatant commanders to know 
where, when, and how their injured troops are doing, will bring AE to 
the leading edge of technology.
    A major advancement in aeromedical evacuation system of the Afghan 
National Army (ANA) Air Corps is the work being done by individuals 
like Major Mical Kupke, Captain Marilyn Thomas, Master Sergeant Brian 
Engle, and Technical Sergeant Janet Wilson who opened a flight medicine 
clinic in Kabul, Afghanistan. These airmen are using all local 
resources available to perform work, including loading patients onto 
MI-17 helicopters, coordinating with the Czech Republic field hospital 
and working with the medevac unit located nearby at Bagram Air Base, 
Afghanistan. As Sergeant Engle stated, ``The ultimate goal is for us to 
be able to step away as the ANA becomes self-sustaining.'' Sergeant 
Wilson stated, ``The fact that we're able to bring something to their 
Air Corps and help the Afghan National Army build up their structure is 
very positive; it makes me proud that I can contribute just a tiny 
portion to that.''
    Our aeromedical staging facilities (ASF) provide critical support 
to the aeromedical system. The 79th ASF at Andrews AFB, Maryland is the 
busiest in the continental United States. Since January 2007, the staff 
has launched and recovered 699 missions, and facilitated the transport 
and care of 7,895 patients to Andrews, Walter Reed Army Medical Center 
and the National Naval Medical Center. The 79th ASF staff includes 31 
permanent and 33 deployed active duty and reserve nursing and 
administrative nursing personnel. Army, Navy, and Marines liaisons also 
work in the ASF assisting their patients with transition back to the 
United States. The patients have a wide variety of injuries and 
illnesses, including those from improvised explosive device (IED) 
blasts, gunshot wounds, traumatic brain injuries, post-traumatic stress 
disorder, and extremity fractures.
    In this calendar year, the 79th ASF received a $4.8 million grant 
to renovate and expand, increasing the bed capacity from 32 to 45. 
Nutritional Medicine from the 79th Medical Group implemented ``The 
Burlodge,'' a program that provides every patient returning from 
theater a homemade hot meal. Dedicated American Red Cross volunteers 
are on hand to welcome every patient upon their return. These 
volunteers offer their assistance in many ways to meet the needs of the 
patients, providing toiletries, clothing, email assistance, and more. 
Major Leslie Muhlhauser and Captain Christopher Nidell of the ASF staff 
recall these patient encounters:
  --One of the administrative technicians sat with a patient all night 
        talking and watching movies, because the patient expressed not 
        wanting to be alone and not being able to sleep.
  --A security forces patient wanted to take a hot shower and wash her 
        hair and was unable to do so on her own due to leg and arm 
        injuries. Three of the ASF staff worked together to protect her 
        wounds and help her shower.
  --One of the nurses sat with a 19-year-old soldier from Kentucky 
        suffering from migraines related to an IED blast exposure. He 
        stayed with the soldier to help him relax until the medication 
        he received began to relieve his pain.
  --The staff coordinated with veterinary services for the care and 
        lodging of two canine battle wounded heroes, one who received a 
        Purple Heart.
  --On one mission, the wind and weather prevented a C-17 and C-130 
        from landing at Andrews AFB Maryland. The ASF flightline crew 
        quickly realigned the organizational plans and met the aircraft 
        at a commercial airport in the National Capital Region (NCR).
  --The nurses watched a mother's face as she and her family waited for 
        the arrival of her son; seeing them together was a privilege.
                           skill sustainment
    Nursing skill sustainment has never been more important than it is 
during our steady state of deployment. Air Force critical care nurses 
have played an instrumental role in the care of wounded and ill 
patients in Operations IRAQI FREEDOM and ENDURING FREEDOM. Critical 
care nursing is a nursing specialty and both civilian and military 
sectors are dealing with a shortage of experienced critical care 
nurses. In an effort to ensure the needs of the critically ill are met, 
the Air Force Nurse Corps partnered with our sister services and 
initiated a fellowship training program in the NCR. During this 
fellowship nurses develop critical care skills at the National Naval 
Medical Center at Bethesda, Maryland, where many wounded patients are 
admitted to the intensive care unit. This fellowship program began in 
January 2007, and recently graduated the first qualified critical care 
nurses. The program produces deployment-ready nurses in 8 months. 
Captain (select) Jonathan Criss joined his fellow classmates Lieutenant 
Amy Tomalavage and Captain Dillette Lindo for graduation via video-
teleconference from Iraq, where he deployed in November. Lieutenant 
Colonel Loreen Donovan, Balad Air Base Intensive Care Unit flight 
commander, praised the preparedness and skills of Captain (select) 
Criss. Lieutenant Colonel Donovan has since taken over as the director 
of the fellowship program, and will incorporate her deployment and 
clinical experiences into the curriculum. The program is designed to 
graduate 10 nurses annually and complements a similar program initiated 
by the Air Force in San Antonio, Texas, in collaboration with the Army.
    The Critical Care Technician Course (CCTC) began in early 2007, as 
a result of the high demand for our critical care technicians. The 
program is conducted at Eastern New Mexico University-Roswell and 
presents 40 hours of didactic and hands-on education. The 59th Medical 
Wing, Wilford Hall Medical Center, located at Lackland Air Force Base, 
Texas, took the lead with this program, holding three classes in fiscal 
year 2007 for 36 technicians. The program has now been expanded for 
fiscal year 2008 into a 5-year contract anticipating four classes for 
56 technicians per year. The 96th Medical Group, located at Eglin Air 
Force, Florida, has contracted with
    ENMC-R for the CCTC and has two classes scheduled in fiscal year 
2008 educating a total of 60 medical technicians. We anticipate pushing 
the possibilities of teaching over 400 critical care medical 
technicians over the next 5 years.
    Whether at war or home station, these critical clinical skills 
remain relevant. Consider this story told by the 39th Medical Group 
Chief Nurse, Lieutenant Colonel Rebecca Gober, from Incirlik Air Base, 
Turkey. ``Staying late catching up on access due to an increased 
exercise schedule, the personnel of the 39th Medical Group at Incirlik 
Air Base, Turkey, suddenly found themselves with four local national 
gunshot victims at their doorstep! Shouts of ``Code Blue'' were heard 
throughout the building. Within a matter of minutes, this small, 
outpatient clinic staff transformed into an emergency triage/treatment 
team rivaling a large trauma medical center. Past training kicked in 
and many were grateful for their recent training at the Center for 
Sustainment of Trauma and Readiness Skills. While lives were being 
saved by the clinical staff, ancillary support teams coordinated 
administrative needs to help identify patients, secure personal 
effects, and arrange transport to outside medical facilities. 
Resuscitative efforts were successful for three of the four victims. 
Only 4 hours passed from the entry of the first victim until every 
supply item was replaced, every cart returned and every room was ready 
for normal operations again. With the number of staff present at that 
time of day, training and teamwork truly were keys to their success.'' 
I am so proud of our nursing team for their performance that day!
                          operational currency
    In response to BRAC integration, additional opportunities to 
maintain operational currency in complex patient care platforms is 
critical. This year we gained 25 training affiliation agreements 
specific to officer and enlisted nursing personnel. This number is 
triple what we reported last year, a fact that assures me of the 
continued clinical readiness of our great Total Nursing Force. Our 
biggest gains were in agreements with civilian facilities. I am pleased 
to inform you that we partnered with nine civilian facilities to pursue 
skills sustainment in critical care, complex medical-surgical care, 
emergency/trauma, and ambulance services. Our Medical Treatment 
Facilities (MTF) remain an ideal training platform for many civilian 
nursing programs as well. In 2007, we added 33 training affiliations 
for civilian nursing programs awarding degrees at baccalaureate, 
masters, and doctoral levels.
    In addition to our civilian training affiliations, I recently sent 
a team to conduct a site visit at the University Hospital in 
Cincinnati, Ohio. This visit was initiated to examine the possibility 
of centralizing an internship Nurse Transition Program (NTP). The 
program allows new graduates the opportunity to transition into 
clinical care with nurse preceptors closely at their side. NTP is 
currently offered at nine Air Force MTFs, but centralizing the program 
into one site would optimize clinical education. The University 
Hospital offers a larger patient population, diverse illnesses, and 
medical/surgical cases including an increased opportunity to care for 
higher level trauma patients. Time management and complex inpatient 
nursing are the number one skill sets required for deployment. NTP is 
currently a 12-week program, but with the offerings at this facility, 
the program may be pared down to 9 weeks. The University Hospital 
offers an ideal environment for a successful civilian NTP program and 
we look forward to the possibility of partnering with them to enhance 
Air Force NTP education.
    We now face the emergence of a new set of issues specifically 
related to our current ``steady state'' of deployment. These include: 
(1) The need to maintain a high level of personal and professional 
readiness; (2) The inner resilience to sustain the mission despite 
daily wartime tragedies and prolonged exposure to secondary trauma; and 
(3) The ability to rejuvenate oneself upon return from deployment, and 
ultimately regain a sense of personal and professional balance. 
Readiness--Resilience--Rejuvenation (R3): Acknowledging and 
understanding the need to address the complexities these three concepts 
represent will pave the way to a vital, stable future for our Total 
Nursing Force. Our military nurse researchers are advancing 
understanding of issues related to R3. Their research data shows a 
common emerging theme: the positive impact of strong wing and unit 
reception upon return from deployment and periodic team debriefings. We 
look forward to additional data and findings in the very near future.
                         research and education
    Through your ongoing support of the TriService Nursing Research 
Program (TSNRP), Air Force Nurse Researchers continue to conduct 
innovative research with wide-ranging implications for the care of 
troops injured on the battlefield. Not only are these Nurse Researchers 
at the forefront of state-of-the-art-military research, they are 
involved in initiatives ensuring their research is translated into 
practical application, improving the clinical care delivered to our 
wounded warriors.
    Since the start of Operation ENDURING FREEDOM in 2001, over 48,000 
patients have been transported by the United States Air Force 
Aeromedical Evacuation system. Critical Care Air Transport Teams 
(CCATT) provide care for 5-10 percent of the injured or ill service 
members who are transported on military cargo aircraft to definitive 
treatment facilities. Through Air Force Institute of Technology 
sponsorship, Colonel Peggy McNeill attended the University of Maryland 
doctoral program in nursing and conducted research to determine the 
effect of two stressors of flight--altitude-induced hypoxia and 
aircraft noise. COL McNeill also examined the contributions of fatigue 
and clinical experience on cognitive and physiological performance of 
CCATT providers. This was accomplished using a simulated patient care 
scenario under aircraft cabin noise and altitude conditions. The 
findings from this research demonstrated that the care of critically 
ill patients is significantly affected by aircraft cabin noise and 
altitude. Safety and quality of care may be positively impacted with 
training and equipment better designed to assist in monitoring and 
assessment during aeromedical transport.
    Air Force Nurse Researchers play a critical role in deployments as 
well. Lieutenant Colonel Marla De Jong, Director of Nursing Research at 
Wilford Hall Medical Center, deployed to Baghdad, Iraq, for 10 months. 
As the first Air Force Program Manager for the Joint Theater Trauma 
System (JTTS), Lieutenant Colonel De Jong used her research and 
leadership expertise to manage data from 15 separate locations for 
9,000 battlefield casualties, author clinical practice guidelines, 
launch a new electronic joint trauma registry, improve trauma 
documentation and the electronic medical record, direct process 
improvement initiatives, educate clinicians, and promote in-theater 
research, pioneering contributions that transformed care on the 
battlefield. Clinical focus areas included administration of 
recombinant coagulation factors, fresh frozen plasma, and fresh whole 
blood; resuscitation of patients with severe burns; assessment for 
traumatic brain injury; use of tourniquets and HemCon bandages; and 
prevention of hypothermia and ventilator-associated pneumonia. Of 
particular importance, Lieutenant Colonel De Jong authored an 
intratheater air transport guideline that improved safe MEDEVAC 
transport of critically injured casualties. Finally, she helped infuse 
JTTS priorities into a North Atlantic Treaty Organization led hospital 
in Kandahar Airfield, Afghanistan. Collectively, these activities have 
saved lives and limbs and improved trauma care throughout the joint 
combat theater of operations.
    Air Force Nurse Researchers are also on the cutting edge of putting 
research into practice on the battlefield. In collaboration with 
colleagues from the Army, Navy and civilian professional nursing 
community, Colonel (Select) Elizabeth Bridges, U.S. Air Force Reserve 
Nurse Corps, IMA Director at the Clinical Investigations Facility at 
Travis Air Force Base, California has developed a Battlefield and 
Disaster Nursing Pocket Guide. This guide was funded by a grant from 
the TSNRP Resource Center. In the coming months, this guide will be 
shared with the Department of Veterans Affairs and Public Health 
Service colleagues. It is a goal of the services to provide a copy of 
this guide to all military nurses and enlisted personnel who deploy in 
support of the war.
    We are making incredible progress with our Center for Sustainment 
of Trauma and Readiness Skills (CSTARS). One of our 3 teaching 
affiliations is with the University of Cincinnati College of Medicine. 
This University is a tertiary referral center for a three-state region 
and is a verified level I trauma center. It is a 495-licensed bed 
facility holding 90 adult critical care beds, 51 of which are surgical. 
In 2007, the University trauma registry volume was 2,464 patients, with 
an average injury severity score (ISS) of 15.73 percent. This ISS is a 
measure of acuity and is used as a standard in all trauma centers. The 
ISS is to ensure our personnel are training to the level of care they 
would be providing during a deployment. The course provides 92 
continuing education contact hours in just 11 training days. This 
consists of 30 hours of lecture material, 5 hours of lab, 48 hours of 
clinical time, 8 hours of simulator time, and 22 hours in flight 
operations. In addition to the Cincinnati site, we have CSTARS located 
in Baltimore, Maryland and St. Louis, Missouri. The CSTARS program is 
open to Active Air Force, ANG, AFRC, Navy, Army, and Department of 
Defense medical employees. In fiscal year 2007, the CSTARS program 
graduated 685, a 10 percent increase from fiscal year 2006 (614), and 
we are actively engaged in increasing that percentage in fiscal year 
2008.
    Recently, I had the opportunity to visit our medical readiness 
training center located at Sheppard Air Force Base, Texas. This site 
provides primary deployment preparation for over 5,000 students 
annually. Approximately 3,400 enlisted personnel receive their basic 
medical readiness training as part of their initial skills curriculum. 
This provides consistent baseline knowledge for all subsequent 
deployment preparation training they will receive throughout their Air 
Force careers. Another 1,600 medics are trained in one of the four 
advanced courses:
  --Contingency Aeromedical Staging Facility (CASF);
  --Aeromedical Evacuation Contingency Operations Training (AECOT);
  --Expeditionary Medical Support (EMEDS); and
  --Medical Readiness Planners Course.
    These courses provide training for Air Force Medical Service (AFMS) 
deployment unit type codes. The CASF, AECOT, and EMEDS courses are 5-
day field-condition, scenario-based training platforms that simulate 
the actual environment medics will live and function in during their 
deployment. Students attending one of these medical readiness courses 
are certified deployment ready with AFMS knowledge and skills required 
to be fully functional upon arrival in theater. The site's 32 
instructors cover a total of 12 Air Force Specialty Codes.
    During my visit to this incredible training center, I received 
overwhelming positive feedback from previous deployed airmen attesting 
to the value of this unique, realistic training opportunity that now 
exists and the profound impact it will make on future deployers.
                            joint endeavors
    Air Force nurses have a unique opportunity to participate in a 
historical Military Health System process directly shaping health care 
delivery for future generations. On September 14, 2007, it was 
announced that the Department of Defense (DOD) would establish the 
Joint Task Force National Capital Region Medical Command (JTF/CAPMED) 
in Bethesda, Maryland, to oversee healthcare delivery services for the 
Air Force, Army and Navy. This new medical command is tasked with the 
responsibility for world-class military healthcare in the NCR, 
integrating healthcare services across the entire region reporting 
directly to the Secretary of Defense. This is the first Command of its 
kind in the history of DOD! The NCR is the most complex area the 
military has due to the number of military services, medical facilities 
and patients, many of whom are casualties returning from the war. As 
America's primary reception site for returning casualties, the number 
one priority of this new Command is casualty care. This new medical 
establishment has several senior leadership positions ranging from 
specialties such as manpower and personnel to clinical operations, 
plans and policy, and education, training and research. Colonel Sally 
Glover and Chief Master Sergeant Joey Williams of the 79th Medical Wing 
are vital members of the JTF/CAPMED J3 nursing cell that is currently 
chaired by Air Force Nurse Corps Colonel Therese Neely. Partnering with 
the senior nursing leadership from all the MTFs in the NCR, this group 
has made tremendous strides in creating a joint nursing platform that 
will apply not only to the Walter Reed National Military Medical Center 
but to all the MTFs in the NCR. The perioperative nursing group was the 
first to integrate adopting national Operating Room Nursing standards 
across the board. In addition, clinical ladder development, clinical 
leadership position selection, and clinical performance metrics are 
being established with a focus towards Magnet Status. Chief Williams' 
leadership in the enlisted group has been critical to ensure the 
appropriate scope of practice for our medical technicians in this joint 
environment. He provides a strong focus on clinical skills sustainment 
for wartime readiness. Most recently, we announced Colonel Barb Jefts 
and Major Raymond Nudo to join the Joint Task Force for DOD in the 
Washington D.C.
    We participate in international joint endeavors every day. One 
example of this occurred at Hickam Air Force Base, Hawaii. Five airmen 
from the 18th Aeromedical Evacuation Squadron (AES) at Kadena Air Base, 
Japan, teamed up with 11 members of the Royal Australian Air Force's 
(RAAF) Health Services Wing in Hawaii. The training focused on how the 
Air Force utilizes the C-17 Globemaster III for medical evacuations. 
Wing Commander Sandy Riley (RAAF) stated, ``We've got expertise in AE, 
but not on the C-17. The C-17 was rapidly introduced into the 
Australian service so this is invaluable training for us to see the 
expertise of the Pacific Air Forces and the 18th AES.'' This small 
investment is likely to yield tremendous results. Bolstering the RAAF's 
AE capability means one of America's staunchest allies in the Pacific 
is now equipped with expanded latitude.
    The Air National Guard provided five medical groups for 
humanitarian events throughout the world including Panama, Guatemala, 
Nicaragua, Bolivia, and El Salvador. State Partnership Programs link 
the United States with partner countries' defense ministries and other 
Government agencies for the purpose of improving international 
relations. Under this program, three medical groups combined efforts 
with the State Partnership Program to provide humanitarian support to 
the partner countries. The medical personnel provided assistance in 
Azerbaijan, Morocco, and Armenia working and exchanging knowledge with 
each country's counterparts. Recently the 144th Medical Group sent 
approximately 30 medics to Santa Teresa, Nicaragua for the Medical 
Readiness Training Exercise (MEDRETE) for New Horizons Nicaragua 2007. 
This program was a joint military humanitarian and training exercise 
which provided new medical clinics and schools to rural communities in 
Nicaragua. Other locations assisted were in Huehuete, Roman Esteban, 
and Nandaime, Nicaragua. The last exercise took place in Diriamba, 
Nandaime, and La Conquista. The total number of patients cared for by 
medics was 7,899. According to the Camp Commander, Lieutenant Colonel 
Aaron Young, the team ``did an outstanding job.'' He went on to say, 
``It was a great joint training opportunity to work with our good 
friends in the Nicaraguan military and the Ministry of Health.'' At the 
final day of the MEDRETE, a ceremony was held with the Mayor of Thomas 
Umana, Nicaragua, Mr. Augustine Chavez. He presented the troops 
certificates in appreciation of their medical care. Mr. Chavez 
commented, ``I could never repay you for the gift you've provided to 
our community.'' This heartfelt expression of gratitude is exactly why 
we do what we do.
    Our Air Force Reserve is doing incredible work as well. In 2007, 
Air Force Reserve nurses and technicians showed a continued zest in 
volunteerism as airmen. A total of 144 reserve nurses and 230 medical 
technicians deployed in support of the Global War on Terrorism which 
included a combination of nurses specializing in flight nursing, mental 
health, critical care, emergency care and medical/surgical nursing. The 
reserve clinical training platforms trained 752 medics in sustainment 
of critical wartime nursing skills. One of our Reserve nurse deployers, 
a very experienced obstetrics nurse, Colonel Laura Saucer, participated 
in a Provincial Reconstruction Team teaching 57 midwives and midwifery 
students in a rural Afghanistan town. The team commented, ``the courage 
of the students was inspiring.'' The team reported that female 
providers in rural areas of Afghanistan are in critical demand, and 16 
of every 1,000 women die in childbirth largely due to no access to 
healthcare. Colonel Saucer described the students as ``wonderful.'' 
After years of oppression, they are so excited to learn and are like 
sponges soaking everything up. This is only one story of good will 
among many from our deployers. Additionally, 133 multi-discipline 
airmen were key participants in the Air Force International Health 
Specialist (IHS) Program over the past year. The organization of IHS 
medical staff journeyed around the world in support of humanitarian 
missions and exercises to include the countries of Vietnam, Morocco, 
Guatemala, Belize, El Salvador, Senegal, Oceania, and Sri Lanka. An 
impressive 34,000+ patients were treated. These small teams of 
healthcare professionals delivered expert medical care and brought good 
will to disenfranchised people of the world while building on their own 
expert skill level. As you can see, our ANG and AFRC are providing 
world-class care, leadership and mentoring across the globe.
                              quality care
    Our Air Force Inspection Agency (AFIA) ensures our patient care is 
first-rate. AFIA conducted over 62 inspections covering active duty 
medical treatment facilities, aeromedical evacuation and clinics served 
by the Air Force Reserve and Air National Guard. Nursing programs were 
evaluated by the Joint Commission and the Accreditation Association for 
Ambulatory Health Care. All programs were reviewed to meet compliance 
with national standards in conjunction with Air Force directives for 
Air Force MTFs and units in fiscal year 2007. We have engaged with our 
Chief Nurses and Senior Aerospace Medical Service Technicians to lead 
the way, ensuring continued world-class medical care is provided to all 
of our DOD beneficiaries. Overall, our nursing programs did 
exceptionally well and will continue to do so in years to come with 
your continued support.
              recruiting, retention, and force development
    Just as with the civilian sector, at the top of our list of 
concerns is what has become a chronic struggle with increasing nursing 
requirements and the growing national nursing shortage. Human resources 
are the single greatest influence on health care. The latest estimates 
developed by the Bureau of Labor Statistics indicate that the United 
States will require an additional 587,000 registered nurses (RNs) by 
2016 to meet the nursing needs of the country
    The Air Force is not immune to these statistics. Over the next 3 
fiscal years, 28.6 percent (953) of our nurse inventory will be 
eligible to retire. Over the last 10 years, 54 percent of the Nurse 
Corps separated as Captains and 19 percent left as Majors. In fiscal 
year 2006, 161 nurses retired and 195 separated for a total loss of 356 
(10.4 percent total attrition rate). Our loss rate has increased 
slightly in fiscal year 2007, with a total loss of 404--178 to 
retirement and 226 to separation (12 percent total attrition rate). 
Almost half of Nurse Corp officers who have separated have less than 8 
years of military service.
    In fiscal year 2006, Air Force nurse recruiting was reported at 62 
percent of 357 with a slight increase in fiscal year 2007 to 63 
percent. Our recruiting services forecast places our risk for nurse 
recruiting at ``high'' for fiscal year 2008 and ``severe'' for fiscal 
year 2009. We are currently offering an accession bonus to our nurse 
recruits in exchange for a 4-year commitment; this bonus will increase 
fiscal year 2009. In addition to our recruiting services, we also bring 
novice nurses into the Air Force through several programs. Utilizing 
the Air Force Reserve Officers' Training Corps (AFROTC), Airmen 
Education & Commissioning Program (AECP), and the Enlisted 
Commissioning Program (ECP), we brought in 47 nurses in fiscal year 
2006 and 61 in fiscal year 2007.
    In fiscal year 2009, we plan to support the nurse incentive special 
pay with $12.5 million. We anticipate that offering the nurse incentive 
special pay will retain approximately 31 percent (1,000 nurses of 3,262 
as of January 11, 2008) of our current inventory for an additional 2 to 
4 years beyond their current active duty service commitment. 
Additionally, we currently offer incentive special pay to Certified 
Registered Nurse Anesthetists (CRNAs) at variable rates dependent on 
active duty service commitment. The annual average for this incentive 
special pay is approximately $35,000 per CRNA. Air Force Nurse 
Practitioners receive board certification pay at varying rates that are 
dependent upon the amount of time served in the specialty. Both the 
CRNA incentive special pay and the Nurse Practitioner board certified 
pay will continue to be offered in fiscal year 2009.
    In this time of increasing nursing shortages, the need to grow our 
own has become evident. Since my last testimony, we have launched our 
Nurse Enlisted Commissioning Program (NECP). NECP is an accelerated 
program for enlisted airmen to complete a full-time Bachelors of 
Science in Nursing (BSN) at an accredited university while on active 
duty. This program will produce students completing their BSN and 
obtaining their nursing license in just 24 months. Airmen who 
successfully complete this program will be commissioned as second 
lieutenants. Our goal is to select 50 candidates per year by fiscal 
year 2010 for this new commissioning opportunity. On a recent trip to 
Ramstein Air Base, Germany, I spoke with Staff Sergeant ``Rae'' Amaya 
who is stationed at Ramstein with the 86th Aeromedical Evacuation 
Squadron. She has been serving her country for nine years and expressed 
her desire of becoming a nurse with this statement, ``The vision of 
getting back to the ``True North'' (which is bedside nursing) was 
inspiring, especially since I'm trying to become a nurse. I have been 
fortunate to be mentored by some very awesome nurses who have made me 
the technician I am today. When I become a nurse--whenever that might 
be--I will do my best to remember, pass on and enforce this vision.'' 
With the NECP program in full swing, we can make dreams like this come 
true.
    In addition, we have continued robust advanced practice nursing 
educational programs through the Uniformed Services University in 
Bethesda, Maryland Graduate School of Nursing, the Air Force Institute 
of Technology, Civilian Programs and the Army-Baylor Master's Program. 
This year we anticipate the graduation of 49 advanced practice degrees 
such as, Family Nurse Practitioners, CRNAs, and PhDs. Enrollment for 
fiscal year 2008 includes 45 advanced practice nurses. Opportunities 
such as advanced degrees foster an environment of professional growth 
and leadership. This further supports retention, recruitment and a 
bolstered force development.
                              recognition
    General T. Michael Moseley, our Air Force Chief of Staff, developed 
the ``Portraits in Courage'' series to highlight the honor, valor, 
devotion, and selfless sacrifice of America's airmen. Two of our 
medical technicians were highlighted this last year, one in each 
category. The first was Staff Sergeant David Velasquez, a technician 
from Langley Air Force Base, Virginia. Sergeant Velasquez was one of 13 
airmen recognized in the ``Portraits in Courage.'' He volunteered for a 
365-day tour to Afghanistan as a medical technician and completed more 
than 90 convoys and numerous missions with the Provincial 
Reconstruction Team and Quick Response Forces. His team was fired upon 
virtually every mission and survived eight serious attacks to their 
convoys. In one instance, Sergeant Velasquez's convoy was enroute to 
the U.S. Embassy when it was hit by an improvised explosive device. The 
vehicle directly in front of his was heavily damaged and two of its 
passengers were killed. His vehicle's turret gunner fell into the 
vehicle on fire and suffered severe shrapnel wounds to his left arm. 
Sergeant Velasquez quickly extinguished the flames, stopped the 
bleeding, and administered life-saving medical aid. This was just one 
of his many heroic acts. He was quoted as saying, ``I was only doing my 
job, nothing special.'' Those who have received life-saving medical 
attention in the heat of battle from him would argue otherwise.
    Six airmen received the new Air Force Combat Action Medal on June 
12, 2007. This medal was created to recognize Air Force members who 
engaged in air or ground combat off base in a combat zone. This 
includes members who were under direct or hostile fire, or who 
personally engaged hostile forces with direct and lethal fire. One of 
those six warriors was Staff Sergeant Daniel L. Paxton, an aeromedical 
technician school instructor, who was assigned to the 42nd Aeromedical 
Evacuation Squadron at Pope Air Force Base, North Carolina at the time. 
He is now assigned as a flight instructor using his critical 
experiences from March 28, 2003. Sergeant Paxton was part of a mission 
to establish a series of tactical medical units along the border of 
Kuwait and Iraq. His convoy came under enemy fire from mortars, rocket-
propelled grenades, machine guns and small-arms fire. Without the 
benefit of intra-vehicle communications, Sergeant Paxton and his team 
reacted to the ambush and returned fire, successfully defending their 
assets as they executed a coordinated withdrawal. Under the cover of 
darkness and using night vision devices, the convoy embarked and the 
enemy again opened fire. During the next 18 hours, the convoy came 
under fire five subsequent times and Sergeant Paxton successfully 
engaged the enemy with return fire, defending himself and the convoy as 
they progressed on their mission.
    In addition, I offer these amazing acts of heroism by our 
Independent-Duty Medical Technicians (IDMT): Staff Sergeant Jason Weiss 
smiled as he thought of Holly. It was just a year ago he had asked her 
to marry him. On December 4th they were to be wed. There was only one 
problem--he was not going to be there. As an IDMT, from the 36th Rescue 
Flight out of Fairchild Air Force Base, Washington, he was going out to 
search for three individuals who had been hiking in the mountains when 
the weather made a sudden change causing an avalanche. Two of them were 
swallowed up by the snow and the third hiker sustained a shattered limb 
and had the onset of hypothermia (body core temperature of 93.5 
degrees). Weiss and his team arrived to find a critical situation. 
``Visibility was so poor that I couldn't see a thing out of my side of 
the Huey,'' said Sergeant Weiss. The Huey crew found a hole in the 
trees and lowered Weiss to the ground, roughly 80 yards from the 
victim. ``When I stepped off the rescue hoist, I sank up to my chest in 
snow. I then crab-crawled for about 40 yards and was able to walk the 
last 40 yards in waist deep snow.'' Sergeant Weiss knew before he left 
the helicopter that there was no time to waste. Low on fuel, with the 
weather worsening, Sergeant Weiss raced to the victims and placed the 
176-pound man over his shoulders in a fireman's carry, and trudged 40 
yards through waist deep snow pushing himself to his limits. He then 
dragged his patient across the snow like a sled for another 40 yards, 
finally reaching the extraction point. On his hands and knees, huffing 
and puffing, with steam rising from his sweaty brow, Weiss's head and 
shoulders suddenly slumped. He could hear the distinctive whir of the 
Huey's engines, indicating his crew was leaving them behind to refuel. 
By this time Sergeant Weiss and the victim were in a full-blown 
whiteout blizzard, and then suddenly he heard the rhythmic sound of 
``whop, whop, whop,'' denoting the Huey was returning for another pass. 
The crew skillfully placed the forest penetrator (hoist) right next to 
Weiss. He then secured his patient for the ride up to the Huey, and 
once inside the helicopter, began treating the 38-year-old man for 
hypothermia, dehydration and a broken leg. He then went on to spend the 
next 3 days on alert, but on December 7th, Sergeant Weiss and Holly 
finally exchanged vows. Holly said admiringly, ``He does such amazing 
things that I have to share him.''
    During a recent outing on the lake with his family, Senior Master 
Sergeant Michael Stephenson-Pino, Superintendent of the IDMT Course, 
witnessed a father and son launched 10-12 feet in the air as the cigar 
shaped tube they were being pulled on behind the boat buckled. This 
situation was further complicated with both of them being launched in 
opposite directions 20 feet apart and disappearing simultaneously under 
the water. As Sergeant Stephenson-Pino immediately sprang into action 
swimming towards the victims, the 10-year-old boy surfaced screaming as 
the father laid motionless face down in the water. Upon reaching the 
father, Sergeant Stephenson-Pino rolled the victim over onto his back, 
opened and maintained the airway effectively restoring his breathing. 
With the unconscious adult in tow, he swam towards the child who was 
panicked and struggling to stay afloat in a life preserver which was 
too large for him. Without losing control of the unconscious adult, 
Sergeant Stephenson-Pino positioned himself behind the child and 
neutralized him as a drowning hazard. Now finding himself stranded in 
30 feet of water and with two near drowning victims in tow, Sergeant 
Stephenson-Pino started swimming towards shore. After having traveled 
30 yards while swimming on his back to the point of near exhaustion 
with both victims, he succeeded in loading them into the boat and then 
utilized his 11 years as an IDMT to stabilize their injuries. He put 
into action what he and his staff teaches our enlisted physician 
extenders and through his advanced training, a humanitarian effort was 
instrumental in preventing the loss of life for the father and child.
    These are just a few stories of many, reflecting the versatility of 
our medical technicians and the dynamic energy they bring to every 
situation.
                             our way ahead
    Nursing is the pivotal health care profession, highly valued for 
its specialized knowledge, skill and care of improving the health 
status of the airmen in our charge and ensuring safe, effective, 
quality care. Our profession honors the diverse population we serve and 
provides officer, enlisted and civilian leadership and clinical 
proficiency that creates positive changes in health policy and delivery 
systems within the Air Force Medical Service. Our 5-year top priority 
plan includes, first and foremost, delivering the highest quality of 
nursing care while concurrently staging for joint operations today and 
tomorrow. Secondly, we are striving to develop nursing personnel for 
joint clinical operations and leadership during deployment and in-
garrison, while structuring and positioning the Total Nursing Force 
with the right specialty mix to meet the requirements. Last, but not 
least, we aim to place priority emphasis on collaborative and 
professional bedside nursing care.
    Mr. Chairman and distinguished members of the Committee, it is an 
honor to be here with you and to represent a dedicated, strong Total 
Nursing Force of nearly 18,000 men and women. United we will Win 
Today's Fight, provide world-class care for our airmen, and Prepare for 
Tomorrow's Challenges.

