[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


                                     

                         [H.A.S.C. No. 111-109]
 
            THE NEW WALTER REED: ARE WE ON THE RIGHT TRACK?

                               __________

                             JOINT HEARING

                               BEFORE THE

                         READINESS SUBCOMMITTEE

                          MEETING JOINTLY WITH

                    MILITARY PERSONNEL SUBCOMMITTEE

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                            DECEMBER 2, 2009

                                     
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13




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                         READINESS SUBCOMMITTEE

                   SOLOMON P. ORTIZ, Texas, Chairman
GENE TAYLOR, Mississippi             J. RANDY FORBES, Virginia
NEIL ABERCROMBIE, Hawaii             ROB BISHOP, Utah
SILVESTRE REYES, Texas               MIKE ROGERS, Alabama
JIM MARSHALL, Georgia                TRENT FRANKS, Arizona
MADELEINE Z. BORDALLO, Guam          BILL SHUSTER, Pennsylvania
HANK JOHNSON, Georgia                K. MICHAEL CONAWAY, Texas
CAROL SHEA-PORTER, New Hampshire     DOUG LAMBORN, Colorado
JOE COURTNEY, Connecticut            ROB WITTMAN, Virginia
DAVID LOEBSACK, Iowa                 MARY FALLIN, Oklahoma
GABRIELLE GIFFORDS, Arizona          JOHN C. FLEMING, Louisiana
GLENN NYE, Virginia                  FRANK A. LoBIONDO, New Jersey
LARRY KISSELL, North Carolina        MICHAEL TURNER, Ohio
MARTIN HEINRICH, New Mexico
FRANK M. KRATOVIL, Jr., Maryland
BOBBY BRIGHT, Alabama
DAN BOREN, Oklahoma
                Dave Sienicki, Professional Staff Member
                Thomas Hawley, Professional Staff Member
                     Megan Putnam, Staff Assistant
                                 ------                                

                    MILITARY PERSONNEL SUBCOMMITTEE

                 SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas                 JOE WILSON, South Carolina
LORETTA SANCHEZ, California          WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam          JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania      THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia                MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire     JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
                 Dave Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member


                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2009

                                                                   Page

Hearing:

Wednesday, December 2, 2009, The New Walter Reed: Are We on the 
  Right Track?...................................................     1

Appendix:

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

                      WEDNESDAY, DECEMBER 2, 2009
            THE NEW WALTER REED: ARE WE ON THE RIGHT TRACK?
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, 
  Chairwoman, Military Personnel Subcommittee....................     2
Ortiz, Hon. Solomon P., a Representative from Texas, Chairman, 
  Readiness Subcommittee.........................................     1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking 
  Member, Military Personnel Subcommittee........................     3

                               WITNESSES

Kizer, Dr. Kenneth W., Chairman, Defense Health Board, National 
  Capital Region Base Realignment and Closure Health Systems 
  Advisory Subcommittee..........................................    10
Mateczun, Vice Adm. John M., USN, Commander, Joint Task Force, 
  National Capital Region Medical................................     8
Middleton, Allen W., Acting Principal Deputy Assistant Secretary 
  of Defense, Health Affairs, U.S. Department of Defense.........     5
Robyn, Dr. Dorothy, Deputy Under Secretary of Defense, 
  Installations and Environment, U.S. Department of Defense......     6

                                APPENDIX

Prepared Statements:

    Davis, Hon. Susan A..........................................    35
    Forbes, Hon. J. Randy, a Representative from Virginia, 
      Ranking Member, Readiness Subcommittee.....................    37
    Kizer, Dr. Kenneth W.........................................    63
    Mateczun, Vice Adm. John M...................................    58
    Middleton, Allen W...........................................    42
    Ortiz, Hon. Solomon P........................................    33
    Robyn, Dr. Dorothy...........................................    48
    Wilson, Hon. Joe.............................................    40

Documents Submitted for the Record:

    Letter from Representative Chris Van Hollen, dated December 
      2, 2009....................................................    85
Witness Responses to Questions Asked During the Hearing:

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

Questions Submitted by Members Post Hearing:

    Ms. Bordallo.................................................    99
    Mr. Loebsack.................................................   101
    Mr. Ortiz....................................................    93
            THE NEW WALTER REED: ARE WE ON THE RIGHT TRACK?

                              ----------                              

        House of Representatives, Committee on Armed 
            Services, Readiness Subcommittee, meeting 
            jointly with Military Personnel Subcommittee, 
            Washington, DC, Wednesday, December 2, 2009.

    The subcommittees met, pursuant to call, at 10:02 a.m., in 
room HVC-210, Capitol Visitor Center, Hon. Solomon Ortiz 
(chairman of the Readiness Subcommittee) presiding.

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

    Mr. Ortiz. The subcommittee will come to order. Today the 
Readiness Subcommittee and the Military Personnel Subcommittee 
meet in a joint session to discuss the Base Realignment and 
Closure (BRAC) realignment of Walter Reed and whether the final 
plans are sufficient to meet a world-class standard.
    The realignment of the Walter Reed National Military 
Medical Center was one of the major decisions included in the 
2005 Base Realignment and Closure process. Its overarching 
reach to close the Walter Reed Army Medical Center and relocate 
those activities to Fort Belvoir and Bethesda have not been 
without controversy or political carnage.
    Because of the substandard conditions found at Walter Reed, 
the former Army Surgeon General and former Secretary of the 
Army were relieved of duty. At the heart of this controversy is 
the fundamental discussion as to what level of care should our 
wounded warriors receive. In my estimation this simple question 
deserves a very simple answer: the best.
    What most intrigues me in this decision process is that I 
am not convinced that the Department of Defense (DOD) shares in 
this simple assessment. The Deputy Secretary of Defense 
indicated that ``development of a world-class medical facility 
is not a destination, but rather a journey of continuous 
improvement.''
    This seems to indicate that the Department cannot obtain a 
world-class medical facility as proposed in the BRAC process in 
the timeline provided. So where does this journey contemplated 
by the Department take us? It would provide us a medical 
facility capable of providing medical care to the military 
concurrent with the BRAC timeline, but it does not deliver the 
world-class expectation envisioned by the BRAC Commission or 
the Department.
    The Defense Health Board (DHB) recently stated that the 
current design would not attain world-class. I find this 
unacceptable. This inability to obtain a world-class medical 
center seems to hide the fact that 4 years have passed since 
the BRAC Commission reported its findings, and yet we still 
have a disorganized medical command, a disjointed funding 
authority, and an inconsistent construction design in support 
of a $2.5 billion effort.
    I have visited the Bethesda campus several times since the 
BRAC Commission finalized its deliberations. While I am 
convinced that the new construction is on the right path, I 
think that the overall requirements to provide the best care to 
our wounded warriors needs to be reassessed, and the full scope 
of work, including related repair work, needs to be reviewed.
    I think the input provided by the Defense Health Board 
provides an excellent roadmap on issues to address. In the end 
I hope that this theory provides answers to the questions about 
what our wounded warriors deserve. I hope that at the 
conclusion of our deliberations, we will be united in saying 
that they do deserve the best.
    The chair now recognizes the distinguished chairwoman from 
California, Mrs. Davis, for any remarks you would like to make.
    [The prepared statement of Mr. Ortiz can be found in the 
Appendix on page 33.]
    Chairman Davis.

    STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
    CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE

    Mrs. Davis. Thank you, Chairman Ortiz.
    Well, here we are again. We are having a hearing about 
Walter Reed. And history, I think, to all of us is important. 
In 2004 the Military Personnel Subcommittee raised a number of 
concerns about how we were caring for our wounded warriors. The 
Department of Defense witnesses told us to trust them and that 
they would make sure that wounded warriors and their families 
were properly cared for. And our reward for that trust were the 
revelations of almost three years ago at Walter Reed.
    Ladies and gentlemen, any response of ``trust us'' simply 
doesn't suffice. While the name ``Walter Reed'' is the same, I 
need to make an important distinction. What was revealed at 
Walter Reed almost three years ago was shameful. Wounded 
warriors and their families were allowed to fall through the 
cracks. They were often left to fend for themselves for 
administrative tasks such as pay and housing.
    However, there is one thing that was never questioned 
during the scandal that had to do with the quality of medical 
care provided at Walter Reed. It was and remains excellent. One 
of our key concerns is that the current plan and the 
organizational structure are simply inadequate and that patient 
care, wounded warrior care, will suffer as a result. Chairman 
Ortiz said it perfectly. There is only one acceptable standard 
of care for our wounded warriors, and that is the best.
    We have had concerns about the plans for the Walter Reed 
National Military Medical Center at Bethesda from the 
beginning. In hearings and meetings we have had Vice Admiral 
Mateczun tell us in effect not to worry, that everything is on 
track, but we have yet to be convinced that that is true. And 
in fact, we have yet to be convinced that the Department takes 
our concerns seriously.
    In last year's National Defense Authorization Act (NDAA), 
we required that an independent design review be done to 
validate the current plan, and that review was completed this 
last summer. And its results are simply unsettling. Among the 
troubling descriptions of the current plan are that it would 
not result in a world-class facility, that it would not meet 
joint commission accreditation standards and that it was 
ambiguous about the vision, the goals and expectations of the 
new century.
    As disconcerting as the independent design review's 
findings were, however, they pale in comparison to the 
Department's response to those findings. And for example--and 
this was mentioned already--``development of a world-class 
medical facility is not a destination, but rather a journey of 
continuous improvement.''
    World-class is most decidedly a destination, one that 
Congress expects its new facility to arrive at before the 
center opens its doors. The definition of world-class will no 
doubt evolve over time, but as the independent design review 
has indicated, the current plan does not meet today's 
definition, and that is unacceptable.
    As Chairman Ortiz mentioned, four years have passed since 
the BRAC recommendations were reported. Two years have passed 
since the Joint Task Force Capital Medicine was established. 
Still we do not know exactly who has overall responsibility for 
this project. Key decisions about funding, staffing and the 
chain of command have yet to be made, and we do not feel that 
the plan meets all of the requirements spelled out in law and 
the BRAC recommendations.
    And we have an independent design review that is highly 
critical of the current plan and organizational structure. 
Since this is our first hearing since the findings of the 
independent design review were released, I would like to hear 
how the Department plans to address the shortcomings 
identified.
    I also look forward to hearing directly from the chair of 
the independent design review, Dr. Ken Kizer, and hope that we 
will have a productive discussion about this incredibly 
important topic. When the hearing ends today, it is my desire 
that we will leave with a better understanding of what needs to 
be done to ensure that the new Walter Reed National Medical 
Center at Bethesda becomes everything that it is supposed to 
be.
    Thank you, Mr. Chairman.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 35.]
    Mr. Ortiz. The chair now recognizes the distinguished 
gentleman from South Carolina, Mr. Wilson, for any remarks that 
he would like to make.

   STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH 
   CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

    Mr. Wilson. Thank you, Mr. Chairman. And thank you and 
Chairwoman Davis.
    As I begin, I would like to move unanimous consent to 
introduce a statement from Ranking Member Randy Forbes of the 
Subcommittee on Readiness. Congressman Forbes is currently at a 
markup of his Judiciary Committee.
    Mr. Ortiz. Without objection, so ordered.
    [The prepared statement of Mr. Forbes can be found in the 
Appendix on page 37.]
    Mr. Wilson. And I appreciate joining our good friends on 
the Readiness Subcommittee today led by Chairman Solomon Ortiz 
and Ranking Member Randy Forbes for our hearing on the progress 
of the Walter Reed National Military Medical Center.
    I welcome the distinguished members of our witness panel. I 
believe that there is nothing more important than providing the 
outstanding members of our military, their families and our 
retirees world-class health care delivered in world-class 
medical facilities. There is no question in my mind they 
deserve nothing less.
    Our family has experienced a quality of service with two 
grandsons born at Bethesda Naval Medical Center and a 
granddaughter born at Portsmouth Naval Hospital.
    The Department of Defense has assured us on several 
occasions that merging Walter Reed Army Medical Center and the 
National Naval Medical Center at Bethesda, two icons of 
military medicine, would result in a single world-class medical 
center that would provide improved access to enhanced medical 
care for our troops and their families and veterans in the 
National Capital Region (NCR).
    Now, I understand that the National Capital Region Base 
Realignment and Closure Health Systems Advisory Subcommittee of 
the Defense Health Board has issued a report that calls into 
question whether the Department's plan to merge these two 
facilities will result in a world-class facility. Further, I am 
aware that the Defense Health Board has expressed concerns 
regarding the Department of Defense's Corrective Action Plan 
published in response to the findings and recommendations of 
the board. It appears that there is still doubt about the new 
facility being world-class.
    Before we hear testimony from our witnesses this morning, 
let me be very clear that the new Walter Reed National Military 
Medical Center opening as a world-class medical facility is not 
negotiable. We cannot accept anything less.
    With that, I would like to thank our witnesses for 
participating today. I look forward to your testimony.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 40.]
    Mr. Ortiz. Thank you, Mr. Wilson.
    Today we have four distinguished witnesses. Representing 
the Department of Defense, we have Mr. Al Middleton, Acting 
Principal Deputy Assistant Secretary of Defense for Health 
Affairs; Dr. Dorothy Robyn, Deputy Under Secretary of Defense 
for Installations and Environment; Vice Admiral John Mateczun, 
Commander, Joint Task Force National Capital Region Medical; 
and Dr. Ken Kizer, Chairman, Defense Health Board, National 
Capital Region Base Realignment and Closure Health System 
Advisory Subcommittee.
    And without the objections, the prepared statement that you 
may have will be accepted for the record. And hearing no 
objection, so ordered.
    Mr. Middleton, welcome. And you may proceed with your 
opening statement whenever you are ready. Good to have you 
here.
    And we are very honored to have an outstanding group of 
witnesses among us this morning. Thank you.
    Mr. Middleton.