    Senator Inouye. As one who has served in the military, over 
2 years in hospitals, I'm especially grateful to nurses. 
Without them, I don't suppose I would be sitting here.
    But because of time constraints, I have many questions on 
recruiting and retention, also questions on incentive pay and 
bonuses. Also questions on the school of nursing, because I've 
been told there's some opposition to the establishment of that 
program, and others. But I will be submitting them to you, if I 
may, for your response.
    And with that, may I recognize Senator Stevens.
    Senator Stevens. Mr. Chairman, I, too will submit my 
questions. I'm delighted to see you all here, and you do bring 
back memories for both of us from our days in the service.
    So, thank you all for what you do.
    Senator Inouye. And, our special angel.
    Senator Mikulski. Please, Mr. Chairman, I'll never live 
this down.
    I just don't want the voters ever to clip my wings.
    I just really have one question, but a comment. First of 
all, again, General Pollock, we want to, again, express our 
gratitude, the way you stepped in, at the request of Secretary 
Gates, during a very troubled time in military medicine. And 
we're so pleased to hear that you're heading up the human 
capital effort. Because it goes to physicians, nurses, social 
workers, other allied health--I'm sure you and General 
Schoomaker and others could talk about the need for x-ray 
technicians, and so on, so we look forward to that.
    I found the testimony of all three of you so poignant, and 
the case examples that you gave, you know, were pretty 
powerful. And I would hope that my colleagues, as well as our 
staff, read them.

                        RECRUITING AND RETENTION

    My question--and I've heard the list, now, of programs, and 
we've talked about this--in a nutshell, what more can we do to 
crack the nursing retention and recruitment? But the first one 
is, retain those that we've got and have them as part of the 
leadership team, and then--what more can we do, what creative 
ideas, or do I wait for yet one more report?
    And just know, Senator Byrd has us at noon, as much as our 
regrets are with the time.
    Admiral Bruzek-Kohler. I think we are finding that the 
incentive plans that we have put in place over the past years 
have been extremely successful for accessions and the loan 
repayment for retention has been dramatic. As we are seeing 
with the incentive specialty pay, that too may have dramatic 
effects.
    Our nurses need to be competitively rewarded financially, 
as well as through improvements in the quality of life and 
through educational programs that we offer. We will continue to 
pursue these kinds of packages through the proper channels.
    Senator Mikulski. So, can I say in a nutshell that, number 
one, stay the course in what we've done. That, in other words, 
we have some great ideas now, we don't need new ideas, what we 
need to do is stay the course, and don't fiscally wimp out on 
what we have underway, would that--and that would also go for 
retention, and also recruitment. Would that be number one? Make 
sure we stay the course?
    Admiral Bruzek-Kohler. Yes, ma'am.
    Senator Mikulski. The second thing is, and this would be 
another conversation. I believe that one of our ways to 
promote--first of all, the whole idea, for those who already 
know the military, to stay and also those to move up--do you 
feel that this Troops to Nurses, as well as perhaps, getting 
additional training in an accelerated way with the LPNs would 
help us crack the code that--because they know, they're in the 
military. They've served in the military. And for those who are 
ready to sign up for the culture of the military, as well as 
the challenges of the military, they would know what they were 
getting into. In a good way.
    General Rank. I'd like to take first crack at responding to 
that.
    I have been supportive of Troops to Nurse Teachers (TNT), 
and I've been supportive of it because of our retiring nurses, 
who are at that 20-year juncture, and there is as part of the 
pick list in TNT that they would go out on a scholarship 
program, and be able to get their next advanced academic degree 
and teach on faculty. That is extraordinary and I know we have 
retiring and retired nurses who are waiting for TNT.
    You would be surprised to learn that there are over 855 
nurses with time in service of greater than 15 years that never 
took the Montgomery G.I. bill.
    Senator Mikulski. And I believe that was something that 
General Pollock had discussed with us--that you use the nurses 
who are about to retire to essentially teach the other nurses, 
which in and of themselves would be role models, mentors, et 
cetera, to recruit and be a magnet for military medicine. Is 
that----
    General Rank. Ma'am, that is my perspective, and that may 
differ from my sister service corps chiefs, and I would also 
like to add to the second portion of your question, where 
Uniformed Services University of the Health Services (USUHS) is 
concerned, I believe it is time for the Air Force Nurse Corps, 
and hopefully our sister services, to offer a Bachelor of 
Science in Nursing (BSN) program to those that have an 
associates and diploma degree.
    I am a diploma nurse and went out for my own bachelor's 
working at Baltimore City Hospital. We need this program to 
open the aperture, and allow an associates degree, and diploma 
nurses to come to USUHS, get their bachelor's and then assess 
them as a bachelor's, with a commitment of time out there.
    They're out there. They want to join our services.
    Senator Mikulski. Well, perhaps, then, Mr. Chairman and 
Senator Stevens, we can follow up on this. What essentially our 
head of the Nurse Corps are talking about is that if you have a 
3-year program----
    General Rank. Two or three, ma'am.
    Senator Mikulski. Or you've been to a community college----
    General Rank. Yes, ma'am.
    Senator Mikulski. You need to move up to a bachelor's 
level. There is wide experience in civil nursing programs in an 
accelerated way. Perhaps we could talk now about USUHS, you 
know, it's in my State, we're very familiar with it. But this 
could be one of the tools we could use, and work on.
    I have other questions, but again, I'll submit them for the 
record. Thank you.
    General Pollock. And I know we'll look forward to providing 
written responses, or coming down to meet with any of your 
staffs on your questions.
    Thank you very much.
    Senator Inouye. I asked the doctors the question as to 
whether personnel under their command felt appreciated. Well, I 
want you to know that in the Army infantry, the person we 
admire the most and adore the most is the medic. He's the one 
who keeps us going and live.

                     ADDITIONAL COMMITTEE QUESTIONS

    But unfortunately, the way they give out medals, they give 
it out for courage, and shooting ability and all of that 
nonsense. And as a result, nurses and doctors and medics don't 
get recognized. I hope you will take it upon yourselves to give 
recognition to the men and women in your command. Because they 
need a little boost.
    [The following questions were not asked at the hearing but 
were submitted to the Department for response subsequent to the 
hearing:]
      Questions Submitted to Lieutenant General Eric B. Schoomaker
            Questions Submitted by Senator Daniel K. Inouye
                       recruiting for specialists
    Question. General Schoomaker, the Army continues to have critical 
shortages in areas like family practice physicians, preventative 
medicine, emergency medicine, and dentists. These specialists are not 
only critical for our GWOT efforts, but make an enormous difference to 
the families of our service members. How is the Army addressing these 
shortfalls in recruiting and retention?
    Answer. We continue to explore ways to provide significant 
incentives to recruit and retain our health care providers. We are 
currently working with Army leadership to develop the appropriate 
implementation guidance for the Critical Wartime Skills Accession Bonus 
for Medical and Dental officers. This bonus will enable us to offer new 
appointees a significant monetary incentive in exchange for an Active 
Duty Service Obligation. We are confident that this bonus will bring 
positive gains to our recruiting efforts. Additionally, we are 
aggressively utilizing the Health Professions Loan Repayment Program to 
attract those individuals who have incurred a debt while undergoing 
training. Finally, we are evaluating the proposed fiscal year 2009 
special pay rates and considering potential increases in special pay 
for certain specialties.
    Equally important, the Army continues to explore ways to improve 
quality of life for our health care providers. As an example, we 
recently expanded our 180-day provider deployment policy, extending 
this popular policy to a broader range of health care professionals. 
This policy reduces the length of deployment for providers, minimizing 
clinical skill degradation and eliminating the deployment length 
disparity that existed between medical personnel of the Army and the 
other Services, resulting in improved morale and quality of life for 
our providers and their Families.
                               recruiting
    Question. General Schoomaker, the Army recently restructured its 
recruiting command, forming a special brigade tasked to provide for the 
five medical recruiting battalions. Do you feel that the restructuring 
of the recruiting command is helping to improve recruiting efforts 
within the medical field?
    Answer. MG Bostick's decision to stand up and resource the Medical 
Recruiting Brigade has proven to be one of the most significant 
administrative decisions to benefit medical recruiting in the past 
decade. I fully support his decision and will continue to assist in 
ensuring its success is sustained.
    Establishment of the Brigade has enhanced medical recruiting by 
strengthening ownership of the recruiting mission and triggering 
positive changes in business practices. This new level of mission 
ownership is characterized by a direct chain of command and a one 
focus-one voice strategy for health care recruiting. MG Bostick's 
decision to supplement the recruiting force with 50 direct military 
overhires has also enhanced the recruiting force, providing more 
individuals focused on the mission.
    The recruiting effort this year continues to improve over the same 
period last fiscal year. The Medical Recruiting Brigade is currently 
461 contracts ahead in comparison to the same time period last fiscal 
year (249 in Regular Army and 212 in Reserves). For the past four 
years, recruiting for the Army Reserve Veterinary Corps has fallen 
short; however, we are postured to exceed the Veterinary Corps mission 
at an earlier point than any previous fiscal year this decade. The Army 
Nurse Corps continues to have sustained success in comparison to last 
fiscal year (ahead 74 Regular Army contracts and 145 Army Reserve 
contracts). The Brigade is ahead by 84 Medical Corps Health Professions 
Scholarship Program (HPSP) scholarships and 11 Dental Corps HPSP 
scholarships compared to this time last year.
                              scholarships
    Question. General Schoomaker, I am always told that the Health 
Professions Scholarship Program is one of the military's most valuable 
recruiting tools for health care professionals. However, I am told that 
the number of applicants per scholarship has substantially dropped over 
the years. To what do you believe this is attributed to and how can it 
be improved upon?
    Answer. I believe that the drop in the number of applicants is a 
result of multiple influences. Obviously, the current Global War on 
Terrorism, coupled with the operational tempo associated with it, has 
had an effect. The availability of funding for school from other 
sources has had an impact also.
    There have been a number of actions taken which seem to be helping 
in turning around the downward trend. In the past several years we have 
increased the monthly stipend we pay the student; it is currently at 
$1,605, and will increase on July 1, 2008 to $1,906. The authority 
provided in the National Defense Authorization Act of Fiscal Year 2008 
to offer up to a $20,000 bonus to Health Professions Scholarship 
Program (HPSP) students will also be helpful. The current use of the 
Critical Skills Accession Bonus in this dollar amount has proven to be 
very effective, and has enabled us to increase the number of students 
we have recruited into the program this fiscal year. Continued support 
and funding for this program are extremely critical.
                    warrior transition units (wtus)
    Question. General Schoomaker, it is our understanding that the WTUs 
are almost serving at full capacity. What are some of the solutions 
you're looking at to ensure that the WTUs are fully equipped and 
staffed to address our soldiers' needs in the future?
    Answer. Achieving the optimal staff-to-patient ratios for the 
Warrior Transition Units (WTUs) has been a challenge for the Army 
Medical Department (AMEDD). Army-wide manpower challenges affect our 
aggressive measures to staff some of the key positions at many of our 
WTU locations. Despite the challenges, however, we are making strides 
toward achieving full capacity. As the WTUs have achieved full 
capacity, we are reducing the level of borrowed military manpower.
    The Medical Command is working closely with the Army Human 
Resources Command and civilian personnel to attract the very best 
Soldiers and civilians to staff the WTUs. The Medical Command and its 
subordinate commands are also utilizing multiple recruitment and 
relocation incentives to staff difficult-to-fill positions. We offer 
civilians recruitment incentives of up to 25 percent of their basic 
pay. We also offer a relocation incentive up to 25 percent of the basic 
pay to current employees willing to relocate to fill critically short 
positions. Given the critical importance of attracting the very best 
Soldiers to fill the squad leader's positions in the WTUs, the Army 
recently approved special duty pay.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
                    walter reed army medical center
    Question. (a) The Dole/Shalala report recommended that the Army 
ensure top quality care at Walter Reed Army Medical Center up till the 
day it closed. Approximately 1 in 5 wounded soldiers go to Walter Reed. 
What is the Army doing to ensure continued high quality care at Walter 
Reed?
    (b) What is the Army's plan to maintain civilian medical, 
administrative and maintenance staff until the last day?
    (c) How will the Army maintain staff who cannot count on being 
reassigned to another DOD facility but are critical to ensuring high 
quality care?
    Answer. (a) Over the past year, Walter Reed staff has very 
carefully and honestly reviewed every aspect of health care delivery. 
Where there was room for improvement, the staff quickly developed 
corrective action and programs to set a new standard for care, 
compassion and healing. The entire team was very proud last year when, 
at the height of the controversy generated by media coverage of 
outpatient problems, Walter Reed was inspected by the Joint Commission 
and fully accredited for health care delivery. With the core practices 
intact and validated, they set out to improve other support services 
that can make a huge difference in the hospital experience of their 
patients.
    Walter Reed initiated action to improve housekeeping, hospitality, 
and responsiveness to all types of patient comments and issues. They 
improved in nutrition care, with room service meals and healthier menu 
choices. They enhanced the handoff with Warriors coming out of Theater 
by reaching forward with an air evacuation cell here to coordinate 
movement and receipt of patients. Walter Reed staff designed and 
purchased and will soon accept delivery of three vastly improved 
patient evacuation vehicles for transporting patients from Andrews Air 
Force Base to Walter Reed.
    Walter Reed tightened up discharge planning, and the handoff from 
the ward to the Warrior Transition Brigade. They improved facilities 
for Warriors and their Families across the Walter Reed campus. To 
improve the coordination and tracking of Warrior in Transition care, 
the Walter Reed team developed the Military Medical Tracking System 
(MMTS). The MMTS automates data pulls from several existing computer 
systems and securely presents that data to case managers and other 
health care team members. This homegrown system has enabled them to 
more closely monitor and coordinate the Warrior healing process and is 
now set for deployment across the Army Medical Department. They also 
installed wireless connectivity throughout Heaton Pavilion and will 
begin deployment early next month of over 1,100 Tablet PCs to enhance 
provider-patient interaction throughout the medical center.
    Recent accreditation site visits by the Accreditation Council of 
Graduate Medical Education (ACGME) resulted in 5 year accreditation 
cycle awards to several Walter Reed programs. Resident and fellowship 
training programs in Neurology, Physical Medicine and Rehabilitation, 
General Surgery, National Naval Medical Center Internal Medicine, and 
the internal medicine subspecialties of Gastroenterology, Hematology/
Oncology, and Endocrinology have all received the maximum accreditation 
cycle of 5 years. In addition, Walter Reed and the National Capitol 
Consortium have an unprecedented 5 physicians on the national Residency 
Review Committees of ACGME.
    Finally, Walter Reed was recognized at the Military Health System 
Conference for Excellence in Customer Service for 2007, outpacing all 
other large medical centers in the Continental United States. Walter 
Reed's current patient satisfaction is above 90 percent according to 
the Army Provider Level Satisfaction Survey (APLSS).
    (b) As a result of Walter Reed Army Medical Center being identified 
on the Base Realignment and Closure (BRAC) list and given the direction 
by the Deputy Secretary of Defense in August 2007, the Army has 
improved its plan to maintain civilian medical, administrative, and 
maintenance staff until closure. The Army is using all existing 
authorities to recruit and retain civilian employees. A majority of the 
authorities have been used in the past successfully, as was a robust 
incentive awards program directed at the civilian workforce. In order 
to ensure that management had full knowledge of the available 
incentives, the Army Medical Command developed and delivered a 
comprehensive supervisor training module on the use of the incentives. 
The Commander will develop a sound business case to seek additional 
funding to support a more robust implementation plan for the use of the 
incentives. A foundation for the business case will come from an 
employee survey that was distributed in mid-April. The survey asked the 
Walter Reed employees what incentive(s) would cause them to stay 
through the BRAC period. To date, nearly 2,000 surveys were completed 
and returned, nearly an 80 percent response rate. The Command is in the 
process of analyzing that data.
    In mid-December, the Walter Reed Army Medical Center and Garrison 
leadership conducted a comprehensive review of their manpower 
authorizations and requirements. The review demonstrated the broad 
scope of Walter Reed's mission. The review also revealed the 
identification of new and expanded missions, which are in direct 
correlation with the needs and requirements of the Warrior in 
Transition Brigade located on the Walter Reed campus. These new 
missions emerged since the installation was listed as a BRAC activity. 
The Walter Reed Army Medical Center Commander started more than one 
year ago to recruit and fill positions associated with these new and 
expanded missions; however, additional resources are required. The 
manpower study that is now underway will validate critical human 
resource requirements and this will allow Walter Reed to increase the 
recruitment targets to fill these vital positions.
    Recruiting new employees and retaining current workforce are top 
priorities for the Walter Reed Commander. A robust marketing effort, in 
combination with a strategic recruitment plan, will ensure a dynamic, 
targeted and focused recruitment effort is maintained. The recruitment 
plan is continually reviewed and revised as needed to meet the changing 
recruitment needs that directly support the new and expanded missions 
of the Walter Reed Army Medical Center.
    (c) In August 2007, the Deputy Secretary of Defense directed that 
the employees at Walter Reed Army Medical Center receive an incentive 
entitled the Guaranteed Placement Program. The employees will be 
guaranteed a position at either the new Walter Reed National Military 
Medical Center or the new DeWitt Army Community Hospital at Fort 
Belvoir. The Army is coordinating with the Joint Task Force Capital 
Medicine on the provisions and details of this program. The Commander 
will brief the Walter Reed civilian workforce on the details as soon as 
guidelines are finalized.
    The Commander will request funding for incentives and personnel 
overhires through fiscal year 2011. The Army is currently working with 
the Senior Oversight Committee program on the fiscal year 2010-15 
Program Objective Memorandum (POM) submission for civilian medical 
health authorities and incentives. The Walter Reed civilian employee 
retention survey is the primary vehicle to obtain specific information 
regarding the incentives that will cause the workforce to remain until 
closure. The Commander intends to follow up in about six months with 
another survey focused on the issues of job satisfaction and 
communications within the organization.
    The Walter Reed commander is aggressively pursuing efforts to 
ensure current and future Walter Reed employees are retained through 
the BRAC. On March 14th, the Commander hosted three very well attended 
and successful Town Hall meetings, which is a component of her ``Care 
of People Plan.'' This plan reflects a comprehensive approach to the 
issue of employee retention. A key component of the plan is a very 
robust communications plan that ensures the flow of information to the 
workforce. Town Hall meetings, an up-to-date website, the Commander's 
BLOG and the employee survey are just a few examples of the Commander's 
efforts to ensure information flow to and from the workforce. The 
Commander has also hired a communications consultant to ensure that all 
possible lines of communication are open and functioning at all times 
and that directed attention is given to the issue of communicating with 
the workforce through this time of uncertainty.
                       wounded soldiers' families
    Question. (a) The Dole/Shalala report recommended enhancing care 
for the families of wounded soldiers throughout the soldier's recovery 
process. It noted that family members are vital parts of the patient's 
recovery team. What has the Army done to enhance care for family 
members of wounded soldiers?
    (b) Who on a soldier's care team is primarily responsible for 
helping families? What training have they received?
    (c) What has DOD done to leverage the help the private sector can 
provide?
    Answer. (a) The Army Medical Action Plan (AMAP) represents a total 
transformation of the way the Army cares for wounded, ill, and injured 
Soldiers (Warriors in Transition) and their family members. Basic to 
this transformation is the recognition that an integral part of caring 
for the Soldier is the need to also care for and support the Soldier's 
family. As part of the execution of the AMAP, the Army has established 
Soldier Family Assistance Centers at installations with Warrior 
Transition Units to provide both Warriors in Transition and their 
Families a ``one-stop shop'' for many services, including: Military 
personnel processing assistance; Child care and school transition 
services; Education services; Transition and employment assistance; 
Legal assistance; Financial counseling; Stress management and 
Exceptional Family Member support; Substance abuse information and 
referral; Installation access and vehicle registration; Management of 
donations made on behalf of Service Members; Coordination of federal, 
state, and local services; Pastoral care; Coordination for translator 
services; Renewal and issuance of identification cards; and Lodging 
assistance.
    The AMAP also established a ``Triad of Care'' concept to manage the 
care and support of each Warrior in Transition and his or her family. 
For Soldiers undergoing a Medical Evaluation Board or Physical 
Evaluation Board proceeding, dedicated physicians, Physical Evaluation 
Board Liaison Officers, and Legal Counselors are available to help 
Soldiers and Families navigate the process. Additionally, Ombudsmen are 
available at Warrior Transition Units to provide Soldiers and Families 
an individual advocate to assist in resolving concerns.
    (b) Under the ``Triad of Care'' concept, a physician who functions 
as the Primary Care Manager, a Nurse Case Manager, and a Squad Leader 
work together to manage the care and support needs of each Soldier and 
his or her family. These three individuals, like all Warrior Transition 
Unit staff, complete a tailored training course which prepares them to 
deal with the issues and concerns of Warriors in Transition and their 
Families. This training ranges from understanding how to identify 
behavioral health needs of Warriors in Transition to assisting with 
transportation and other needs. Additionally, Medical Evaluation Board 
physicians, Behavioral Health professionals, Physical Evaluation Board 
Liaison Officers, Legal Counselors, and Ombudsmen receive targeted 
training to enable them to effectively care for Warriors in Transition 
and their Families as an integral unit.
    (c) As part of the development of the Army Medical Action Plan 
(AMAP), as well as with the development of performance standards for 
all Warrior Transition Unit staff, best practices were incorporated 
from a variety of disciplines, including private practitioners and 
accreditation bodies. The Comprehensive Care Plan developed by the 
multi-disciplinary team caring for each Warrior in Transition for the 
purpose of providing a holistic approach to recovery, rehabilitation, 
and reintegration was developed in collaboration with the National 
Rehabilitation Hospital to leverage industry expertise in order that 
the integral unit of Warriors in Transition and their Families benefit 
from the most up-to-date approaches possible.
                      comprehensive recovery plan
    Question. (a) Dole /Shalala recommends that every wounded soldier 
receive a comprehensive recovery plans to coordinate recovery of the 
whole soldier, including all: Medical care and Rehabilitation, 
Education and Employment Training, Disability Benefits Managed by a 
single highly-skilled recovery coordinator so no one gets ``lost in the 
system. Do all patients get a comprehensive recovery plan?
    (b) What steps have you taken to train and hire skilled recovery 
coordinators?
    (c) Do soldiers have the single coordinator to provide continuity? 
What training do recovery coordinators receive?
    (d) Are they trained as soldiers, or as case managers?
    Answer. (a) Warriors in Transition assigned to Warrior Transition 
Units have received dedicated planning and management of their care by 
the care Triad of Primary Care Manager, Nurse Case Manager, and Squad 
Leader. Warriors in Transition assigned to Warrior Transition Units 
since March 1, 2008 have further benefited from the development of 
Comprehensive Care Plans (CCPs). The CCP represents a holistic approach 
to managing care that addresses physical, mental, spiritual, and 
emotional healing and provides an integrated approach to recuperation.
    (b) The Army Medical Action Plan (AMAP) established the Triad of 
Care concept for managing care which assigns each Warrior in Transition 
to a team comprised of a physician who functions as each assigned 
Soldier's Primary Care Manager, a Nurse Case Manager, and a Squad 
Leader. Nurse Case Managers are experienced Registered Nurses assigned 
to manage the care of 18 to 36 Warriors in Transition, depending on the 
complexity of care required. As with all Warrior Transition Unit staff, 
these Nurse Case Managers receive specific training in care management.
    (c) The Care Triad manages the care of assigned Warriors in 
Transition throughout their recovery, rehabilitation, and reintegration 
either back to duty or prepared to be productive civilians. This 
approach ensures maximum familiarity by the members of the Triad with 
each Warrior in Transition for which they are responsible. In the event 
Warriors in Transition must transfer to a different Warrior Transition 
Unit to continue their recovery, the Triad at the losing Warrior 
Transition Unit coordinates the transfer with the Triad receiving the 
Soldier at the new location to ensure a smooth transition.
    (d) Each member of the Triad receives specific training in the care 
needs of Warriors in Transition and the processes in place at Warrior 
Transition Units for accomplishing this care. Specific certification 
training is provided to all Warrior Transition Unit staff to ensure a 
common understanding within and between Warrior Transition Units in how 
to care for Warriors in Transition. The Nurse Case Manager members of 
the Triad are Registered Nurses with considerable experience in 
developing and executing care plans. Their mission is to ensure that 
the care and support Warriors in Transition receive is carried out in 
the most effective manner possible. This mission both relies on 
professional training and experience as well as knowledge of the 
military and how to manage Soldiers.
                                 ______
                                 