   STATEMENT OF ALLEN W. MIDDLETON, ACTING PRINCIPAL DEPUTY 
ASSISTANT SECRETARY OF DEFENSE, HEALTH AFFAIRS, U.S. DEPARTMENT 
                           OF DEFENSE

    Mr. Middleton. Thank you, sir. Mr. Chairman, Madam 
Chairwoman and distinguished members of the subcommittees, good 
morning. I am Al Middleton, the Acting Principal Deputy 
Assistant Secretary of Defense for Health Affairs. I am pleased 
to be here today to discuss progress in the implementation of 
the 2005 clinical BRAC recommendations for the National Capital 
Region.
    As you know, the BRAC Commission report to the President 
released in November of 2005 directed the Department to close 
Walter Reed Army Medical Center in Washington and to realign 
the facility with the National Naval Medical Center in 
Bethesda, creating the Walter Reed National Military Medical 
Center, and to build a new community hospital at Fort Belvoir, 
Virginia, by the BRAC deadline of September 15th, 2011.
    The Military Health System must fulfill a sacred 
responsibility to care for our Nation's service men and women, 
their families and those who have served before us. I am 
grateful for the many dedicated men and women who have answered 
the call to duty, and we are working to ensure that we create a 
health care facility that is well positioned to meet our 
service men and women, veterans and wounded warriors in the 
National Capital Region and throughout the country.
    As principal advisor to the Secretary of Defense for the 
Department's health care program, the Office of the Assistant 
Secretary of Defense for Health Affairs maintains oversight of 
the clinical BRAC actions, including the transformation of the 
National Capital Region currently under way. I am pleased to 
report that we are on track to implement the BRAC 
recommendations by the statutory deadline of 15 September 2011.
    However, we must acknowledge that completion of 
construction activities represents only part of the story. We 
sincerely appreciate the efforts of the Defense Health Board 
Subcommittee and acknowledge that their findings and 
recommendations can only help us in our quest to be world-class 
in the National Capital Region and throughout the Military 
Health System.
    Addressing the complexity and resolving the challenges of 
BRAC transformation in the National Capital Region clearly 
necessitates the knowledge and the insight that the members of 
the health system advisors of the subcommittee possess.
    Executing BRAC and creating an extraordinary health care 
delivery system in the National Capital Region in a relatively 
short period of time is certainly one of the most difficult 
undertakings in the history of the Military Health System. The 
Joint Task Force National Capital Region Medical (JTF CAPMED) 
was created to lead this clinical transformation in the 
National Capital Region.
    Despite the challenges and complexities inherent in this 
task, we should not lose sight of the great progress that has 
been made to date. This single act of consolidating two medical 
centers into one, constructing a new robust community hospital 
in proximity to the majority of beneficiaries, is a major 
accomplishment.
    The creation of the JTF CAPMED as the overarching market 
manager has been important to this effort, and I am confident 
that we are headed in the right direction and appreciate the 
Defense Health Board Subcommittee's detailed roadmap to achieve 
a world-class delivery system built upon world-class facilities 
at Bethesda and Fort Belvoir.
    I look forward to working with the JTF CAPMED in the future 
and the military services and other stakeholders to implement 
the subcommittee's vision. Although our primary focus has been 
completing the BRAC recommendations before the deadline, we 
understand that creating outstanding health care facilities as 
a long-term commitment to improve beyond BRAC, and additional 
investments are required to achieve that end state.
    We are prepared to support the JTF CAPMED and the military 
services in identifying additional non-BRAC requirements and to 
ensure that they are considered in the future budget requests. 
We continue to work to provide every man and woman in uniform 
with the best health care possible, and we appreciate this 
committee and the committee's continued support as we strive to 
excel in everything that we do.
    Mr. Chairman, Madam Chairwoman and distinguished members of 
the subcommittee, I would like to thank you for the opportunity 
to address you today. I will be pleased to respond to any 
questions you may have in the ongoing dialogue that we will 
have to move us all closer to the jointly held goal of a world-
class health system. Thank you.
    [The prepared statement of Mr. Middleton can be found in 
the Appendix on page 42.]
    Mr. Ortiz. Dr. Robyn, you might proceed whenever you are 
ready. You can get close to the mic.

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

    Dr. Robyn. Oh, thank you. It helps to turn the mic on.
    Chairman Ortiz, Chairwoman Davis, Congressman Wilson, 
Delegate Bordallo, distinguished members of these two 
subcommittees, I am honored to appear before you to discuss the 
question of the new Walter Reed--are we on the right track?
    I am the Deputy Under Secretary of Defense for 
Installations and Environment (I&E). I have been in that 
position since July. My office is a major advocate within the 
Department of Defense for getting military facilities the 
budget they need in order to do their job effectively, mainly 
to support mission occupants. My office also oversees the BRAC 
process from start to finish.
    The BRAC has, among other things, been a significant engine 
for re-capitalization of our enduring military facilities. 
Hospitals and other medical facilities in particular have 
received a significant amount of funding as part of the latest 
BRAC round, the 2005 BRAC round.
    To answer the question posed by this hearing--are we on the 
right track with respect to the new Walter Reed--it is helpful 
to recall how we got to this point. Specifically, several 
concerns about the state of medical care in the National 
Capital Region drove the 2005 BRAC decision.
    First of all, there was a growing mismatch between the 
location of the eligible beneficiaries with active duty 
families concentrated in the southern part of the region and 
the location of the major medical facilities to the north. 
Second, Bethesda and Walter Reed had significant excess 
inpatient capacity.
    And third, Walter Reed's infrastructure was deteriorating 
due to the combination of heavy use and chronic under-
investment. It would have, by our estimate, cost hundreds of 
millions of dollars--between $500 million to $700 million--to 
renovate or replace the existing Walter Reed facility and would 
have taken between 6 and 15 years to accomplish that process.
    By closing Walter Reed, and expanding and improving 
facilities at Bethesda and Fort Belvoir, the BRAC decision 
allows the Department to more effectively channel its 
resources. And in the Department's view, this reallocation of 
resources, combined with the shift to a joint service delivery 
approach in the National Capital Region, promises to transform 
medical care delivery in this area.
    With less than two years to go, we are on schedule, and we 
are on track to deliver the promised benefits by the BRAC 
deadline of September 2011. The Defense Health Board 
Subcommittee provided an excellent roadmap, to use your words, 
Chairman Ortiz, for that transition, but they have in recent 
weeks suggested that the Department should possibly delay the 
BRAC construction process, pending further planning of 
additional improvements--improvements that are outside the 
scope of BRAC that the subcommittee believes are necessary to 
make the new Walter Reed world-class.
    We fully agree with the need for additional improvements, 
but we think it is not necessary to halt the BRAC construction 
process. And we think to do so would jeopardize their benefits 
that this endeavor promises. And let me cite three reasons why 
I believe that.
    Most important, without the discipline of the BRAC process, 
we could not have overcome the inertia and the impediments to 
change that created the problems that are described in the 
first place. But we need to keep the discipline of the BRAC 
process in place in order to solve that problem.
    Second, we need to continue to operate the existing 
Bethesda Naval Hospitals even as we renovate and expand this 
facility. It is a little bit like building a new Woodrow Wilson 
Bridge while continuing to operate the existing bridge. We have 
to do both things at once. So there is a real limit to the 
amount of construction and activity that we can undertake there 
at one time.
    And third, by and large the kinds of additional 
improvements being discussed to make the new facility world-
class can be addressed separately and subsequently. Thus, 
continuation of the BRAC construction process will not result 
in wasted effort. By contrast, if we suspend the BRAC 
construction process, we will substantially delay and possibly 
jeopardize the benefits that this promises.
    So in conclusion, it is a large, complex undertaking, as 
you have heard, but it represents a reasonable and balanced 
approach to combining the functions of the old Walter Reed with 
the new. And it will result in a delivery system that is 
superior to what we have now, and one on which we can continue 
to build in the future. My message is simple. This undertaking 
would not have been possible without BRAC, without discipline 
of BRAC. If we relax that discipline, we jeopardize those 
benefits with little, if any, offsetting benefit.
    So in conclusion, my simple message is keep the pressure 
on. Let us stay the course. Thank you very much.
    [The prepared statement of Dr. Robyn can be found in the 
Appendix on page 48.]
    Mr. Ortiz. Thank you.
    Vice Admiral Mateczun, whenever you are ready with your 
statement, you can proceed, sir.

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

    Admiral Mateczun. Thank you, Chairman Ortiz, Chairwoman 
Davis, Ranking Member Forbes, committee members. Thank you for 
the opportunity to share with you the progress of the 
Department in realigning the medical assets of the National 
Capital Region to create the Military Health System's first 
fully integrated, jointly operated and staffed health care 
delivery system.
    This transformation will allow the DOD and the military 
services to capitalize on their collective strengths, maintain 
high levels of readiness, provide world-class health care to 
our Armed Forces and their families, both active and retired.
    I want to take the opportunity to thank the Military 
Personnel and Readiness Subcommittees for their continuous 
support and oversight. Your visit to Bethesda back in March was 
greatly appreciated, and the meetings that we have had since 
then have certainly provided the guidance and direction that we 
needed. I would like to commend Dr. Kizer and the Defense 
Health Board Subcommittee on the NCR for their work in defining 
world-class, and then their recommended steps to achieve that 
world-class.
    The attributes that they talk about in the world-class 
institutions do not all exist in any one place that I know of 
in the world. They are goals that we must strive to achieve, 
and there are many of those attributes of world-class that 
exist today at Walter Reed--not just world-class, but best-in-
class, best-in-the-world.
    If you want amputee and prosthetics care, Walter Reed is 
the place that you want to be today. If you have an open 
traumatic brain injury, then Bethesda is the place that you 
want to be. Those are examples of some of the quality of care 
that is going to go on when we combine these two centers. There 
will be no diminishment of any of those attributes of world-
class care that already exist today at Walter Reed or Bethesda.
    Our goal now is to strive towards the rest of the 
attributes that Dr. Kizer's committee has so well put together. 
Now, Dr. Kizer's getting ready to publish and make these 
guidelines available. They have been enacted into statute in 
the Fiscal Year (FY) 2010 NDAA and provide a new guideline for 
us. So as part of that evolution, as they have gone from BRAC 
to the post-February 2007 commitment to our wounded warriors, 
we now have a new standard just established within the last two 
months.
    We have had the Defense Health Board report to be able to 
work on. We are not disagreeing with any of the recommendations 
that the Defense Health Board has made. We are committed to 
achieving world-class standards at the new Walter Reed National 
Military Medical Center and the Fort Belvoir Community 
Hospital.
    The Capital Region Medical BRAC projects and the journey to 
world-class are inextricably linked. The DHB required a master 
plan to be developed. And in fact, in the Fiscal Year 2010 
NDAA, there is a requirement that the Department do that. This 
comprehensive master plan will synchronize the current efforts 
that are going on, both with the BRAC and then those other 
efforts that will be needed to achieve as many as possible of 
the attributes of world-class that the panel so well laid out.
    That master plan will satisfy the requirements of 2714 of 
the Fiscal Year 2010 NDAA, which is required by the 31st of 
March. I would say that the Department is on schedule to meet 
the BRAC deadline. In our former briefs to you, I told you 
about our progress towards the initial outfitting and 
transition contract. That contract was awarded last week, and 
we have a highly competent group of general and subcontractors 
that will be performing that activity.
    That was one of the last contractual pieces that we will 
have to meet in terms of the construction and outfitting to be 
able to achieve the BRAC deadline. And there are no data 
points, and I will reiterate again there are no data points 
that I know, that say we would be unable to meet the BRAC 
deadline.
    Casualty care is my number one priority. We are committed 
not just to world-class care, but to the best care that can be 
provided anytime, anyplace, to the wounded that are coming to 
us from the theaters in Iraq and Afghanistan. And we will 
suffer no diminishment of care or patient safety during this 
transition to be able to achieve the goals that the Department 
has.
    Chairman Ortiz, Chairwoman Davis, Ranking Member Wilson, 
committee members, thank you again for your interest and 
support in the transformation. We are committed to providing 
this health care not just to our wounded, but to all of our 
beneficiaries. Your support and oversight have made 
immeasurable contributions to this process. The Department will 
continue to work with the military services to make this 
integrated regional health care system the first in the country 
within the Military Health System.
    We look forward to a fruitful and collaborative partnership 
with this committee. Thank you for the opportunity to be with 
you today.
    [The prepared statement of Admiral Mateczun can be found in 
the Appendix on page 58.]
    Mr. Ortiz. Thank you, Admiral.
    Dr. Kizer, whenever you are ready, sir.

  STATEMENT OF DR. KENNETH W. KIZER, CHAIRMAN, DEFENSE HEALTH 
  BOARD, NATIONAL CAPITAL REGION BASE REALIGNMENT AND CLOSURE 
              HEALTH SYSTEMS ADVISORY SUBCOMMITTEE