               Questions Submitted by Senator Ted Stevens
                             grow-the-army
    Question. The Army is accelerating their Grow-the-Army initiative, 
and hopes to reach their goal of 547,400 personnel as soon as possible. 
Is the Army medical community also growing in personnel to address the 
increased need for combat medics? Do you have the resources to support 
this growth?
    Answer. Each Brigade Combat Team (BCT) includes approximately 250 
medical personnel, approximately 200 of which are enlisted health care 
specialists. With the acceleration of the ``Grow-the-Army'' initiative 
and the increase in BCTs, medical structure in the Operational Army 
will increase. In addition, the ``Grow-the-Army'' also includes 
increases in Army medical manpower in the Institutional Army.
    In the absence of significant retention incentives, it will take 
several years to fully man these additional spaces. Our request for 
additional military medical manpower to support ``Grow-the-Army'' 
requirements is still being assessed within Headquarters Department of 
the Army. Depending on the results of this assessment, additional 
accession and retention incentives may be required to support this 
growth. These incentives would need to be developed in coordination 
with our Sister Services using the authorities provided to the Office 
of the Secretary of Defense in the fiscal year 2008 National Defense 
Authorization Act with regard to restructuring Medical Special Pays.
                             brac deadline
    Question. The Navy has announced an award for the design-build of 
the new Walter Reed National Military Medical Center at Bethesda. Do 
you believe this project is still on track to be completed by the BRAC 
deadline of 2011?
    Answer. The Naval Facilities Engineering Command (NAVFAC) announced 
on March 3, 2008 the award of a design and construction contract 
required to establish the new Walter Reed National Military Medical 
Center (WRNMMC), Bethesda, MD. The construction contract was awarded to 
Clark/Balfour Beatty, Joint Venture in the amount of $641.4 million. 
The environmental planning process guided by the National Environmental 
Policy Act is still ongoing and the final issue of the Record of 
Decision is pending for May 2008.
    The design and construction phases for the new WRNMMC, Bethesda 
have been closely coordinated between NAVFAC, TRICARE Management 
Activity and the Joint Task Force, Capital Medical and appears to be on 
track for completion by September 2011 pending any unforeseen 
complications. The design build contract allows for the greatest 
flexibility as we move forward with this project.
    Question. What challenges still need to be addressed in completing 
the build out of this facility by the BRAC deadline?
    Answer. The design, construction, and transition into the new 
Walter Reed National Military Medical Center, Bethesda poses many 
challenges. The Environmental Impact Study and subsequent signing of 
the Record of Decision must be completed on time. Delays in either of 
these areas will push back the construction schedule.
    The design phase of the new Walter Reed National Military Medical 
Center is an iterative process requiring ongoing adjustments to the 
blue prints to ensure the functionality of all clinical areas moving 
from Walter Reed to the new Walter Reed National Military Medical 
Center. We must ensure that adequate space has been provided to meet 
the mission and deliver world-class care to all beneficiaries entrusted 
to our care.
    Walter Reed's Centers of Excellence must be included in the new 
Walter Reed National Military Medical Center. These world-class 
research, teaching, and clinical centers must maintain the same 
capability and capacity in their new facilities.
                       medical center realignment
    Question. Are there Service specific concerns or issues with 
regards to this realignment that you are working through with your Navy 
counterpart? What are they?
    Answer. The Army and the Navy have separate organizational 
structures for Walter Reed Army Medical Center (WRAMC) and the National 
Naval Medical Center (NNMC). Each command contributed to the design of 
a common organizational structure for the new Walter Reed National 
Military Medical Center. The newly created organizational structure 
combines the best of both WRAMC and NNMC and will greatly facilitate 
the integration of clinical, clinical support and administrative 
processes.
    The Army and Navy have strong health profession education programs. 
Most of Walter Reed's and National Naval Medical Center's Graduate 
Medical Education (GME) programs have functioned as fully integrated 
joint programs since 1997, under the National Capital Consortium. We 
have worked together to continue to integrate the three remaining GME 
programs (Transitional Internship, Internal Medicine Residency, and 
General Surgery Residency programs). Some health profession education 
programs are unique to the Army (e.g., Licensed Practical Nurse 
training for medics). We are concerned about the future of these 
programs in the National Capital Region after realignment.
                                 ______
                                 
           Questions Submitted by Senator Christopher S. Bond
                behavioral health specialists shortages
    Question. Thank you for appearing here today. I'd like to start by 
commending all the services for their selfless service on the front 
lines of the War on Terror. Our Military, young men and women, young 
Soldiers, Marines, Sailors and Airmen have performed admirably on an 
asymmetric battlefield and against an irregular enemy. Thank you.
    We are obligated to provide the best support available to our 
service men and women. Many in our Active and Guard ranks are deploying 
to Iraq and Afghanistan for the 3rd and 4th times. An increasing number 
of military personnel are returning from combat duty with varying 
degrees of Post Traumatic Stress Disorder (PTSD). There is also an 
alarming spike in military suicide rates. It is clear that there is a 
relationship between suicide rates and PTSD. We must make sure that our 
men and women have access to the care they deserve when they return 
from combat. My staff has been investigating the status of behavioral 
health care throughout the military and has consistently found that 
behavioral health care assets remain in short supply. Of those 
specialists, few have experience working with soldiers returning from 
combat deployments. I'm also told that the military has had a 
challenging time trying to convince prospective specialists to relocate 
to a relatively desolate outpost. Twenty Nine Palms is a great example. 
If given a choice between working at a military base near an urban area 
with attractive living conditions, and a base off the beaten path, I 
believe a potential employee would choose the more lucrative living 
area 90 percent of the time.
    What are you doing to alleviate the shortage?
    Answer. The Army Medical Command (MEDCOM) is diligently working to 
fill 266 new behavioral health positions identified in the continental 
United States, and has currently filled 168 of those positions for a 63 
percent fill rate. MEDCOM will also fill 64 new behavioral health 
positions in Europe and 8 behavioral health positions in Korea.
    The military is competing in a market that suffers from a shortage 
of qualified mental health professionals. Additional incentives 
specific to behavioral health providers are needed to recruit and 
retain these professionals in the Army. Currently, Licensed Clinical 
Psychologists are offered the Critical Skills Retention Bonus (CSRB) at 
a rate of $13,000 per year for 2 years or $25,000 per year for 3 years. 
The Health Professions Loan Repayment Program (HPLRP) is available for 
the accessions of 5 Clinical Psychologists and the retention of 20 
Clinical Psychologists per year at the rate of $38,000 per year. The 
Health Professions Scholarship Program is available to students 
pursuing a doctorate in Clinical Psychology in exchange for an active 
duty service obligation. Social Workers in the grade of Captain are 
offered the Army CSRB at the rate of $25,000 per year for a 3-year 
active duty service obligation. The HPLRP is available for the 
accessions of 5 Social Workers and the retention of 20 Social Workers 
per year at the rate of $38,437 per year. A Masters of Social Work 
program has been established at the U.S. Army Medical Department Center 
& School in affiliation with Fayetteville State University. The program 
will accommodate up to 25 students per year starting in Academic Year 
2008. Psychiatric Nurses and Psychiatric Nurse Practitioners are 
authorized to receive Registered Nurse Incentive Special Pay (RNISP) at 
a rate of $5,000 per year for 1 year, $10,000 per year for 2 years, 
$15,000 per year for 3 years and $20,000 per year for 4 years. The 
Uniformed Services University of Health Sciences has introduced a new 
Adult Psychiatric Mental Health Nurse Practitioner (PMH-NP) program. 
The PHM-NP program is a 24-month, full-time program beginning in 
Academic Year 2008; Army allocations are to be determined. 
Psychiatrists who execute a multi-year special pay contract (extending 
their active duty service obligation) are paid at the rates of $17,000 
per year for a 2-year contract, $25,000 per year for a 3-year contract 
and $33,000 per year for a 4-year contract. The Critical Wartime Skills 
Accession Bonus is approved and programmed for future use as a lump sum 
bonus of $175,000 for 10 Psychiatrists in return for a 4-year active 
duty service obligation.
                      behavioral health resources
    Question. Thank you. To follow up, I'd ask Army leaders to consider 
a proposal to allow active duty forces to access the behavioral health 
care resources available at the nation's Vet Centers. These facilities 
provide care for PTSD and are manned by veterans and specialists 
familiar with the needs of veterans and our active duty forces. It 
seems a tremendous waste in resources to limit eligibility to our Vet 
Centers to veterans only if there are soldiers who require care but 
have limited or no assets available to them.
    Would you support legislation that allowed active duty forces 
access to behavioral health resources at the nation's Vet Centers?
    Answer. Any proposal that increases a Soldier's ability to access 
needed care is always welcomed, and we believe this may be a useful 
option over time.
                               eye trauma
    Question. Switching gears, I'd like to talk about the Centers of 
Excellence recently developed by the Department of Defense. Congress, 
in the Wounded Warrior section of the NDAA enacted January 2008, 
included three military centers of excellence, for TBI, PTSD, and Eye 
Trauma Center of Excellence. The two Defense Centers of Excellence for 
TBI and Mental Health PTSD are funded, have a new director and are 
being staffed with 127 positions, and are going to be placed at 
Bethesda with ground breaking in June for new Intrepid building for the 
two centers. I'm sure you are aware that there have been approximately 
1,400 combat eye wounded evacuated from OIF and OEF.
    Does DOD Health Services Command have current funding support and 
adequate staffing planned for the new Military Eye Trauma Center of 
Excellence and Eye Trauma Registry? If not, when can the committee 
expect to be provided specific details on implementation?
    Answer. The Assistant Secretary of Defense for Health Affairs 
recently directed the Army to take the lead in the joint effort to 
develop an implementation plan for a Center of Excellence in 
Prevention, Diagnosis, Mitigation, Treatment, and Rehabilitation of 
Military Eye Injuries. Currently, no funds are dedicated to the Center 
of Excellence or the Eye Trauma Registry. The Department of Defense 
Health Affairs Steering Committee for this Center of Excellence is 
still finalizing the concept, staffing requirements, central office 
location, agenda, and timeline. Specific details on implementation 
should be available by the end of the third quarter, fiscal year 2008.
                      joint military health system
    Question. There has been a lot of discussion in recent years about 
making military medicine more joint. Do you believe changes in the 
governance of the Military Health System are needed to make military 
medicine more effective and efficient?
    Answer. Absolutely. Our experiences in Operations Iraqi Freedom and 
Enduring Freedom highlight the necessity for jointness, coalition 
partnerships, and an appropriate mix of active and reserve component 
personnel. A Unified Medical Command has the potential to improve 
delivery of military medical support across the full spectrum of 
conflict, from combat operations to peacetime family member health 
care.
    The Army Medical Department has looked hard at governance of the 
Military Health System (MHS) and developed a proposal for a Unified 
Medical Command that we believe provides the following advantages: a 
more effective and efficient governance; improved delivery of health 
care to the beneficiary population; efficiencies gained through 
elimination of Service stovepipes; a single accounting system; and a 
single point of accountability. It also ensures the Service medical 
departments retain their individuality where appropriate, as there are 
some differences in mission and skill sets that do need to remain.
    However the governance ultimately evolves, it is important that it 
maintains a military command and control structure and that the chain 
of command be streamlined to maximize responsiveness and optimize 
outcomes. The recent activation of the Joint Task Force National 
Capital Region is an opportunity to help inform our efforts and shape 
the future transformation of MHS governance.
                                 ______
                                 
          Questions Submitted to Major General Gale S. Pollock
            Questions Submitted by Senator Daniel K. Inouye
                        specialty pay for nurses
    Question. General Pollock, the Army initiated a specialty pay (IPS) 
to retain highly skilled, certified nurses. However, only 50 percent of 
nurses eligible for the bonus have accepted. Is this due to a 
difficulty in communicating incentives, or is it just another strong 
sign at the difficulty to retain Army nurses?
    Answer. Since last reported, the Army Nurse Corps is pleased to 
convey that the percentage of nurses who are eligible for Registered 
Nurse Incentive Special Pay (RN ISP) and have taken the bonus is up to 
74 percent. Additionally, in response to this new incentive program, 
many Army Nurses are actively pursuing national certification in order 
to qualify for RN ISP. Therefore, we fully expect both the eligible 
population and the acceptance rate to steadily increase. In order to 
help facilitate certification, many Army Medical Treatment Facilities 
are offering review courses and study groups to assist nurses in 
preparing for certification exams. In addition, the Federal Nursing 
Chiefs have partnered with the American Nursing Association and 
American Nurses Credentialing Center to reinstate certification in 
several specialties. The RN ISP program has already proven to be an 
essential retention tool, as evidenced by the surge in Army Nurses 
pursuing certification to qualify.
                           nurse/pandemic flu
    Question. General Pollock, Northcom and Department of Defense 
Health Affairs office drafted the Department's plan to respond to a 
pandemic flu, but there is no mention of nurses. What role do you see 
nurses taking in a pandemic flu scenario?
    Answer. The Army Nurse Corps recognizes that, in order for the 
Department of Defense's plan to be successful, human resources will be 
necessary to respond to and sustain any pandemic flu scenario. Nurses 
are an integral part of providing the medical services required in the 
event of an outbreak. From pre-hospital care, hospital/acute care, 
palliative care, and alternative care sites, the role of the registered 
nurse in responding to a pandemic emergency is critical and 
significant. The strategies for building surge capacity within the 
health care system to meet the significantly increased demand that a 
pandemic event would place on the system must include nurses in order 
to be successful.
                           school of nursing
    Question. General Pollock, the National Defense Authorization Act 
for Fiscal Year 2008 directed the Secretary of Defense to establish a 
school of nursing within the Uniformed Services University of Health 
Science. Is the Nurse Corps supportive of this effort and what is the 
timeline for establishing the school?
    Answer. The Army Nurse Corps does not support the creation of an 
undergraduate nursing program at the Uniformed Services University of 
Health Science (USUHS). The nursing mission of USUHS is to prepare and 
educate students as advanced practice nurses, scientists, and scholars 
for service as future leaders in military operational environments, 
federal health systems and university settings. The Army Nurse Corps 
recommends that baccalaureate level education remain in the civilian 
sector, and that the Army continue to improve scholarship opportunities 
for all accession sources.
    A Department of Defense School of Nursing is expected to produce 50 
nurses for the first class graduating in fiscal year 2012. However, the 
Army would only receive approximately 10-20 new accessions from the 
program, yet the Army Nurse Corps requires 250-450 accession per year. 
Therefore, an increased investment in existing civilian Bachelor of 
Science in Nursing (BSN) completion programs would help us recruit and 
access a greater number of nurses much faster.
    Establishing a BSN degree completion program at USUHS would be more 
beneficial to the Army. Currently, there are a significant number of 
junior Army Nurse Corps officers in the U.S. Army Reserves who have not 
completed their BSN degree. To be promoted and serve in leadership 
roles, those officers will need to complete their education.
                          promotion selection
    Question. General Pollock, the Army has promoted retention of 
clinical nurse specialists. Do the clinicians have the same promotion 
selection as nurses on the administrative track?
    Answer. All Army Nurses have the same promotion opportunity rate 
through Lieutenant Colonel (LTC). Army Nurses are given the opportunity 
to progress in rank as they demonstrate nursing proficiency and 
effective leadership traits. However, the promotion opportunity to 
Colonel (COL) is very limited for all Army Nurse officers, regardless 
of specialty. Some specialties have a better promotion rate to COL 
because we have requirements-driven promotions for those groups.
    The Army Nurse Corps is seeking more LTC and COL authorizations. 
COL authorizations with emphasis on clinical and leadership acumen are 
needed to better develop junior and mid-grade Nurse Corps officers to 
serve in a variety of complex clinical roles. We have a greater demand 
for more senior officers with a progressive clinical career pathway 
background to serve as mentors and coaches much like the Medical and 
Dental Corps now have under Defense Officer Personal Management (DOPMA) 
exemption. Current retention initiatives have increased retention 
significantly among field grade clinical nurses who are retirement 
eligible, despite limited opportunities to serve as a COL in a DOPMA-
constrained promotion model. DOPMA exemption for the Army Nurse Corps 
would provide greater structure at the LTC and COL ranks to meet the 
needs of more senior and experienced clinicians at the bedside while 
improving retention rates among officers seeking a progressive clinical 
career pathway.
                       nurse psychological health
    Question. General Pollock, the Army has instituted a number of 
programs to address the increase of psychological health issues among 
service members. However, nurses are also deploying and are responsible 
for treating psychological health issues. Are there any specific 
psychological health programs targeted at our military nurses?
    Answer. The Army psychological health programs target all military 
members. Pre and Post deployment psychological screening, one component 
of health surveillance, has been used extensively to predict job or 
illness-related outcomes and to determine risk indicators. In addition, 
``Battlemind'' training has been implemented throughout the Army. The 
goal of this training is to develop a realistic preview, in the form of 
a briefing, of the stresses and strains of deployment on Soldiers. Four 
training briefs have been developed and are available for Soldiers, 
Leaders, and Families.
    The Army Medical Department (AMEDD) recognizes the impact of 
deployments on our staff, as well as the impact of the high-operational 
tempo on staff members who are not deployed, but who are taking care of 
the same injured OEF/OIF patients. Accordingly, AMEDD has implemented 
Compassion Fatigue and Resiliency program initiatives to target AMEDD 
staff. All medical treatment facilities have access to a centralized 
web-based program entitled, ``Provider Resiliency Training.'' The Army 
Medical Department has also instituted an assessment, education, 
intervention and treatment program for Provider Fatigue and Burnout. 
Centralized products for Provider Resiliency Training have been 
developed, resulting in standardized, efficacy-based education and 
training that has enhanced resiliency of care providers who have 
participated and provided attendees who are experiencing Provider 
Fatigue and Burnout the tools necessary to mitigate their condition. 
Additionally, Behavioral Health Clinicians, hospital-level Provider 
Resiliency Champions and Care Team personnel have been trained and 
certified as Provider Fatigue Educators and/or Therapists. The Army 
Medical Department (AMEDD) is also establishing Care Teams at our 
Medical Centers and larger Medical Facilities to focus on provider 
compassion fatigue intervention. These Care Teams will use a community 
health model of intervention, taking services to the wards and clinics 
for providers and other staff in our hospitals.
                         contracting for nurses
    Question. General Pollock, in order to facilitate optimal nurse 
staffing, contract staffing support companies have been used. Have 
these companies met your needs for recruiting contract nurses in a 
timely manner, and providing quality nurse?
    Answer. In order to compensate for the nursing deficit and the 
current operational tempo, we have expanded contract nursing support 
considerably. For fiscal year 2007, we contracted for 717.6 full-time 
equivalents in registered nursing across the U.S. Army Medical Command 
(MEDCOM) at a cost exceeding $53.6 million. The advantage of contract 
nursing is the ability to bring an individual on board quickly and 
provide flexibility to meet both short-term and long-term needs. 
Contract nurses can do this in a matter of a few days as opposed to the 
weeks/months it takes us to bring a General Schedule (GS) nurse 
onboard. The educational and credentialing requirements are the same 
for contract nurses and the overall quality of contract nurses is good.
    While contract nursing supports operational needs, it is not a 
sound long-term strategy. Contract nurses pose additional 
complications, such as: (1) variance with nursing competencies and 
training backgrounds affects performance in a military hospital; (2) 
lack of loyalty to the organization; (3) a ``short horizon'' mindset; 
and (4) constant turbulence requires resources to train and orient. 
Wherever possible, medical treatment facilities throughout MEDCOM are 
replacing contract nurses with General Schedule (GS) nurses.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
                partnership with university of maryland
    Question. The Defense Appropriations subcommittee asked each branch 
to report on the nursing shortage and efforts in which you are 
currently engaged or see potential.
    In your response, you discussed the faculty augmentation program or 
the Army's partnership with the University of Maryland. In this 
partnership, you argue that DOD received no direct incentive to begin 
the partnership, yet the Army still benefits from the project. Can you 
please speak to these benefits and the future of the partnership?
    Answer. The partnership program with the University of Maryland 
provides the opportunity for detailed Army Nurse Corps officers to 
acquire unique educational, training, and supervisory skills that 
better prepare these officers to serve in a variety of positions. 
Appropriate utilization of these officers could include a variety of 
educator positions within medical treatment facilities, in a number of 
phase II clinical training sites, clinical nurse specialists in large 
teaching facilities, and clinical head nurses who are pivotal in the 
training and development of junior civilian and military staff nurses. 
The skills these officers are expected to acquire through this program 
include developing and implementing curricula, supervising clinical 
skills of baccalaureate students, building partnerships with academia, 
evaluating collegiate-level students, developing testing and evaluation 
instruments, developing evidence-based clinical practice, developing a 
methodology evaluating critical thinking, integrating medical 
simulation into the education process, and evaluating scholarly 
writing.
    A significant outcome expected from this program is improved 
recruiting for Army Nursing. The Army Nurse instructors are in uniform 
and demonstrate on a daily basis the quality and professionalism of the 
Army Nurse Corps. They serve as indirect recruiters and are readily 
available to answer questions from potential accession candidates, not 
only from the nursing school, but within the clinical settings of area 
hospitals.
                            nursing shortage
    Question. The United States is currently facing one of the most 
severe nursing shortages in its history. While nursing schools have 
been making a concerted effort to increase enrollments to meet current 
and projected demand, 40,285 qualified applicants were turned away in 
2007 according to the American Association of Colleges of Nursing. The 
top reason cited was a lack of qualified nurse faculty.
    The legislation I introduced earlier this year, The Troops to Nurse 
Teachers Act of 2008 (S. 2705), creates several avenues by which 
military nurses can become nurse educators. The subsequent increase in 
the number of nurse faculty would allow schools of nursing to expand 
enrollments and alleviate the ongoing nursing shortage in both the 
civilian and military sectors. Considering the military has a 
significantly higher percentage of Masters and Doctorally prepared 
nurses than in the civilian population--ideal for vacant faculty 
positions--how does the Army view this program as part of a successful 
strategy to address the military nurse shortage?
    Answer. The Army Nurse Corps supports the Troops to Nurse Teachers 
Act of 2008 and believes that using the expertise of our retired 
military nurse population to teach in civilian nursing education 
programs will help alleviate the national nursing shortage by 
increasing the civilian nurse instructor pool. Additionally, it will 
expose nursing students to the benefits of a military career. Finally, 
programs that detail qualified active duty nurses into collegiate 
nursing instructor positions could benefit military nurse recruiting 
and retention efforts. However, since this program addresses the 
national nursing shortage, the Department of Defense is not the best 
federal funding partner.
                           nursing education
    Question. The Army recruits, in particular, nurses with a 
baccalaureate degree in nursing. The Agency for Healthcare Research and 
Quality has found that baccalaureate nurses are the key to providing 
safe, high quality care that leads to improved patient outcomes. What 
benefits do these nurses bring to military health care?
    Answer. The Army Nurse Corps (ANC) has continued to recognize the 
quality of clinical care associated with higher-level preparation and 
seeks to maintain an all professional Corps with a standard entry-level 
education requirement. Bachelor of Science in Nursing (BSN) programs 
provide a uniform and standard curriculum accredited by certifying 
bodies under the auspices of the Department of Education. This 
accreditation process assures uniformity in the educational and 
clinical preparation of ANC accessions without significant variance. 
The BSN is also the minimum educational entry for advanced degree 
eligibility, professional certification, and post-baccalaureate 
training.
    The research literature strongly supports the conclusion that 
nursing care provided by nurses with a BSN or higher-level degree 
results in improved patient outcomes, shorter hospitalization, greater 
patient satisfaction, and reduced patient mortality. These benefits are 
brought to the military health care system because all of our Active 
Component ANC officers have at least a baccalaureate degree in nursing. 
The Reserve Component has recently adopted this professional nursing 
model. All officers in the Army are required to have or attain a 
bachelor's degree, and it is imperative that Nurse Corps officers are 
educated to this standard to provide both top-quality care and required 
professional leadership.
    Question. In your written testimony, you also emphasize the 
important role of Nurse Practitioners. Can you elaborate on the 
importance of Advanced Nursing degrees for the military and the 
importance of partnering with accredited schools of nursing?
    Answer. As the Global War on Terrorism continues, the Army requires 
greater flexibility to meet the primary health care needs of Soldiers. 
These needs occur primarily at the operational unit level and at troop 
medical clinics on forward operating bases. Nurse practitioners have 
provided the Army with highly-qualified primary care providers who are 
able to offer their expertise at brigade and higher levels while 
helping to relieve some of the critical shortages faced by the 
physician and physician assistant communities. Soldiers and leaders are 
highly satisfied with the care provided by nurse practitioners, which 
has resulted in increased requests for nurse practitioners on the 
battlefield.
    Health care delivery practices and theory continue to evolve and 
change. To address this dynamic environment, the Army Nurse Corps has 
forged professional partnerships with accredited schools of nursing. 
These partnerships focus on educating nurses and enhancing their 
ability to practice in a changing environment. Army nursing leaders 
believe that these formalized cooperative efforts have helped dissolve 
the traditional barriers between military and civilian education and 
practice. The partnerships also provide new education and practice 
opportunities that are vital in promoting nursing professionalism.
                            nursing shortage
    Question. Can you speak to the increasing demand for nurses in your 
branch as a result of the ongoing war in Iraq?
    Answer. The persistent conflicts in Iraq and Afghanistan have 
placed increased demands on all military nurses. 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.
    The Army Nurse Corps' high attrition rates can be attributed to the 
frequency and length of deployments. Nurses with high-demand 
specialties deploy more frequently. Based on exit survey results over 
the past four years, officers choose to leave the Army Nurse Corps 
after a deployment, rather than potentially deploy again. As a result, 
more nurses are needed to lower the frequency of deployments and help 
the Army Nurse Corps' retention efforts.
    In addition, our re-deployed nurses are caring for the same 
Soldiers they cared for on the battlefield--Soldiers who have complex 
injuries that require more nurses with a higher skill level than ever 
before. The emotional toll from caring for these severely injured 
patients in both deployed and non-deployed settings creates a need for 
more nurses to ameliorate this effect.
                           nursing recruiting
    Question. One of the major recruitment strategies for the Army and 
other Military Nurse Corps is the Reserve Officers' Training Corps or 
ROTC. In recent years, how effective has this program been in 
recruiting and preparing nurses for a career in the Army Nurse Corps? 
How well does this program recruit underrepresented populations to the 
Army?
    Answer. The Army Nurse Corps accesses officers for the Active 
Component through a variety of programs, including the Reserve 
Officers' Training Corps (ROTC), the Army Medical Department Enlisted 
Commissioning Program, the Army Nurse Candidate Program, and direct 
accession recruiting, with ROTC being the primary accession source. 
Over the past four years, we have not achieved our annual ROTC mission 
for 225 nurses; however, each year shows improvement. In an attempt to 
resolve continued strength shortfalls within the Army Nurse Corps, 
overproduction of the direct accession mission has been authorized and 
encouraged.
    Demographic data provided by U.S. Army Cadet Command indicate that 
ROTC nurses are a more diverse population than the national nurse 
population. 68 percent of ROTC-contracted nurses are Caucasian, 12 
percent are Asian-American, 7 percent are African-American, 7 percent 
are Hispanic, 2 percent are American Indian, and 4 percent are unknown. 
By comparison, national nursing statistics indicate that 88.4 percent 
are Caucasian, 3.3 percent are Asian-American, 4.6 percent are African-
American, 1.8 percent are Hispanic, and 0.4 percent are American-
Indian. Additionally, men represent about one-third of the Corps' 
strength compared to about 7 percent of civilian nursing professionals.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
                            integrated care
    Question. (a) The Dole/Shalala Report recommends DOD and VA develop 
integrated care teams with physicians, nurses, health professionals, 
social workers, and vocational rehabilitation professionals. The Army's 
Warrior Training Unit has physicians, nurse case managers, and squad 
leaders?
    (b) Are we asking our nurses to do the job of social workers?
    (c) What training do they receive to do this?
    Answer. (a) Each Warrior in Transition (WT) Soldier is now assigned 
or attached to a Warrior Transition Unit (WTU), with an assigned 
military squad leader, nurse case manager, and primary care manager 
(physician). Commonly referred to as the ``Triad of Care'', this team 
forms the core of the WTU which is exclusively dedicated to overseeing 
and managing the healing process for each WT Soldier. At 35 Army 
hospitals around the world, each WTU serves with the singular purpose 
of helping each Soldier transition to productive lives, either within 
the Army as successful Soldiers or outside of the military as respected 
members of their communities, equipped with all of the Veterans 
benefits they are entitled.
    (b) Nurse Case Managers (NCM) are not being asked to assume the 
duties normally associated with social workers. In the WTUs, case 
management is a collaborative process under the population health 
continuum which assesses, plans, implements, coordinates, monitors, and 
evaluates options and services to meet each Soldier's health needs 
through communication and available resources to promote quality, cost-
effective outcomes. Clinical case managers are licensed health care 
professionals with varying levels of education and credentials who 
practice without direct supervision. All Warrior Transition Unit Case 
Managers are Registered Nurses. Social Workers are participants of the 
multi-disciplinary team, but their role and responsibilities are 
clearly established and distinct from those of nursing personnel. Each 
WTU has priority access or even exclusive use in some cases to licensed 
social workers, behavioral health providers such as psychiatrists and 
counselors, and vocational rehabilitation professionals such as 
occupational therapists.
    (c) Case Managers are required to complete nine Distance Learning 
Training Modules and 40 hours of classroom training during their 
orientation. The Army Medical Department (AMEDD) Center & School (C&S) 
sponsors this training. The AMEDD C&S is finalizing an agreement with a 
well known University to offer a 80-hour comprehensive CM training 
course for the Army's military and civilian NCMs. Completion of the 
course will prepare the NCM for National Certification in Case 
Management. As a matter of standing regulation, we require all medical 
professionals serving within the AMEDD to maintain their respective 
professional credentials.
                       nurse psychological health
    Question. (a) The Army nurse corps has the highest attrition of any 
officer branch of the Army. What are you doing to monitor the stress on 
our nurses?
    (b) What service are we providing them to help deal with that 
stress?
    (c) How many additional nurses do you need to recruit to ensure we 
can meet our commitment to our wounded soldiers?
    (d) What is your plan to meet the growing need?
    (e) What are the major obstacles?
    Answer. (a) Army Nurse Corps (ANC) leaders monitor stress on nurses 
in a variety of ways. Supervisors and Deputy Commanders for Nursing, as 
well as ANC Branch Career Managers talk with officers on a regular 
basis to address their individual and collective stressors. Deployment 
equity, length of deployment, shift work, career progression tracks and 
retention programs have all been modified to alleviate the stress on 
Army nurses. In addition, the ANC instituted an exit interview in order 
to study and address attrition variables from the view of those who 
decided to leave Army service.
    (b) Several services have been implemented as part of the Army 
Medical Department Care Giver Support Program at Walter Reed Army 
Medical Center (WRAMC), Landstuhl Regional Medical Center (LRMC), and 
Brooke Army Medical Center (BAMC). BAMC has a formalized stand-alone 
program for dealing with Provider Fatigue, and BAMC's Department of 
Behavioral Health responds to staff requests for assistance and 
provides training and sensing sessions. WRAMC, LRMC and BAMC each have 
access to a centralized web-based program entitled, ``Provider 
Resiliency Training.'' The Army Medical Department has also instituted 
an assessment, education, intervention and treatment program for 
Provider Fatigue and Burnout. Centralized products for Provider 
Resiliency Training (PRT) have been developed, resulting in 
standardized, efficacy-based education and training that has enhanced 
resiliency of care providers who have participated and provided 
attendees who are experiencing Provider Fatigue and Burnout the tools 
necessary to mitigate their condition. Additionally, Behavioral Health 
Clinicians, hospital-level Provider Resiliency Champions and Care Team 
personnel have been trained and certified as Provider Fatigue Educators 
and/or Therapists. The Army Medical Department (AMEDD) is also 
establishing Care Teams at our Medical Centers and larger Medical 
Facilities to focus on provider compassion fatigue intervention. These 
Care Teams will use a community health model of intervention, taking 
services to the wards and clinics for providers and other staff in our 
hospitals.
    The Army's Institute of Surgical Research (ISR) received $1 million 
and is in the process of creating a Compassion Fatigue program with a 
respite room for staff. It will be a prototype. We are already 
providing services and have a roster of experts who will come to teach 
and train staff. We have also had an Advanced Practice Psychiatric 
Nurse working with staff for a year.
    (c) In order to meet our commitment to our wounded Soldiers, the 
Army Nurse Corps recently identified a need for additional budgeted end 
strength of 300 Army Nurses. The current mission shortfall is 184, and 
the ANC needs an additional 116 nurses to meet ``Grow-the-Army'' 
requirements.
    (d) An analysis of current shortfalls has been incorporated into 
the plan to grow the Army Nurse Corps. The analysis indicates that the 
following mission areas require additional assets: Warrior Transition/
Case Management; Psychological Nursing; Rehabilitation; Intensive Care 
Mission; Emergency Nursing; Residency for New Graduates; and Training. 
The plan to meet these needs will be carried out over the next four 
years and include requests to expand all Army Nurse accession and 
retention programs.
    (e) There are several major obstacles impeding retention of Army 
Nurses. These include competition with the civilian job market, rising 
civilian salaries, and poor promotion opportunities for ANC officers. 
Other factors include the operational tempo, frequency of deployments, 
and the emotional burnout of caring for Wounded Warriors.
                                 ______
                                 