    Dr. Kizer. Good morning, Chairman Ortiz, Chairwoman Davis, 
Ranking Members Forbes and Wilson, distinguished members. Thank 
you for inviting me to make some comments this morning. 
Everyone here knows the history of how we got here this 
morning, so I will not take any time to make comments in that 
regard. And I thank you for including my written testimony in 
the record.
    I would like to use my allocated time for comments to make 
two main points that will augment my written testimony.
    First, in your consideration about the evolution of Walter 
Reed to become a world-class medical facility, it is important 
to keep in mind that the committee's work to date has reviewed 
only the design plans for the visible architecture of the new 
Walter Reed National Military Medical Center. That is, we have 
reviewed only the design plans for the physical structure of 
the facility. It is not yet possible to review the invisible 
architecture of the facility.
    By ``invisible architecture'' I mean the values and the 
culture of the organization, the attitude or morale of the 
staff, and other less tangible design features of the new 
facility that will in the long run be the most important 
determinant of whether the new Walter Reed performs at a level 
of excellence that would make it world-class.
    No matter how new or modern or sophisticated is the visible 
architecture of the facility, the physical structure alone can 
never make a world-class medical facility. More importantly, 
however, it can prevent the facility from becoming world-class.
    The second point I would like to highlight is that, as has 
been commented on by others, that there does not appear to be 
any significant disagreement about the deficiencies that have 
been identified in the plan, nor about ultimately what needs to 
be done to correct them. The Department seems to agree with the 
subcommittee's findings--the subcommittee that I represent--and 
acknowledges that the current design plans will not produce a 
world-class medical facility.
    We applaud their candor in this regard, and we recognize 
that the road getting us to this point has had some hills and 
curves, to use that metaphor. We also applaud the good work and 
the diligent efforts of many individuals to make Walter Reed 
the world-class facility.
    And while the Department has stated that it is committed to 
achieving world-class status, and we commend this expressed 
commitment, its response to the committee's report does not 
provide sufficient detail or specificity to determine whether 
the planned corrective actions are on the right track or will 
be achieved in a reasonable time or at a reasonable cost, in my 
committee's judgment.
    I believe that the committee would feel more confident that 
things were on the right track if the statements about 
commitment were accompanied by detailed plans for fixing the 
problems, if those plans had clear milestones and deadlines, 
and if it were clear that someone had the necessary authority 
and control to execute those plans. Until these latter things 
are in hand, I do not see how we as an independent panel would 
feel confident that we are in fact on the right track.
    I should perhaps clarify a bit a point made by one of the 
other witnesses, and that is that the Defense Health Board has 
not recommended that construction be delayed or suspended. We 
do believe that there is a limited time opportunity and a 
diminishing window of opportunity to fix some of the identified 
problems at a lower cost and with less disruption and 
inconvenience to patients and the staff, if these problems are 
fixed sooner rather than later.
    In closing, let me say that I believe there are few issues 
more important to readiness in military personnel than our 
troops knowing that the best possible health care will be there 
for them when they are harmed in the defense of our Nation. I 
am reminded of this by frequent health care related questions 
from my daughter, who is currently on active duty as a 
recruiter with the Marine Corps. And her recruits often ask her 
about the health care that they will receive if they enlist or 
should they be injured on duty. And she not infrequently picks 
up the phone and says, ``Dad, what about this?''
    Frankly, when we send our children into harm's way, we have 
a responsibility to ensure that they have the peace of mind of 
knowing that they will have world-class medical care, should 
they need it. And anything less than that is simply not good 
enough.
    Representing the committee that has produced the report 
that you are familiar with, we would urge that whatever action 
is necessary be taken to ensure that the new Walter Reed 
National Military Medical Center, and indeed our entire 
military health care system everywhere, is world-class. Thank 
you. I would be pleased to answer any questions that you may 
have.
    [The prepared statement of Dr. Kizer can be found in the 
Appendix on page 63.]
    Mr. Ortiz. Thank you, Doctor.
    Mr. Middleton, I have a question for you. I have read the 
Joint Task Force's issued statement that they are committed to 
establishing a world-class medical center at the hub of the 
Nation's premier regional health care system. Is the Department 
committed to obtaining this vision? I mean I think they are, 
but I would like to hear from you. When do you expect to obtain 
this capability, and at what additional cost? Maybe you can 
enlighten the committee on my question.
    Mr. Middleton. Thank you. Thank you for that question, sir.
    I think directly the answer to your question is yes. There 
has been in my view no evidence that we are not committed to 
that vision, that every effort that was made into BRAC--and I 
think all of you are familiar with the additional resources 
that were added to enhance and to accelerate the BRAC 
construction in the National Capital area, both at Fort Belvoir 
and at Bethesda, where a big investment by the Department to 
bring that capability on board as soon as we possibly could.
    The addition of warrior treatment centers, you know, the 
enhancements that we are making with centers of excellence at 
Bethesda, as you are well aware of, the involvement of the 
Fisher Foundation in putting in another Intrepid Center of 
Excellence there as a donation to the government, I think all 
speak to that commitment that we have all made to make this 
world-class.
    I think that what we have to do is realize that within the 
BRAC confinement of what we do in BRAC, we want to get that 
capability onboard as soon as we can. We know at Bethesda that 
is going to be 66 single rooms, for example, okay, modern, 
first-class rooms up there. We know that there's a lot of rooms 
out there that we are going to have to get back to and 
renovate. And as Dr. Robyn said, you can't tear the whole thing 
apart at one time.
    We know down at Fort Belvoir we are building perhaps the 
finest community hospital that has been built in this country 
in terms of its capabilities, in terms of what is going to 
happen at that facility, and the facility itself. I think that 
the commitment is there.
    But I am reminded of Dr. Kizer's comments about the six 
domains of world-class, only one of which is core 
infrastructure. There are other parts of being world-class, and 
there are plenty of examples in this country of operations that 
are not necessarily in first-class facilities, but are world-
class operations. And so our commitment is to both.
    We want to do the facilities at a time phase. We will have 
to go beyond the BRAC deadline in order to do some of these 
renovations up at Bethesda. That is part of our plan. And as 
Admiral Mateczun and the JTF folks put in their master plan for 
the National Capital area, we will see that time phasing, the 
BRAC phase, the concurrent phase, the phase that occurs during 
BRAC and goes after BRAC.
    And then there are things we will have to do after BRAC--
not go back and redo what we have done. We will have to use 
that space as a leverage point, then, to launch. If we had 
built a new Belvoir 10 years ago, we would have that at a 
leveraged spot that we could do, but we are going to get that 
all at the same time.
    So once we get that platform done, then we can swing around 
and do the rest of the facility so that the plan is at the same 
time we have to work on those other five domains that are 
articulated in the subcommittee's report. So to answer you 
correctly, sir, directly we are committed to it--absolutely.
    Mr. Ortiz. There was another part to the question. Maybe 
you can touch on it--at what additional cost?
    Mr. Middleton. That has not been determined, sir. I mean it 
would be presumptive of me to give you a dollar figure, because 
I think as the master plan is built, as we build that master 
plan, you know, over the next few months, we will have a better 
articulation of, well, okay, what is it going to take, then, to 
go back and renovate this space?
    You know, we need some demand analysis, too. We need to 
know precisely the number of beds and the kinds of beds--for 
example, new operating rooms (ORs). How many ORs do we need? We 
know that we have 17--16, 17--ORs that need to be renovated. Do 
they all need to be at 600 square feet? Or can some of them be 
procedure rooms? Do we need to have--those are all the things 
that have to come out in the master plan. And that will then 
inform the budget decision, sir.
    Mr. Ortiz. And I can understand Dr. Kizer saying that maybe 
we should try to do it all at the same time now. I am pretty 
sure we are going to hear some complaints from some of our 
constituents, the families of the wounded warriors, when they 
are assigned to the new facility, the new operating rooms 
versus the old ones.
    And I would not--I guess you ladies and gentlemen will be 
at the forefront to answer those questions to the constituents. 
Why in the world did I go to this 12, 15, old surgery rooms 
instead of going to the 2 or 3 new surgery rooms? I mean how 
are we going to address that? Do you think that might be a 
problem to any of you?
    Admiral Mateczun. Chairman Ortiz, let me talk specifically 
to the question of the operating rooms at Bethesda. When we 
came to brief the Deputy's response to the DHB report, we had a 
number of questions about the coordination of the renovation 
plan that the Navy is doing on the OR projects with the overall 
vision, taking that back, called everybody to the table. We 
were just out at the University of California-Los Angeles 
(UCLA) to take a look at the ORs of the future out there.
    And our goal right now is to evolve those operating rooms 
as we go. So the three new operating rooms are certainly 
extraordinarily large. They were being built in a new 
construction. And we will arrive at a vision that will help us 
to move towards the world-class in terms of the operating rooms 
that currently exist and the renovations that are there.
    That will potentially leave us with a shortfall of 
operating rooms. We can either make that up through changing 
the ORs' schedules. That is, start times can extend well into 
the day to do the same number of cases, or we can potentially 
look at new OR construction in the future.
    But we are committed to moving ahead and moving towards 
that world-class standard at this point. I haven't made the 
final decision yet. I have to see what the cost is going to be. 
But we have taken that at your advice and tried to incorporate 
that into the movement towards world-class.
    Mr. Ortiz. When is that coming now?
    Admiral Mateczun. We should be finished this month with the 
review, the costing to the contractors, and arrival at a 
decision.
    Mr. Ortiz. This next month did you say? Did I hear correct?
    Admiral Mateczun. December--yes, sir.
    Mr. Ortiz. Yes. Okay.
    I just have one more question, and then I am going to yield 
to my good friend, Chairman Davis.
    But, Dr. Robyn, I understand that several fiscal accounts 
are being used to implement the BRAC recommendation of a 
premier medical center, including BRAC funds, Defense Health 
funds, and Operation and Maintenance funds. However, I am not 
convinced that all of these funding sources are being used to 
obtain the same vision. I can be mistaken now, but can you 
explain how the Department intends to synchronize these 
facility accounts and obtain a world-class medical center? 
Maybe you can bring everything together. How are we going to do 
that?
    Mic.
    Dr. Robyn. As I said, we are focused on trying to take 
advantage of the discipline of the BRAC process to achieve the 
goals that were set out as part of the BRAC recommendation. And 
that will be deliver an integrated health care delivery system 
in the National Capital Region that is superior to what we have 
now.
    It will not be everything that it can be and should be, and 
so it will be necessary to go beyond the BRAC process in order 
to achieve world-class and to use funding outside of the BRAC 
process.
    How will that be synchronized? I mean I think that is where 
the master plan will guide us in terms of how much additional 
funding that would take. But we are using as much in the way of 
BRAC resources as it takes to achieve and go beyond the BRAC 
vision.
    As you well know, we have gone well over the initial 
estimate of what the BRAC reconstruction renovation would take, 
the difference between. We have gone to $2.4 billion. The 
national estimate was about $800 million. That is not mostly 
inflation and construction costs. That mostly represents actual 
additional expansion, additional improvements, the kinds of 
things that Mr. Middleton talked about that were not originally 
part of the BRAC vision.
    So I think the master plan will be the mechanism for 
synchronizing it. How much will it cost? We are still trying to 
figure that out.
    Mr. Ortiz. Chairwoman Davis.
    Mrs. Davis. Thank you. Thank you very much.
    I want to talk a little bit about the structure. And, Dr. 
Kizer, you mentioned in your comments that you would be 
confident if there were more detailed plans and whether or not 
you were certain that you could get there with the necessary 
authority and control.
    And I wanted to turn to Mr. Middleton and ask about that, 
because part of the concerns have been around those issues. The 
Military Health System operates with the Assistant Secretary of 
Defense at the top. And that is the way it is structured 
today--not necessarily making a judgment about that, but that 
is the way it is structured.
    How does the current arrangement with JTF CAPMED fit into 
that structure? Vice Admiral Mateczun reports directly to the 
Deputy Secretary of Defense, but there has really been a 
question about who is the arbiter when there is disagreement 
between Health Affairs and JTF CAPMED, between the services and 
JTF CAPMED. Who is the arbiter there? Does everything need to 
be handled by Deputy Secretary Lynn?
    And then we go over to the staffing as well. Would the 
services still be responsible for programming and budgeting 
personnel for the facilities under the control of JTF CAPMED? 
Will JTF CAPMED assume this responsibility? I know that that 
has been a concern. Could you help us better understand that? 
And what have been the discussions to see whether in fact that 
is on the right track?
    Mr. Middleton. Thank you. It is a complex issue, as you 
articulated, Madam Chairman.
    Well, a couple of points. We have established within the 
Department an integrated product team, a team that actually the 
Assistant Secretary or currently, Ms. Ellen Embrey, who is 
performing the duties of the Assistant Secretary, formerly Dr. 
Ward Casscells, and Dr. Robyn's predecessor, Wayne Arny and now 
Dr. Robyn--an Overarching Integrated Product Team (OIPT), we 
call it, in order to articulate the issues that come up, that 
arise.
    What are the concerns? What are the issues? We haven't had 
that meeting for some time, because we haven't had a series of 
issues that require that. And that gets back to the authorities 
question. We have worked through last year--and I know Dr. 
Mateczun can articulate this better than I--a series of 
meetings in order to articulate the authorities over the 
personnel. And we worked on manning documents for the military 
personnel, and we have still an issue about the civilian 
personnel and which Title authorities that Dr. Mateczun would 
have over those folks.
    There remains, I think, still the issue of the ultimate end 
state as to, okay, who is actually going to be responsible for 
the resources within that? On our side on the Health Affairs 
and TRICARE management activities side, we recognize the fact 
that in order to actually run the operation for the National 
Capital Area, they will have to have the authority over the 
resources.
    What we can offer to Dr. Mateczun, and have offered to Dr. 
Mateczun and the JTF, is the ability to have transparency and 
visibility into all of the budgeting issues that occur within 
those facilities. You know, there are 37 facilities within the 
National Capital Area. That is a lot of facilities, and they 
cross three different accounting and finance systems. So this 
gets more complicated the deeper you get into it on how you 
actually do this. So what we have tried to do is provide him 
and his staff with all the transparency and where the resources 
occur.
    In terms of the differences, I will tell you that there 
haven't been many differences between Health Affairs and the 
JTF CAPMED on moving forward with world-class vision, with 
getting all the authorities, with teeing up these issues so 
that Secretary Lynn can make the decision. I think that 
represents in some respects Secretary Lynn's deep interest in 
all this and wants to be informed, as did his predecessor.
    So it is a very complicated matter, Chairwoman, that I 
don't think is yet resolved. I think that is what we are about 
to do in the next several months is to work through these 
thorny issues of the authorities.
    We have a lingering issue as to what actually physically 
constitutes the Walter Reed National Medical Center, which 
buildings on the Bethesda campus belong to the National Medical 
Center versus which are infrastructural issues that belong to 
the Navy Medicine or what are the issues that belong to the 
Navy Installations Command. So we have to work through all of 
these issues.
    Mrs. Davis. I think the concern is that we are so far down 
the line, and yet these issues still exist.
    And, Dr. Kizer, you know, you have been looking at this as 
well. Does it make you feel any better to hear what Mr. 
Middleton just said?
    Dr. Kizer. Well, on the one hand, it is a complicated 
issue. I acknowledge that. But on the other hand, it is also a 
very simple issue. Someone has to be in charge. And to make an 
integrated delivery system work, one entity has to be vested 
with both the operational and budgetary control. On an 
editorial note, I suppose the committee is a little perplexed 
that this foundational issue of authority is problematic to 
resolve in a hierarchical organization like the Armed Forces.
    Mrs. Davis. Is that part of the problem--that there are 
obviously multiple services here as well?
    Mr. Middleton. I think Dr. Kizer, you know, would say that. 
I think what Dr. Kizer is alluding to is the fact that it 
should be easy to make those decisions, because it is a 
hierarchical organization. Someone just needs to make the 
decision and do it.
    Mrs. Davis. But there are several hierarchies.
    Mr. Middleton. There are several hierarchies and there's a 
lot of equities in this issue, you know, between the Surgeons 
General. They have authorities here, and they have 
responsibilities for these folks. And Dr. Mateczun will, and 
his office will, ultimately have some responsibilities and 
authorities as well. And we are just going to have to work 
through each one of those.
    And we have worked through a couple of them. And we have 
worked through the military piece, the military personnel 