               Questions Submitted by Senator Ted Stevens
                            nursing shortage
    Question. With a shortage of nurses to recruit from, and as the 
Army continues to grow their end strength by 65,000, how do you 
maintain the Army Nurse Corps to support a larger force?
    Answer. We anticipate that the size of the Army Nurse Corps will 
grow. The increase in forecasted end strength is based on force 
projection models that take into consideration current and future 
workload. In addition, as the Army Nurse Corps increases in size, our 
civilian nurse work force will also grow to support the expanded 
medical requirements a larger force will bring. To maintain this Army 
Nurse force, growth is required throughout the structure to ensure 
junior clinicians receive appropriate mentoring and coaching, and to 
allow senior nurses to organize and lead the very dynamic trends in 
both the Army and nursing.
                                 ______
                                 
     Questions Submitted to Rear Admiral Christine M. Bruzek-Kohler
            Questions Submitted by Senator Daniel K. Inouye
                       nurse corps age exemption
    Question. Admiral Bruzek-Kohler, I have been informed that the 
Nurse Corps is one of the only medical fields without the ability to 
recruit individuals who are older than 42 because of a Title 10 
restriction which requires a person to be able to complete 20 years of 
active commissioned service before their 62nd birthday. Currently the 
Medical Corps, Dental Corps, and Chaplain Corps are exempt from this 
age requirement. Are there efforts to exempt Nurse Corps officers to 
also be exempt from this age requirement?
    Answer. There are currently no efforts to seek this age exemption 
for the Nurse Corps. The Nurse Corps met its recruiting goal for fiscal 
year 2007 for the first time in four years and with recent increases in 
the Nurse Accession Bonus (an increase to $20,000 for a three-year 
commitment and $30,000 for a four-year commitment), Navy is projecting 
to meet its fiscal year 2008 recruiting accession goal within the 
current age limitations of Title 10.
    The Nurse Corps Community Manager closely monitors the changing 
demographic of individuals entering into the nursing profession, and 
will consider legislative relief as a possible course of action should 
the requirement arise.
                         humanitarian missions
    Question. Admiral Bruzek-Kohler, what role does the Nurse Corps 
have in drafting the Pandemic Flu plan or other humanitarian missions?
    Answer. Navy nurses have been involved in a myriad of activities 
related to Pandemic Flu (Influenza) Plan at both at the Bureau of 
Medicine and Surgery (BUMED) level and their local military treatment 
facilities in which they work.
    For example, one of our nurses went to Hawaii to assist a six 
person planning group for Pacific Fleet Pandemic Influenza plans, 
carrying over concepts for the Pacific Command Pandemic Influenza plan 
(some of which originated at the BUMED's Homeland Security code). Navy 
nurses have availed assistance with the review of the Navy Medicine 
Pandemic Influenza instruction and offered recommendation on equipment, 
logistical requirements and medication (Tamiflu) shelf life extension 
programs in coordination with the Navy Medicine Logistics Command.
    Our nurses have also been engaged in Pandemic Influenza planning 
and training sessions hosted by the Guam Department of Homeland 
Security.
    Navy nursing specialties with backgrounds and training expertise in 
disaster relief and emergency management are particularly well-suited 
to assist with planning responses for pandemic influenza and 
humanitarian missions. These nurses can readily serve as leaders in 
planning and surveillance issues surrounding patient care and force 
protection. Navy nurses may also be called upon to serve in the role of 
Public Health Emergency Officer (based on location of the treatment 
facility and availability of other health professional resources). 
Additionally, our nurses may be representatives on command Emergency 
Management Committees, participating in local Pandemic Influenza 
tabletop training and exercise.
    There are Navy nurses on both of our hospital ships as well as on 
grey hulls located around the world. While their jobs are more directly 
aligned with the provision of nursing care in humanitarian missions, 
they may be involved in the planning stages to ascertain the numbers 
and types of nursing specialties necessary to meet mission objectives 
and patient care requirements.
                          usuhs nursing school
    Question. Admiral Bruzek-Kohler, the National Defense Authorization 
Act for Fiscal Year 2008 directed the Secretary of Defense to establish 
a school of nursing within the Uniformed Services University of Health 
Science. Are the Nurse Corps supportive of this effort and what is the 
timeline for establishing the school?
    Answer. The Navy Nurse Corps would welcome the exploration of the 
following possible student populations for admission to a School of 
Nursing at USU:
  --Associate Degree Nurses (ADN) who could pursue BSN or even bridge 
        to MSN. The ADN pool holds an ``untapped'' recruiting 
        opportunity that has not been fully explored as accessions to 
        the Navy Nurse Corps must hold a BSN. Additionally, this 
        population of candidates possesses greater clinical experience 
        and offers a more mature, dedicated student with finite 
        professional goals.
  --Students who have completed liberal arts prerequisites and are 
        seeking admission into programs that are focused on core 
        curriculum leading to degree conferral of BSN/MSN.
  --Opportunities for distance education/on line degree completion 
        programs would also be appropriate for the two aforementioned 
        groups and are of interest to the Navy Nurse Corps.
  --Non-nursing degree holders (BS or BA) who seek BSN or MSN degrees. 
        The Navy Nurse Corps Community Manager has received calls from 
        officers in the Unrestricted Line Community (Surface Warfare 
        and Nuclear) who were interested in staying in the Navy and 
        acquiring their BSN.
    The Navy Nurse Corps understands that the timeline for 
establishment of the school of nursing will be reported in a report to 
Congress that is being prepared by the DOD/Uniformed Services 
University of Health Science in response to Sec. 955 of the fiscal year 
2008 National Defense Authorization Act.
                         nurse promotion rates
    Question. Admiral Bruzek-Kohler, do you see low promotion rates for 
nurses as a reason for Navy nurses to separate?
    Answer. No, I do not see low promotion rates as a reason for Navy 
Nurses to separate. Navy nursing is DOPMA constrained in the controlled 
grades and over the last six years from 2002 to 2008 have met DOPMA 
constraints. Active plans are underway to adjust grade strength to meet 
promotion needs.
                    mental health treatment research
    Question. Admiral Bruzek-Kohler, what role do Navy nurses have in 
research for post war mental health treatment?
    Answer. A Navy Nurse Corps officer has a trajectory of research 
looking at the mental health needs of Navy Service members--from 
assimilation at Boot Camp to reintegration. His latest study is 
developing methods for both the patients and caregivers to cope with 
anxiety-stress to PTSD. These studies are conducted across the 
branches. Several Navy nurses are co-investigators on his studies as 
well as the Army. It is funded via the Tri-Service Nursing Research 
Program
    We also join our colleagues from sister Services in the support of 
nursing research endeavors related to Stress, and Post Traumatic Stress 
Disorder vs. Mild Traumatic Brain Injury through the Tri-Service 
Nursing Research Program. Studies funded in fiscal year 2007 and future 
fiscal year 2008 studies will be conducted on topics of Deployment and 
Coping.
                      contract nurse requirements
    Question. Admiral Bruzek-Kohler, the entry requirement for active 
duty Navy nurses is a bachelor's in nursing. To provide consistent, 
quality care, is the same standard applied when hiring contract nurses?
    Answer. With rare exception, Navy Medicine contracts allow for 
Bachelors of Science in Nursing degrees (BSNs), associates degrees, or 
nursing school diplomas. This is a long standing practice. All of the 
aforementioned levels of academic preparations meet the requirement for 
taking the registered nurse licensing exam. We have not had any issues 
with ``consistent, quality care'' that are attributable to the 
educational experience of any one of those groups versus any other. We 
face an extremely tight labor markets for nurses at many of our 
hospitals and do not wish to decrease our overall level or quality of 
care by trying to limit our recruitment to only BSN nurses at this 
time.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
                military nurse recruitment and retention
    Question. What do you consider the most challenging aspects to 
military nurse recruitment and retention? Can you discuss your most 
successful nurse recruitment and retention initiatives?
    Answer. Last fiscal year, we met our active duty direct accession 
goals and are on track to do so this fiscal year. Our top three 
programs which yield the greatest success in recruiting include the 
Nurse Accession Bonus (NAB), Health Professions Loan Repayment Program 
(HPLRP) and Nurse Candidate Program (NCP).
    The Nurse Accession Bonus is targeted towards civilian nurses who 
hold bachelors or masters degree in nursing from an accredited school 
of nursing and avails $20,000 for a three year commitment and $30,000 
for a four year commitment.
    The Health Professions Loan Repayment Program assists nurses with 
accumulated nursing school tuition costs. While primarily a retention 
tool, HPLRP has been used in conjunction with the NAB as a recruiting 
incentive to yield a five year active commission service obligation.
    The Nurse Candidate Program offered only at non-ROTC Colleges and 
Universities, is directed at students who need financial assistance 
while in school. NCP students receive a $10,000 sign-on bonus and 
$1,000 monthly stipend.
    The establishment of a Recruiting and Retention cell at the Bureau 
of Medicine and Surgery (BUMED) with a representative from each 
professional corps has also been helpful to our recruiting endeavors. 
These officers act as liaisons among Commander Naval Recruiting Command 
(CNRC), Naval Recruiting Districts (NRD), recruiters and our military 
treatment facilities. They also travel to local/national nursing 
conferences or collegiate recruiting events.
    Student Pipeline Programs are very successful in attracting future 
candidates and ensure a steady supply of trained and qualified Nurse 
Corps officers. These pipeline programs include Nurse Candidate 
Program, Medical Enlisted Commissioning Program, Naval Reserve Officer 
Training Corps (NROTC) Program and the Seaman to Admiral Program.
    We have also established mentorship programs to cultivate 
professional growth while enhancing retention of our Nurse Candidate 
Program and NROTC students, who are our best recruiters. Other factors 
contributing to recruiting success: location of duty stations and the 
opportunity to participate in humanitarian missions.
    We have implemented a number of retention initiatives to offset 
this attrition. Our critical juncture appears to be among nurses at the 
6 to 10 year length of service.
    The Health Professions Loan Repayment Program Scholarship assists 
Navy Nurse Corps officers with accumulated nursing school tuition 
costs. In fiscal year 2008, 42 active duty nurses were selected with 
average debt load of $27,300 with two years of obligated service. 
Interest in this program typically exceeds available funding.
    Additionally, the Duty under Instruction Program for Nurse Corps 
Officers provides the Nurse Corps Officer the opportunity for advanced 
educational degrees in nursing at the Masters and Doctoral levels. For 
the first time since 1975, this program was made available to nurses 
within their first tour of duty.
    A Tri-Service Registered Nurse Incentive Special Pay (RN ISP) Plan 
was released for Navy Nurses in February 2008 to target retention of 
undermanned critical wartime specialties as identified by the Chief, 
Bureau of Medicine and Surgery. For the Navy Nurse Corps this included: 
perioperative, critical care, family and pediatric nurse practitioners. 
This program offered tiered bonuses $5,000/1 year of obligated service, 
$10,000/2 years of obligated service, $15,000/3 years of obligated 
service and $20,000/4 years of obligated service. This program requires 
the nurses to work in their specialty area full-time, maintain national 
specialty certification and possess either a Masters of Nursing in the 
concentrated area of practice or have completed a Surgeon General's 
approved course.
                        troops to nurse teachers
    Question. If the Troops to Nurse Teachers program were authorized 
and funds were appropriated, how do you think it would impact the Navy 
Nurse Corps' recruitment and retention efforts?
    Answer. For the second consecutive year, the Navy Nurse Corps is on 
track to meet direct accession goals.
    The Navy Nurse Corps views this program primarily as a retention 
incentives program that gives Nurse Corps Officers an ``off ramp'' 
opportunity to teach for two to three years. They would then accrue 
obligated service back into the Medical Department with the hope that 
they would continue a 20 year or longer career.
    Should the program be funded, the most appealing provision would be 
the ``off ramp'' that gives nurse corps officers the opportunity to 
teach for two to three years. As a retention tool, it would accrue 
obligated service back into the Medical Department with the hope that 
they would continue a 20 year or longer career. It would essentially 
provide another way to retain nurses who might otherwise be disinclined 
to remain on active duty.
                            case management
    Question. In your written testimony, you discuss the importance of 
case management and how the Navy works in conjunction with other 
branches to coordinate care for soldiers' recovery at home. For 
example, you discussed the Naval Hospital Great Lakes work with the 
North Chicago VA Medical Center. Can you elaborate on this partnership 
and how the nursing shortage is affecting the ability to expand the 
program?
    Answer. The collaborative efforts initiated between Naval Hospital 
Great Lakes and the North Chicago VA Medical Center began in 
anticipation of the integrated federal health care center. Meetings 
involving Utilization Management/Case Management departments have 
occurred and have been most helpful in aligning and coordinating 
patient services in other parts of the Midwest (particularly in other 
Veterans Integrated Service Networks--VISNs). These early meetings have 
also fostered shared use of training resources, enhanced rapport and 
identified system unique (VA and Navy Military Treatment Facility) 
processes that must be reviewed and reconciled during the move towards 
the integration.
    At Naval Hospital Great Lakes, there are presently three personnel 
working in case management roles (two are registered nurses and one is 
a licensed clinical social worker). They anticipate that by October 
2008, they will have two more case managers on board. Case management 
at Naval Hospital Great Lakes is available not only to returning 
warriors, but also to their families. Naval Hospital Great Lakes 
indicated that there should be no challenges with program expansion if 
the anticipated positions are acquired as planned.
                      increasing demand for nurses
    Question. Can you speak to the increasing demand for nurses in your 
branch as a result of the ongoing war in Iraq?
    Answer. The Navy Nurse Corps Psychiatric mental health nursing 
community estimates it will need six additional Psychiatric Mental 
Health Nurse Practitioners to meet the expected demands of Marine Corps 
Operational Stress Control and Readiness (OSCAR) teams, but is allowing 
for up to 18 nurses in this specialty to facilitate rotations. This 
growth is being built into our future out service training program 
plan.
    We anticipate a requirement for at least 24 critical care nurses 
(with likely ``plus-up'' to 36 critical care nurses) based on 
modifications in USMC growth calculations. These assets will reside in 
the ICUs of our Military Treatment Facilities during non-deployed phase 
of rotation cycles. The Registered Nurse Incentive Specialty Pay 
program will help fortify the inventory of critical care nurses and 
perhaps actually draw some nurses from our communities of Medical/
Surgical or General Nursing to Critical Care. Our ER/Trauma inventory 
is presently manned at 109 percent, and this specialty group may also 
avail support to the growing critical care need.
                         mous with universities
    Question. In your written testimony, you discuss the Memorandums of 
Understanding that the Navy Nurse Corps has with neighboring 
universities. You talk about the role of nurses as clinical preceptors, 
guest lecturers, and the importance of naval medical centers serving as 
sites for clinical rotations. Can you discuss the benefits that the 
Navy Nurse Corps Officers receive from these MOUs?
    Answer. Teaching has long been a role associated with Navy Nursing. 
We teach our patients, hospital corpsmen, novice nurses in our Corps, 
and at times even young interns. Navy nurses serving as faculty, guest 
lecturers and preceptors for local nursing students via our MOUs reap 
countless, albeit non-tangible rewards. They have the opportunity to 
engage with civilian students and faculty, provide a wealth of clinical 
and operational experiences to nurses who perhaps have never been 
exposed to nursing in a wartime environment and serve as ambassadors of 
the United States Navy. Our young nurses are not too far removed from 
the days in which they too were going through clinical rotations, thus 
they are often readily ``identified with and looked up too'' by 
students.
    Likewise, our nurses are encouraged and mentored by the faculty 
from these schools of nursing we partner with. The faculty challenges 
them to pursue advanced education and research opportunities as they 
recognize the scope of their clinical experience in the military 
greatly supersedes that of their civilian colleagues.
                                  rotc
    Question. One of the major recruitment strategies for the Navy and 
other Military Nurse Corps is the Reserve Officers' Training Corps or 
ROTC. In recent years, how effective has this program been in 
recruiting as well as preparing nurses for a career in the Navy Nurse 
Corps? How well does this program, or other recruitment programs, 
recruit underrepresented populations to the Navy?
    Answer. Board review of eligible applicants for NROTC scholarships 
are held throughout the year. Each application is thoroughly reviewed 
and presented to the board members. In fiscal year 2008 Commander, Navy 
Recruiting Command (CNRC) was tasked with providing 220 applications 
for the NROTC Nurse Corps option and attained 250 applications. Of 
these, 126 were selected and offered a scholarship, equaling a 50 
percent selection rate. In fiscal year 2007 the application goal was 
220 and 264 applications were attained. Of these, 123 were selected and 
offered a scholarship, equaling a 46 percent selection rate. The show 
rate at the schools that year was 75 students (61 percent of those 
selected).
    The NROTC Program has been very effective in attracting applicants 
for the Nurse Corps. We have a production goal of 60 Nurse Corps 
officers yearly and with that in mind we select approximately 120-125 
applicants each year to meet this goal. Successful preparation for 
applicants is assured through a strong nursing program at affiliated 
schools. The programs prepare the Midshipman or Officer Candidate to be 
successful when taking the National Council Licensure Examination--
Registered Nurse (NCLEX-RN). Our pass rate is very high for our nursing 
graduates, until we achieve nearly all of our production goals.
    The NROTC Nurse Corps option does a good job in attracting 
underrepresented populations. The CNO benchmark for diversity is that 
36 percent of the Officer corps in 2037 should be diverse. Applicants 
for the Nurse Corps option for the 2007-2008 program year were 41 
percent diverse. As a comparison, applicants to the four-year NROTC 
program were 28 percent diverse in 2007-2008. The current board year 
(fiscal year 2008) data indicates that 50 percent of the diversity 
nursing applicants were selected for NROTC nursing scholarship offers. 
We have also placed two Candidate Guidance Officers at the Naval 
Service Training Command, Pensacola, Florida, for the express purpose 
of reviewing and assisting diversity applicants with successful 
application completion and selection for NROTC scholarships.
    The Nurse Corps option of the NROTC Program is sought after by 
applicants, selects and enrolls diverse students, and produces 
outstanding officers to the Navy's Nurse Corps.
                            nursing shortage
    Question. The United States is currently facing one of the most 
severe nursing shortages in its history. While nursing schools have 
been making a concerted effort to increase enrollments to meet current 
and projected demand, 40,285 qualified applicants were turned away in 
2007 according to the American Association of Colleges of Nursing. The 
top reason cited was a lack of qualified nurse faculty.
    The legislation I introduced earlier this year, The Troops to Nurse 
Teachers Act of 2008 (S. 2705), creates several avenues by which 
military nurses can become nurse educators. The subsequent increase in 
the number of nurse faculty would allow schools of nursing to expand 
enrollments and alleviate the ongoing nursing shortage in both the 
civilian and military sectors. Considering the military has a 
significantly higher percentage of Masters and Doctorally prepared 
nurses than in the civilian population--ideal for vacant faculty 
positions--how does the Navy view this program as part of a successful 
strategy to address the military nurse shortage?
    Answer. While retired military nurses as faculty could help assuage 
the nursing faculty shortage, the impact of military nurse recruiting 
is difficult to predict. One might hypothesize that by virtue of having 
a former military nurse as an instructor, the students would be more 
receptive to military careers.
    The most appealing provision of the Troops to Nurse Teachers 
program is the ``off ramp'' that would give nurse corps officers an 
opportunity to teach for two to three years. As a retention tool, it 
would accrue obligated service back into the Medical Department with 
the hope that they would continue a 20 year or longer career. It would 
essentially provide another way to retain nurses who might otherwise be 
disinclined to remain on active duty.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
                            stress on nurses
    Question. Military nurses are more stressed than they have been in 
40 years, with multiple deployments, heavy loads of wounded soldiers, 
and time away from their own families and communities? What are you 
doing to monitor the stress on our nurses? What service are we 
providing them to help deal with that stress? How many additional 
nurses do you need to recruit to ensure we can meet our commitment to 
our wounded soldiers? What is your plan to meet the growing need? What 
are the major obstacles?
    Answer. At the National Naval Medical Center, our psychiatric 
mental health nurses and others individuals with mental health nursing 
experience make rounds of the nursing staff and pulse for indications 
of increased stress. They then provide to the identified staff, 
education on ``Care for the Caregiver.'' They are available to help 
with challenging patient care scenarios (increased patient acuity, 
intense patient/family grief, and staff grief) and offer themselves as 
attentive, non-judgmental listeners through whom the nurses may vent.
    In addition to the classes on ``Compassion Fatigue'' offered by 
command chaplains to our nurses and hospital corpsmen, some commands 
host provider support groups where health professionals meet and 
discuss particularly emotional or challenging patient cases in which 
they are or have been involved. Aboard the USNS Comfort, Psychiatric 
Mental Health Nurses and Technicians were located at the deckplate in 
the Medical Intensive Care Unit, Ward and Sick Call to help nurses that 
might not report to sick call with their complaints of stress.
    In many of the most stressful deployed locations, our senior nurses 
are acutely attuned to the psychological and physical well-being of the 
junior nurses in their charge. They ensure that staffing is sufficient 
to facilitate rotations through high stress environments. Nurses are 
encouraged to utilize available resources such as chaplains and 
psychologists for guidance and support in their deployed roles and 
responsibilities.
    Our deploying nurses have been asked to hold positions requiring 
new skill sets often in a joint or Tri-Service operational setting. As 
individual augmentees, they deploy without the familiarity of their 
Navy unit, which oftentimes may pose greater stress and create special 
challenges. Our nurses who fulfill these missions require special 
attention throughout the course and completion of these unique 
deployments. I have asked our nurses to reach out to their colleagues 
and pay special attention to their homecomings and re-entries to their 
parent commands and they have done exactly that.
    At U.S. Naval Hospital Okinawa, nurses ensure that deploying staff 
members and their families are sponsored and assisted as needed 
throughout the member's deployment. A grassroots organization, 
Operation Welcome Home, was founded by a Navy Nurse in March 2006 with 
the goal that all members returning from deployment in theater receive 
a ``Hero's Welcome Home''. To date over 5,000 Sailors, Soldiers, Airmen 
and Marines have been greeted at Baltimore Washington International 
Airport (BWI) by enthusiastic crowds who indeed care for them as 
caregivers.
    The Navy Nurse Corps Psychiatric mental health nursing community 
estimates it will need six additional Psychiatric Mental Health Nurse 
Practitioners to meet the expected demands of Marine Corps Operational 
Stress Control and Readiness (OSCAR) teams, but is allowing for up to 
18 nurses in this specialty to facilitate rotations. This growth is 
being built into our future out service training program plan.
    We also anticipate a requirement for at least 24 critical care 
nurses (with likely ``plus-up'' to 36 critical care nurses) based on 
modifications in USMC growth calculations. These assets will be 
maintained in the ICUs of our Military Treatment Facilities during non-
deployed phase of rotation cycles. Our ER/Trauma inventory is presently 
manned at 109 percent, and this specialty group may also avail support 
to the growing critical care need.
                                 ______
                                 
               Question Submitted by Senator Ted Stevens
               navy nurse corps support to army and usmc
    Question. I am told that the Navy has stepped in to take on 
additional missions to support the Army and Marine Corps in theater. 
What ways have the Navy Nurse Corps stepped up to support our deployed 
service members.
    Answer. Navy nurses continue to support joint missions at 
Expeditionary Medical Facilities (EMFs) in Kuwait and Djibouti, 
Landstuhl Regional Medical Center and with deployed units in 
Afghanistan and Iraq.
    At EMF Kuwait, our nurses provided care for 3,564 casualties 
(received and treated over six month period from July-December 2007). 
They additionally coordinated and supported immunizations for Japanese, 
British and Korean troops and a Kuwait-staged mass-casualty/interagency 
drill and Advanced Cardiac Life Support programs with the American 
Embassy in Kuwait. In addition to EMF Kuwait, Navy nurses serve on a 35 
member team at EMF Djibouti, providing medical services to more than 
1,800 personnel assigned to Combined Joint Task Force-Horn of Africa 
and care for an average of 315 patients any given week.
    At Landstuhl Regional Medical Center, 98 Navy Reserve Component 
nurses work alongside their colleagues from the Army and Air Force. 
During the past two years, Navy nurses from this contingent have also 
worked in the warrior management center and made great strides in the 
provision of optimal care to the wounded as they transit on flights 
from Landstuhl Regional Medical Center to military treatment facilities 
in the Continental United States.
    The preparation of our forward deployed nurses is accomplished with 
the support of the Navy Individual Augmentee Combat Training (NIACT). 
Prior to deploying, personnel are sent to NIACT at Fort Jackson, South 
Carolina, where the training consists of combat, survival, convoy, 
weapons handling and firing, and land navigation.
    The Navy Nurse Corps Psychiatric mental health nursing community 
requires six additional Psychiatric Mental Health Nurse Practitioners 
to meet the Operational Stress Control and Readiness team, but is 
allowing for up to 18 nurses in this specialty to facilitate rotations. 
This growth is being built into our future out service training program 
plan.
    We anticipate a requirement for at least 24 critical care nurses 
(with likely ``plus-up'' to 36 critical care nurses) based on 
modifications in USMC growth calculations. These assets will be 
maintained in the ICUs of our Military Treatment Facilities during non-
deployed phase of rotation cycles. The Registered Nurse Incentive 
Specialty Pay program will help fortify the inventory of critical care 
nurses and perhaps actually draw some nurses from our communities of 
Medical/Surgical or General Nursing to Critical Care. Our ER/Trauma 
inventory is presently manned at 109 percent, and this specialty group 
may also avail support to the growing critical care need.
    Navy nurses at U.S. Naval Hospital Okinawa ensure that deploying 
staff members and their families are sponsored and assisted as needed 
throughout the member's deployment. A grassroots organization, 
Operation Welcome Home, was founded by a Navy Nurse in March 2006 with 
the goal that all members returning from deployment in theater receive 
a ``Hero's Welcome Home''. To date over 5,000 Sailors, Soldiers, Airmen 
and Marines have been greeted at Baltimore Washington International 
Airport (BWI) by enthusiastic crowds who indeed care for them as 
caregivers.
                                 ______
                                 
          Questions Submitted to Vice Admiral Adam M. Robinson
            Questions Submitted by Senator Daniel K. Inouye
                          safe harbor program
    Question. Admiral Robinson, the Navy operates the Safe Harbor 
program to provide case management for injured sailors and marine. Are 
there lessons learned from the Army WTUs that should be incorporated in 
the Navy and vice versa for the Army?
    Answer. The Department of the Navy operates two programs, Navy Safe 
Harbor for wounded, injured and ill Sailors, and the Marine Corps 
Wounded Warrior Regiment to care for wounded, injured and ill Marines. 
The Bureau of Medicine & Surgery provides medical case management for 
all members of the Department of the Navy but relies on Safe Harbor and 
the Wounded Warrior Regiment to provide effective and timely non-
clinical case management for its members. These two tightly aligned 
programs also work very closely with the Army's Warrior Transition Unit 
(WTU)/Army Wounded Warrior (AW2) programs, as well as the Air Force 
Wounded Warrior program. Through numerous venues, the Services 
collaborate on new initiatives and institutionalizing best practices, 
including: Wounded, Injured and Ill Senior Oversight Committee Lines of 
Action Working Groups; Quarterly Wounded Warrior Program Commanders 
meetings; Working Group meetings on the fiscal year 2008 National 
Defense Authorization Act; and Joint/Interagency Federal Recovery 
Coordinator Training Sessions.
    While the focus of these forums are primarily non-medical case 
management issues there is an inextricable link between the medical and 
non-medical needs of a recovering service member and their family. 
Although the delivery mechanisms and organizations providing service 
and support are different among the services the commonality across the 
DOD enterprise is to ensure the most consistent level of high quality 
of care and assistance to those recovering.
                        recruiting and retention
    Question. Admiral Robinson, what are your top constraints to 
recruiting and retaining the appropriate levels and quality of military 
medical personnel? Is legislative or financial relief being sought to 
address these concerns?
    Answer. The top constraint to Medical Recruiting is, generally, 
medical professionals do not consider military service as a first 
option for employment. Civilian salaries are more lucrative than 
military pay and continue to outpace the offer of financial incentives 
(bonuses and loan repayment) to our target market. We are also limited 
by the size of the pool of Medical and Dental School graduates. Over 
the last ten years the percentage of females in Medical school has 
increased. Females tend to have a lower propensity to join the 
military. Other challenges include concerns over excessive deployments 
and mobilizations, both of which impact on Navy's ability to meet 
Reserve Medical Officer Recruiting goals. Some Medical Professionals 
fear the potential loss of their private practices.
    Navy Recruiting continually evaluates areas where we need help 
meeting recruiting requirements for health professionals, and as we 
identify new tools and incentives, we would request new legislative 
and/or financial relief.
    All services work with Assistant of Secretary of Defense (Health 
Affairs) to develop compensation levels for all Health Service 
professionals in the military.
    The medical communities work within the Navy's budgetary process to 
address financial issues related to compensation.
    Navy has implemented significant increases in retention bonuses 
across all Medical and Dental specialties in recent years.
    The top constraint for retention for medical department officers is 
pay disparity between military compensation and civilian compensation. 
Military compensation, especially for the certain specialties, lags 
their civilian counterparts.
    Recently enacted legislation in NDAA fiscal year 2008 consolidating 
the special and incentive pays of the health care field will provide 
the Navy flexibility for special and incentive pays.
    The Medical and Dental Corps was approved for a Critical Skills 
Retention Bonus (CSRB) in February 2007, and received an increase to 
their special pays in October 2007.
    The Medical Service Corps enacted CSRB in September 2007 for 
clinical psychologists at the first retention decision point.
    Several Nurse Corps undermanned specialties were recently granted 
an incentive special pay to boost retention. This is the first time the 
Nurse Corps received a special pay to increase retention in undermanned 
specialties.
    For non-monetary issues, the Navy has a Task Force looking at 
qualitative retention initiatives (i.e., sabbatical, telecommuting and 
increasing child care availability).
                            specialist pool
    Question. Admiral Robinson, all three Services are having 
difficulty recruiting and retaining in medical fields such as 
psychology and psychiatry because you are competing for the same 
individuals in many instances and because there is a national shortage 
in these specialties. Is there anything that the military can do to 
increase these pools of specialists?
    Answer. To improve recruiting success, the Navy can either improve 
our penetration into the existing pool of specialists or try to 
increase the pool. We can improve our penetration by offering accession 
bonuses to attract existing mental health providers, and we can 
increase the pool of specialists by offering scholarships, internships, 
fellowships or collegiate programs as an incentive for new students to 
enter these fields with a military commitment. Furthermore, section 604 
of the 2009 National Defense Authorization Request contains a provision 
for an accession bonus for fully trained clinical psychologists.
    The Navy has developed the following initiatives to increase the 
number of mental health specialists.
  --The Navy has recently developed a Post-doctoral Clinical Psychology 
        One Year Fellowship program to reduce the inventory deficit by 
        tapping the demand for post-doctoral training in the civilian 
        community. This program provides the opportunity to obtain 
        supervised training hours, and become licensed within their 
        first year of active duty. The Navy has also increased the 
        number of clinical psychology internship seats for 2009, and is 
        in the process of further expanding the clinical psychology 
        internship program at Naval Medical Center, Portsmouth VA.
  --The Navy recently implemented a Critical Skills Retention Bonus for 
        Clinical Psychologists. The incentive is $60,000 ($15,000/year) 
        for 4-year contract at MSR. Clinical Psychology Officers with 
        3-8 years of commissioned service are eligible.
  --The Navy has recently established a Critical Wartime Skills 
        Accession Bonus for accessing fully trained Psychiatrists, and 
        has increased the number of psychiatry residency seats for 
        training new Psychiatrists.
  --In order to retain Psychiatrists on active duty the Navy increased 
        the 4 year Psychiatry Multi-Year Special Pay (MSP) from 
        $17,000/year in fiscal year 2006 to $25,000/year in fiscal year 
        2007 and increased it again to $33,000 in fiscal year 2008. 
        There is discussion at DOD Health Affairs to increase this 
        retention bonus again in fiscal year 2009.
  --The Navy has also initiated a Nurse Corps graduate program at the 
        Uniformed Services University of the Health Sciences (USUHS) to 
        educate psychiatric/mental health nurse practitioners to 
        support mental health requirements.
                                  hpsp
    Question. Admiral Robinson, I have been made aware that the Navy 
has had difficulty utilizing the HPSP as a recruiting vehicle. If this 
program doesn't work for the Navy, what will?
    Answer. In fiscal year 2008, Navy funded a $20,000 accession bonus 
for Health Professions Scholarship Program (HPSP) participants in 
addition to the scholarship and stipend. Additionally, DOD increased 
the HPSP monthly stipend amount significantly from $1,349 to $1,605. 
The stipend will increase again effective July 1, 2008 to $1,907. 
Together, with a renewed focus on medical recruiting, these monetary 
incentives have positively impacted interest in the HPSP program. To 
date, in fiscal year 2008, we recruited 38 percent of our annual goal 
compared to 27 percent at this point last year. Also, an increase of 
tuition for Dental School has helped in recruiting of HPSP. 
Additionally, in fiscal year 2008 and fiscal year 2009 we are offering 
the Health Services Collegiate Program (HSCP) for the Medical Corps for 
the first time. We will evaluate the impact of this new program and 
determine if we should continue it in fiscal year 2010 and beyond.
    We will continue to evaluate areas where we can improve this 
program or identify other programs to meet our recruiting requirements 
for health professionals.
                    military to civilian conversions
    Question. Admiral Robinson, Navy medicine has been hardest hit by 
the military to civilian conversions. I understand that the 
Department's guidance is still under review and the Navy had planned 
additional conversions in fiscal year 2009. What are your anticipated 
personnel and financial shortfalls in fiscal year 2009?
    Answer. Navy Medicine is not planning to convert additional billets 
in fiscal year 2009, as per section 721 of the fiscal year 2008 
National Defense Authorization Act which prohibits the conversion of 
military medical and dental positions to civilian positions. Under this 
section there are 4,216 military medical positions that will be 
restored during the period 2010 to 2015. The Navy's projected fiscal 
year 2009 Mil-Civ plan, which is dependant on our access to military 
personnel funds, calls for 282 restorations (200 enlisted, 42 
physicians and 40 nurses) at a cost of approximately $26.75 million. 
The Navy's recruiting accession plans have been modified to accommodate 
these increases.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
                      integrated health care teams
    Question. The Dole/Shalala Report recommends DOD and VA develop 
integrated care teams with physicians, nurses, health professionals, 
social workers, and vocational rehabilitation professionals. What is 
the Navy doing to implement this recommendation? Are we asking our 
medical personnel to do the job of social workers? To the extent that 
medical personnel are assigned in case manager or social worker, what 
training do they receive to do this?
    Answer. Per Navy Medicine's policy, the multi-disciplinary teams 
meet each week for inpatients and every other week for outpatients to 
discuss the care and coordination services for all severely injured or 
ill service members. The multi-disciplinary team consists of 
physicians, nurses, discharge planners/social workers, clinical and 
non-clinical case managers, therapists, chaplains, VA representatives 
to include Federal Recovery Coordinators, medical board and wounded 
warrior program personnel.
    The role of the social worker may overlap with other members of the 
health care team, for the identification of needs and referrals to 
appropriate resources; this process is multidisciplinary. Clinical case 
managers may be either nurses or social workers. Each individual must 
have 2-3 years of experience in the related field. Certification in 
case management is expected within 3 years of hire. Each individual 
receives orientation and training on case management at that facility 
before engaging with a patient. Training opportunities via 
teleconferencing are also provided on a biweekly basis. Non-clinical 
case managers are involved in the planning, formulation, 
administration, evaluation, consultation and coordination of actions 
and services dealing with the continued care and support of wounded, 
ill and injured Sailors and their families. They are trained and have 
significant experience in assisting injured Sailors and family members 
in understanding and dealing with current life events through 
information and referral, as well as, guiding them through the maze of 
bureaucracy during a time of stress and transition.
                      families of wounded warriors
    Question. The Dole/Shalala report recommended enhancing care for 
the families of wounded soldiers throughout the soldier's recovery 
process. It noted that family members are vital parts of the patient's 
recovery team. What has the Navy done to enhance care for family 
members of wounded service members in its care? Who on a service 
member's care team is primarily responsible for helping families? What 
training have they received? What has DOD done to leverage the help the 
private sector can provide?
    Answer. Navy military treatment facilities (MTF) use social 
workers, health benefit advisors (HBA) and administrative support 
personnel to provide assistance and answer questions to all 
beneficiaries, particularly families, about healthcare benefits and 
medical support services available as a TRICARE benefit or in the 
civilian sector. Multidisciplinary teams consisting of medical 
providers, nurses, clinical case managers, non-clinical case managers 
from the Navy's Safe Harbor Program and the USMC's Wounded Warrior 
Regiment, ancillary service personnel, pastoral care personnel, social 
workers and patient administration officers assist family members of 
wounded, ill and injured service members in understanding treatment 
regimens, administering after-care requirements and providing 
appropriate/timely disability evaluation counseling throughout the 
continuum of care. Management and coordination of the service member's 
care is a ``team'' effort which includes the treating provider, MTF 
support personnel (i.e. social workers, patient administration) and the 
family. Clinical and non-clinical case managers and social workers are 
responsible for helping families. DOD and Navy Medicine is committed to 
providing resources and programs for families of all wounded, ill and 
injured services members. There are a number of family support programs 
that are successfully contributing to the well-being of the family.
    Navy's Fleet and Family Centers provides comprehensive, 24/7 
information and referral services to family members through the 
Military One Source links and center support programs.
    Navy Safe Harbor Program provides proactive non-clinical case 
management to Sailors and their families in dealing with personal 
challenges from the time of injury through transition from the Navy and 
beyond. The Navy's commitment is to provide wounded, ill, and injured 
Sailors personalized non-medical support and assistance and guide them 
through the existing support structure. This is accomplished through 
addressing the non-medical needs and reinforcing the message that they, 
our heroes, deserve the very best attention and care of a grateful 
nation.
    The Ombudsman Program promotes healthy and self-reliant families. 
The Ombudsman serves as a critical information link between command 
leadership and Navy families. They are trained to disseminate 
information both up and down the chain of command, including official 
Department of the Navy and command information, command climate issues 
and local quality of life (QOL) improvement opportunities. The 
Ombudsman provides the family a command level advocate to ensure the 
family understands and is engaged in determining best course of medical 
care and recovery for the service member.
    The Navy Morale, Welfare and Recreation (MWR) administers a varied 
program of recreation, social and community support activities on U.S. 
Navy facilities worldwide. Their mission is to provide quality support 
and recreational services that contribute to retention, readiness and 
mental, physical and emotional well-being of Sailors and their family 
members. Many of these programs provide recreational relief for family 
member responsible for the long-term rehabilitation and recovery of 
wounded, ill and injured service members.
    Naval Service Family Line is a volunteer, non-profit organization 
dedicated to improving the quality of life for every Sea Service 
family. This is achieved by answering questions form spouses about the 
military lifestyle, referring spouses to organizations which may be 
able to assist them, publishing and distributing free booklets and 
brochures which contain very helpful information, and developing 
successful educational programs for the Sea Service spouse.
    Marine Corps Community Services (MCCS) exists to serve Marines and 
their families wherever they are stationed. MCCS programs and services 
provide for basic life needs, such as food and clothing, social and 
recreational needs and even prevention and intervention programs to 
combat societal ills that inhibit positive development and growth.
    Wounded Warrior Regiment currently has Patient Affairs Teams (PATs) 
located at strategic Medical Treatment Facilities to assist and support 
families of wounded, injured, and ill Marines and Sailors with any 
requirements they may have. These teams are located at the following 
sites: Landstuhl Regional Medical Center, Germany; National Naval 
Medical Center, Bethesda, MD; Walter Reed Army Medical Center, 
Washington, DC; Portsmouth Naval Hospital, Portsmouth, VA; Richmond VA 
Polytrauma Center, Richmond, VA; Tampa VA Polytrauma Center, Tampa, FL; 
Minneapolis VA Polytrauma Center, Minneapolis, MN; Camp Lejeune Naval 
Hospital, Camp Lejeune, NC; Brooke Army Medical Center, San Antonio, 
TX; Balboa Naval Hospital, San Diego, CA; Camp Pendleton Naval 
Hospital, Camp Pendleton, CA; Naval Hospital Twenty-nine Palms, Twenty-
nine Palms, CA; Tripler Army Medical Center, Honolulu, HI; and Palo 
Alto VA Polytrauma Center, Palo Alto, CA.
    These PATs assist family members with numerous administrative and 
logistic issues such as: lodging, travel arrangements, in-and-around 
travel, Invitational Travel Orders, Bed-side Orders, charitable 
organizations support, travel advances, travel claims, service 
intermediaries with hospitals, benefits assistance, Department of 
Veterans Affairs liaison, Social Security Administration Claims 
processing, and any other requirements they may have.
    Military One Source provides both a web site and toll-free number 
for service members and their families to locate information and 
resources dealing with deployment planning, family support resources 
and referral to private sector agencies supporting the military family.
                      comprehensive recovery plan
    Question. Dole/Shalala recommends that every wounded soldier or 
Marine receive a comprehensive recovery plan to coordinate recovery of 
the whole soldier, including all Medical care and Rehabilitation, 
Education and Employment Training, and Disability Benefits Managed by a 
single highly-skilled recovery coordinator so no one gets ``lost in the 
system.''
    Do all patients get a comprehensive recovery plan?
    Answer. The Senior Oversight Committee, Co-Chaired by Deputy 
Secretary of Defense (DEPSECDEF) and Deputy Secretary of the Veterans 
Administration (DEPSECVA), Line of Action (LOA) #3 (Case Management), 
is currently working to address Recovery Care Coordinator functions, 
responsibilities, workload, and resources. DON Representatives from 
Navy Safe Harbor, Marine Corps Wounded Warrior Regiment and Navy 
Medicine are actively engaged in this LOA 3 effort. LOA #3 is 
identifying Recovering Service Members based on a tiered approach by 
acuity of wound, illness, or injury and psychosocial needs that would 
benefit from a comprehensive recovery plan.
    Question. What steps have you taken to train and hire skilled 
recovery coordinators?
    Answer. LOA #3 is working towards a unified training solution with 
standardized curriculum modules for all services, allowing for some 
service unique required training.
    Question. Do service members in the Navy's care have the single 
coordinator to provide continuity?
    Answer. The identification of a recovery care coordinator who will 
oversee the completion of a comprehensive recovery plan as recommended 
by Dole/Shalala, will be a further enhancement to the Navy's already 
robust care management program. The Navy's comprehensive casualty care 
program provides support and assistance to all wounded, ill and injured 
Sailors and their family members throughout their phases of recovery to 
reintegration or to transition from the service.
    Question. What training do recovery coordinators receive?
    Answer. Standardized training is currently under development.
    Question. Are they trained as soldiers, or as case managers?
    Answer. Training will focus on non-medical case/care management 
with modules on how to access medical support if presented with 
clinical issues.
                                 ______
                                 