piece, last year. We are working now through the civilian 
personnel piece and the Title 5 authorities and those kinds of 
issues. We are working through those now.
    Mrs. Davis. Could you give any kind of a timeframe, because 
there is a number of concerns about construction, and obviously 
personnel as well. But when do you think we appropriately 
should be able to say, okay, you know----
    Mr. Middleton. We are there.
    Mrs. Davis. Yes, exactly.
    Mr. Middleton. Yes, yes. Anything I would say would be 
speculative on my part, because I am not sure I even fully 
understand all of the thorny contracting issues that go--the 
contentiousness that could occur. But I would hope that as we 
re-energize the OIPT here very soon, that we will be able to 
work through these in a fairly expeditious way.
    And my commitment then would be that to both committees 
that we will report back on that, you know. We can report back 
on where we stand on these issues and articulate those to you 
in the weeks and months ahead, if that is reasonable for you.
    Mrs. Davis. Is the master plan itself--I mean we have asked 
you to create the master plan. Are some of these decisions 
beyond the ability of the Department to make? Should somebody 
else help make them?
    Mr. Middleton. I don't believe that is true. I don't 
believe that is true. I think we have all the authorities we 
need to make these decisions. If there is a special--if there 
is something that I am unaware of, and I would refer that to 
Dr. Mateczun as well; he may know something--but I don't know 
of any authority that we don't have to make the decisions.
    There are some matters around Title 5 authorities that get 
a little thornier--for instance, second and third order issues 
about auditing and things like that, but I think we have the 
authority to do it. But I defer that to Dr. Mateczun.
    Admiral Mateczun. Chairwoman Davis, as part of the master 
plan that is due back, the authorities issue is one of the 
threads that we are interweaving. We have a group that is 
working specifically on all authorities issues, and as far as I 
know, there are none that are outside the authorities of the 
Department.
    Mrs. Davis. Congress, you know, had asked for this master 
plan. Do you think that kind of work would have gone on 
irrespective of that request?
    Admiral Mateczun. Yes, ma'am, absolutely. In fact, two of 
those are--actually, three of them are pending decisions left 
for the Deputy Secretary that we have had identified. We had 
the manpower and civilian personnel issues. The other three 
that are still pending are the force mix between the two 
hospitals, the resources--how do the resources flow, which is 
highly technical, and we will come to an answer on that.
    And then ultimately, what is the governance of the JTF? So 
these are identified issues that that Defense Health Board, you 
know, sees this issue as foundational. We agree. It is a 
difficult thing to struggle with, to think about aligning 
authorities in a different way than they exist today in the 
Department.
    Mrs. Davis. Thank you. I appreciate that.
    Thank you very much, Mr. Chairman. I have some additional 
questions, but I want to be sure everybody has a chance to ask. 
Thank you.
    Mr. Ortiz. Mr. Wilson.
    Mr. Wilson. Thank you, Mr. Chairman.
    And thank you, Madam Chairwoman, too.
    For the panel, thank you for being here today.
    And in particular, Secretary Middleton, I appreciate your 
work with TRICARE. This is crucial for our military, for their 
families, for our veterans, and for survivors. So your 
stewardship is greatly appreciated by me.
    As we proceed today, Dr. Kizer, the advisory committee 
reported several findings and recommendations that would bring 
the new Walter Reed closer to the goal of being a world-class 
medical facility. Which of the recommendations that you feel 
DOD did not adequately address in their assessment is the most 
critical to delivering safe, quality patient care, and why?
    Dr. Kizer. I think there are several levels that one could 
address that. I think the issues that the committee views as 
paramount at the moment is the authority issue, which we have 
talked about some already, the alignment of funding streams, 
which continues to seemingly be at the root of many of the 
issues related to the master plan, which I would put as the 
third critical issue.
    And when I speak of the master plan, there are, again, 
several types of master plans that are needed. Ostensibly, they 
would all roll into one master plan, but there is the master 
plan for the Walter Reed facility itself. There is a need for a 
master plan of the Bethesda campus, where the Walter Reed 
facility is co-located or approximate to multiple other 
facilities that it will work with on an intimate basis. And 
then there is the need for a master plan for the entire 
National Capital Region and the more than 30 different medical 
commands that reside within that multi-state area.
    Now, beyond that there are a number of other issues 
relating to operating rooms and surgical pathology and a number 
of other things, which we had detailed, and I would defer to my 
written testimony and other comments that were made already 
about those.
    But I think fundamentally until the authority issue is 
resolved, we really can't deal with the--or at least it is hard 
to understand how you are going to deal with the funding issue. 
And until the funding issue is dealt with, it is hard to 
understand how you are going to deal with the master plan 
issue. And then you get into all of the specifics about 
operating rooms and then single rooms and information 
technology (IT) systems, et cetera, et cetera.
    Mr. Wilson. And you brought up about authority.
    And, Admiral Mateczun, you are facing such extraordinary 
challenges, so best wishes trying to--in your position. And 
what authority do you currently have to direct the funds to 
resolve the design and construction issues that have been 
raised by the Defense Health Board?
    And, of course, there has been a reference several times, 
and again just a second ago, about the situation of two 
patients to a room instead of one, particularly in light of the 
concern that everyone has about the rise of infections in 
hospitals in the United States.
    Admiral Mateczun. The monies that have been needed to 
correct these deficiencies are all working within the 
Department, and the funds are identified, not programs yet, not 
allocated completely, but each of the issues that Dr. Kizer 
identified in terms of the current construction and the 
deficiencies we have been able to work with.
    There is a question of whether or not there will need to be 
new construction that we have to do in the master plan. There 
are going to be 52 double patient rooms left at Bethesda. Part 
of the Department's change in 2007 in enhance and accelerate 
was to start renovation of those rooms and conversion into 
single patient rooms. Still, 54 will remain at the--or 52 will 
remain at the end of BRAC.
    And the question is what to do with those rooms, not 
disagreeing with, you know, the need and the movement in the 
country as the country is moving towards a single patient room 
standard. That will require renovation of those remaining 
rooms. And since there is no space in the construction left, 
that would likely require new construction.
    We are also taking a look at the fundamental demographics 
of the population and their demands as we work towards an 
integrated delivery system to validate the--the number of beds 
that we would need and integrate that into the master plan as 
well.
    Mr. Wilson. And I hope again that--and I know you are 
looking into that. And as I visit hospitals, I frequently find 
that they have quickly been rearranged for a single patient.
    And, Dr. Kizer, a final question for me. The Army has 
indicated they will be managing 400 warriors in the transition 
at the new Walter Reed and needs 300 barracks rooms for the 
soldiers. Please explain the plan for accommodating not only 
the Army Warrior Transition Unit (WTU) population, but the Navy 
and Marine recovering wounded warriors as well. In addition, 
please explain the plans for accommodating the families of the 
wounded warriors at the Bethesda campus.
    Dr. Kizer. Well, sir, I don't think I am the right person 
to answer that question, since those are questions that frankly 
we raised in our report, were issues like that, as to how they 
would in fact--a number of these other services that need to be 
provided, how they would be, because it was not apparent from 
the plans that we saw. And this is, of course, part of what is 
needed in the master plan.
    I would just add to--on the prior question--to the response 
that Admiral Mateczun gave that one of the findings of the 
committee was the need for current and prospective forward-
looking demand analysis for the services. The current capacity 
and design of the facility was based on a 2004 retrospective, 
backward-looking demand analysis. Things have changed. The 
population has changed. Technology has changed. Care practices 
have changed. And we really need a more forward-looking demand 
analysis to guide the master plan and as a design piece.
    Mr. Wilson. And to conclude, Admiral Mateczun, I think it 
was passed to you. If you could comment, that would be very 
nice.
    Admiral Mateczun. Yes, Mr. Wilson. Thank you. This is 
additionally one of those--partially, one of those instances of 
changing requirements. The Army is taking a hard look at how it 
manages the warrior transition and in particular the non-
medical attendants, as well as family members.
    And so each of the services has a different requirement 
generations mechanism that they use to take a look at that. We 
are at this moment combining all of those requirements. The 
Center for Army Analysis has done a study on that requirement. 
We will be incorporating those. Admiral Mullen has a specific 