               Questions Submitted by Senator Ted Stevens
                         support to usmc growth
    Question. The Marines are growing an additional 27,000 personnel in 
end strength, while the Navy has planned a reduction in forces. What 
steps are you taking to try and meet the need of a larger Marine Corps 
ground force for deployments while maintaining the right size force in 
the Navy?
    Answer. President's Budget 2008 included a top line funding and 922 
end strength increase for Navy in support of the USMC's growth of 
27,000 personnel. The Navy increase includes approximately 800 discrete 
billets, with the remainder comprised of student training billets. Out 
of the 800 specific billets, the majority are Hospital Corpsmen and 
medical officers. The billet requirements were provided by USMC Total 
Force Structure Division, Deputy Commandant for Combat Development and 
Integration.
    In addition to the manpower funding, Navy was also allocated a 
funding increase for general skills and flight training.
    Sailors and Naval Officers are being assigned to the new billets in 
a phased manner in parallel with the ramp up of the USMC growth. The 
assignment of the first several hundred personnel is underway, and Navy 
foresees no obstacles in filling the remaining billets.
                        wrnmmc bethesda deadline
    Question. The Navy has announced an award for the design-build of 
the new Walter Reed National Military Medical Center at Bethesda. Do 
you believe this project is still on track to be completed by the BRAC 
deadline of 2011?
    Answer. Barring any unforeseen site conditions or major design 
changes, the Navy believes that the schedule for this project is on 
track to meet the BRAC 2005 deadline of September 2011.
                       wrnmmc deadline challenges
    Question. What challenges still need to be addressed in completing 
the build out of this facility by the BRAC deadline?
    Answer. Challenges can arise from several areas including the 
timely receipt of funding, completion of traffic flow improvements, 
equipment installation, unforeseen conditions found during building 
renovation work and unknowns encountered in the field such as lead, 
mercury, and asbestos. The coordination of several contractors 
concurrently working on site and the movement of staff from Walter Reed 
to Bethesda will also be challenging. All these challenges must be 
successfully managed in order to meet the deadline of September 2011.
                           wrnmmc realignment
    Question. Are there Service specific concerns or issues with 
regards to this realignment that you are working through with your Army 
counterpart? What are they?
    Answer. There are issues of governance and operational efficiencies 
that are presently being worked by Navy and Army for the new Walter 
Reed National Military Medical Center. I am diligently working with the 
Commander, Joint Task Force National Capital Region Medical and the 
Surgeon General of the Army to ensure that the planning, construction 
and future governance of the state of the art military medical center 
in the National Capital Region fully complies with the BRAC 
requirements, best serves our warriors and military beneficiaries and 
is an icon for world class medical care when completed in 2011.
               military to civilian conversion standstill
    Question. I understand that all medical military to civilian 
conversions are at a standstill as directed by the fiscal year 2008 
Defense Authorization Act that was signed into law this past January. 
Can you tell us how this will impact care in the Medical Treatment 
Facilities? Do you have a plan in place to fill the slots that were 
originally supposed to be converted?
    Answer. There will be some shortfalls in staffing for the next 
several years. However, the reversal of the military to civilian 
conversions is not the sole reason for the shortfalls. Certain health 
professional specialties are very difficult to access and retain for 
both military and civilian positions.
    Depending on our access to military personnel funds, the Navy is 
planning to restore 282 military billets in fiscal year 2009, with the 
remaining military positions being bought back between fiscal year 2010 
and fiscal year 2015. The plan is to use contract personnel and term 
government service employees to alleviate this gaps caused by the time 
lag until the military endstrength can be completely restored and 
filled.
    military to civilian conversion--benefits of military personnel
    Question. What are the benefits to having military personnel in 
these medical professions?
    Answer. More medical professionals in uniform increases Navy 
medicine's ability to surge when necessary during extended conflicts. 
The increased uniform medical personnel reduces the stress on the force 
during high-tempo periods of operations thus causing a trickle down 
effect increasing retention and allowing a healthy operational rotation 
of medical professionals.
                military to civilian reversal challenges
    Question. Despite funding challenges, what other challenges do you 
foresee in the coming year with regards to a reversal of Military to 
Civilian conversions?
    Answer. The recruiting and retention of medical professionals will 
be increasingly difficult for the foreseeable future. There is a 
growing national shortage of medical professionals in the United States 
and there will be an increased competition to recruit health care 
professionals in both the military and civilian sector. The military's 
best strategy to recruit and retain medical specialists is to grow our 
own specialists through strong graduate and resident education programs 
coupled with competitive incentive packages after training obligations 
have expired.
                                 ______
                                 
           Questions Submitted by Senator Christopher S. Bond
                     behavioral health care assets
    Question. Army and Navy Surgeon General Question. What are you 
doing to alleviate the shortage?
    Answer. Currently the Services have numerous incentives to attract 
and retain behavioral health specialists. Some have been recently 
enacted from the fiscal years 2007 and 2008 NDAA and we are monitoring 
the effects on recruiting and retention.
Psychiatry (Medical Corps)
    Eligible for the following entitlements: Variable Special Pay, 
Additional Special Pay, and Board Certified Pay.
    Eligible for the following discretionary special pays: Incentive 
Special Pay (ISP) $15,000/year and Multiyear Special Pay (MSP) 2 year--
$17,000/year, 3 year--$25,000/year, and 4 year--$33,000/year. The 4 
year MSP for Psychiatrist has increased from $17,000/year in fiscal 
year 2006 to $25,000/year in fiscal year 2007 to $33,000 in fiscal year 
2008. The Health Professional Incentive Work Groups (HPIWG), a tri-
service work group run by DOD Health Affairs, is contemplating another 
increase in fiscal year 2009.
    The NDAA 2008 allows up to $400,000 Critical Wartime Skills 
Accession Bonus (CWSAB) for board certified direct accessions. DOD/HA 
has authorized $175,000 accession bonus for psychiatrists who accept a 
4 year commitment. The HPIWG will be increasing the CWASB amounts in 
fiscal year 2009.
    Psychiatrists are eligible for the Health Profession Loan Repayment 
Program (HPLRP) if they meet eligibility requirements. HPLRP can be 
used as an accession incentive and as a retention incentive. This 
program provides up to $38,300 per year to repay qualified school 
loans. HPLRP obligation runs consecutively with other obligations.
Clinical Psychologists (Medical Service Corps)
    The Navy recently implemented a Critical Skills Retention Bonus for 
Clinical Psychologists. The incentive pays $60,000 ($15,000/year) for 
4-year contract at MSR. Clinical Psychology Officers with 3-8 years of 
commissioned service are eligible.
    Psychologists are eligible for the Health Profession Loan Repayment 
Program (HPLRP) if they meet eligibility requirements. HPLRP can be 
used as an accession incentive and as a retention incentive. This 
program provides up to $38,300 per year to repay qualified school 
loans. HPLRP obligation runs consecutively with other obligations.
    Clinical Psychologists are eligible for Board Certified Pay.
    The HPIWG is currently working on implementing an accession bonus 
and retention bonus for Clinical Psychologists in fiscal year 2009 
using the new consolidated medical special pay authority in NDAA 2008.
Social Workers
    Social Workers are also eligible for Health Professionals Loan 
Repayment Program (HPLRP) as an accession and retention tool.
    Social Workers are eligible for Board Certified Pay.
    The HPIWG is currently working on implementing an accession bonus 
and retention bonus for Social Workers in fiscal year 2009 using the 
new consolidated medical special pay authority in NDAA 2008.
Mental Health Nurse Practitioners
    Nurse Corps recently recognized Registered Nurse Mental Health 
Nurse Practitioners with subspecialty code.
    Once approved by Assistant Secretary of Health Affairs Mental 
Health Nurse Practitioners will be eligible for board certified pay.
    Mental Health Nurse Practitioners are eligible for the Health 
Profession Loan Repayment Program (HPLRP) if they meet eligibility 
requirements. HPLRP can be used as an accession incentive and as a 
retention incentive. This program provides up to $38,300 per year to 
repay qualified school loans. HPLRP obligation runs consecutively with 
other obligations.
    Fully qualified Mental Health Nurse Practitioner entering the Navy 
would qualify for the Nurse Accession Bonus (NAB), $20,000 for a 3 year 
commitment or $30,000 for a 4 year commitment. This bonus can be 
combined with the HPLRP as a 3 year NAB accession incentive requiring a 
5 year commitment.
    Starting in fiscal year 09 Mental Health Nurse Practitioners will 
be eligible for the Registered Nurse Incentive special Pay. This is a 
multi-year special pay up to $20,000 per year for a 4 year contract.
                              vet centers
    Question. Thank you. To follow up, I'd ask Army leaders to consider 
a proposal to allow active duty forces to access the behavioral health 
care resources available at the nation's Vet Centers. These facilities 
provide care for PTSD and are manned by veterans and specialists 
familiar with the needs of veterans and our active duty forces. It 
seems a tremendous waste in resources to limit eligibility to our Vet 
Centers to veterans only if there are soldiers who require care but 
have limited or no assets available to them.
    Would you support legislation that allowed active duty forces 
access to behavioral health resources at the nation's Vet Centers?
    Answer. Yes, Navy Medicine would support legislation for this; 
however, we already have authority to share resources and have some 
agreements in place where mental health services are exchanged, 
primarily the VA providing the mental health services to DOD. Our main 
concern would be whether the VA has the capacity to provide mental 
health services to active duty service members.
    military eye trauma center of excellence and eye trauma registry
    Question. Switching gears, I'd like to talk about the Centers of 
Excellence recently developed by the Department of Defense. Congress, 
in the Wounded Warrior section of the NDAA enacted January 2008, 
included three military centers of excellence, for TBI, PTSD, and Eye 
Trauma Center of Excellence. The two Defense Centers of Excellence for 
TBI and Mental Health PTSD are funded, have a new director and are 
being staffed with 127 positions, and are going to be placed at 
Bethesda with ground breaking in June for new Intrepid building for the 
two centers. I'm sure you are aware that there have been approximately 
1,400 combat eye wounded evacuated from OIF and OEF.
    Does DOD Health Services Command have current funding support and 
adequate staffing planned for the new Military Eye Trauma Center of 
Excellence and Eye Trauma Registry? If not, when can the committee 
expect to be provided specific details on implementation?
    Answer. The Office of the Secretary of Defense (Health Affairs) is 
coordinating the implementation of the Military Eye Trauma Center of 
Excellence.
                   military health system governance
    Question. There has been a lot of discussion in recent years about 
making military medicine more joint. Do you believe changes in the 
governance of the Military Health System are needed to make military 
medicine more effective and efficient?
    Answer. Navy Medicine supports a governance structure where the 
three Surgeon's Generals participate collaboratively. The current 
governance structure allows for services to address issues in a 
``joint-like'' environment thereby ensuring effective and efficient use 
of resources. The structure also recognizes unique service 
requirements, such as health services training to support the future 
agility of the Marine Corps, where there may be no overlapping service 
capability. There is no need to change the governance structure at this 
time, however, Navy Medicine will continue to foster participation in 
Joint requirements and acquisition projects to ensure interoperability 
between services.

                          SUBCOMMITTEE RECESS

    Senator Inouye. And with that, I thank you very much for 
your testimony, and the subcommittee will stand in recess until 
April 23, and at that time, we'll receive testimony on the 
Missile Defense Agency.
    Thank you very much.
    [Whereupon, at 11:48 a.m., Wednesday, April 16, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]
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