interest in this, and I believe we will come to resolution on 
that issue very quickly.
    Mr. Wilson. Well, we appreciate your efforts.
    Thank you, Mr. Chairman.
    Mr. Ortiz. Before I yield to Mr. Taylor, I would like for 
the record to include a statement from our good friend, Chris 
Van Hollen, for the record. Hearing no objection, so ordered.
    [The information referred to can be found in the Appendix 
on page 85.]
    Mr. Ortiz. Mr. Taylor.
    Mr. Taylor. Thank you, Mr. Chairman. And thank you for 
having this hearing.
    Admiral Mateczun, I am going to shift gears just a little 
bit, but I don't get to see you that often. Over the past 
couple of years, the different service secretaries have been 
very cooperative. Let me backtrack. It seems that every young 
amputee that I have met with expresses a very strong desire 
to--to continue to serve. They have paid a terrible price for 
their participation on the team. They want to stay on the team.
    And one of the ways that I would think that we could help 
them to stay on the team and do something meaningful would be 
to have them assigned to the different service academies either 
as assistant coaches or squad level officers, plumbers, 
carpenters, whatever, depending on what their Military 
Occupational Specialty (MOS) was and what they did in the 
private sector before they joined the service.
    And to the best of my knowledge, every one of the service 
secretaries have signed onto this. But also to the best of my 
knowledge, very few have actually been assigned to the service 
academies. It has also been the intention of Chairman Skelton 
to expand this to the different Reserve Officer Training Corps 
(ROTC) programs, with the thought being that the service 
academies are limited to Colorado and New England states, 
whereas the ROTC programs are in every state. So again, they 
would be doing meaningful work, in the case of the ROTC 
programs, closer to home.
    There is a Capitol Hill guide. I regret that I don't know 
his name, but every week he brings wounded warriors to the 
Capitol. Every week we stop and say hi to them, and every week 
I ask these kids if they have been told about this program. And 
not one of them is aware of it.
    Again, I know you have got a million things on your plate, 
and I can only imagine how difficult your job is. But how can 
we do a better job of making these opportunities available to 
folks so they can stay on the team, do meaningful work for 
their nation, continue to wear the uniform, and do something 
worthwhile for their nation, which is what their desire is, and 
give them a seamless transition, should their decision be to go 
back to the private sector, a seamless transition back to the 
private sector and buy them some time. What could we do to get 
that word out?
    Admiral Mateczun. Thank you, Mr. Taylor. It is, you know, a 
wonderful thing that is going on now. We moved into a 
rehabilitation, capabilities-based rehabilitation model in the 
services that really didn't exist before these current 
operations in Iraq and Afghanistan. And so based on the 
capabilities that the individuals have, the limbs that they 
have lost and where they might be able to go, I know that 
almost everybody would like to have them work in their areas 
and work with them.
    One of the opportunities that we will have at the Walter 
Reed National Military Medical Center is an area where we will 
jointly be able to provide information to all those folks. 
Since all of the amputees as they go through rehabilitation 
will be at Walter Reed, we will be able to disseminate that 
through each of the service mechanisms in a more comprehensive 
and joint way. We are committed as well to making sure that 
they understand all of the opportunities that they have.
    Mr. Taylor. Well, Admiral, this has been policy for well 
over a year. And again, not one of these young people that are 
taking tours of the Capitol has been made aware of it. And so 
again, I do understand that you have a heck of a lot of 
responsibilities, but I would make this request of you face-to-
face, that your organization do a better job making this 
available.
    And if there are some impotence either administratively or 
in the code that are keeping this from happening, let us know 
so we can address it in next year's session. And I will just 
give you one for instance. Merchant Marine Academy Captain Ebbs 
is our chief staffer for the Seapower Subcommittee--just came 
back.
    They have barracks that don't have hot water. For $30,000 
worth of plumbing equipment and the properly skilled people in 
that building to fix that, we could fix that tomorrow. And I 
have got to believe that you have got some injured Seabees who 
could be doing that job or Army people from the Army 
construction battalions.
    Again, I do see some opportunities to provide these young 
people with meaningful work while they stay in the service. We 
are missing them somehow. And I would hope that you would get 
back to me on how we are going to correct that.
    Admiral Mateczun. Yes, Mr. Taylor. I will take that back.
    [The information referred to can be found in the Appendix 
on page 89.]
    Mr. Taylor. Okay. Thank you very much, Admiral.
    Thank you, Mr. Chairman.
    Mr. Ortiz. Dr. Fleming.
    Dr. Fleming. Yes, thank you, Mr. Chairman.
    I would like to ask the panel to elaborate on the concept 
of world-class medical facilities as it applies to what would 
emerge from this merger, if you will.
    Admiral Mateczun. Dr. Fleming, thank you. You know, we are 
headed towards an integrated delivery system for the first time 
within the Military Health System. The National Capital Region 
is the largest concentration of military medical forces and 
beneficiaries that we have in the country--500,000 
beneficiaries, 300,000 enrolled in the TRICARE Prime program 
that we have.
    As we move towards this integrated delivery system, we are 
working, trying to come to our master plan on how to integrate 
both specialty and primary care into that integrated delivery 
system. What you will see at Bethesda will be one of the 
premier quaternary medical centers that we have in the country 
in the end state. And what we need to do--it will be both the 
referral medical center and a specialty medical center for the 
area.
    The community hospital at Fort Belvoir will provide general 
specialty services to what is now the majority of the area's 
population, which is shifting south over the last couple of 
years. And so those things will come together as part of the 
integrated delivery system.
    In terms of the vision itself for what will not be 
happening at Walter Reed, we are taking a look at integrating 
not just the current terrific capabilities for amputee care, 
traumatic brain injury. There is also the National Intrepid 
Center of Excellence, which is going to be there for Traumatic 
Brain Injuries (TBI) and Post Traumatic Stress Disorder (PTSD), 
working with Dr. John Niederhuber from the National Cancer 
Institute (NCI) in a collaboration where we will start moving 
towards a comprehensive cancer center with NCI designation for 
all of our beneficiaries. That will be the first within the 
Military Health System.
    And in each of the areas that we are moving towards, we are 
looking towards achieving world-class. We are in a particularly 
good location. We are right across the street from the National 
Institute of Health, and we have a medical school right on our 
campus. As part of the strategic plan, we are looking at how to 
bring together the medical center and medical school in a new 
model for academic medicine for the country. So those are some 
of the things that we are doing. I don't know if that answers 
your question, sir.
    Dr. Fleming. Let me follow up, and then I will open it back 
up to the panel. When you say ``integration,'' do you mean 
assigning Air Force physicians or providers to Navy facilities 
and vice versa? Are we looking at integrating all providers 
into one service? What--can you elaborate on that?
    Admiral Mateczun. The facilities themselves will be--the 
personnel will be jointly assigned--that is, that personnel 
from all of the services will be at both of the facilities. In 
terms of the integration, from the patient perspective what we 
are looking at is having them see an integrated delivery 
system. They will see joint providers, providers from all the 
services. But what we are really working towards is what they 
will see as the integrated delivery of care across all the 
services that we have.
    Dr. Fleming. And will this tend to happen in facilities 
around the world? Will you begin to see this jointness? Or are 
we talking about just in this area here?
    Admiral Mateczun. No, there are only a few areas in the 
country where there is more than one service hospital. The 
National Capital Region and San Antonio are the two biggest, so 
it is unlikely that you will see much of this anywhere else.
    Dr. Fleming. I see.
    Others?
    Mr. Middleton. Jointness is not unprecedented. We have had 
Air Force staff working in the hospital in Landstuhl for a 
number of years. We will do the same endowment as we close the 
Wilford Hall Medical Center down in San Antonio. Much of that 
staff is going to go to the Brooke Army Medical Center, and 
that will be a jointly staffed hospital.
    I think the integration also speaks to the way in which 
patients flow through the system seamlessly so they can move 
from the primary care setting that we have around the area to 
our secondary and tertiary care facilities as well. So I think 
the integration piece and how information flows seamlessly, I 
think that is all part of the world-class vision.
    So talking about around the globe, we want to make sure 
that information flows along with the patient. So whether it is 
a serviceman injured in Iraq or Afghanistan that is coming back 
to Landstuhl, or whether it is someone who gets in a motorcycle 
accident outside St. Louis, they are moved through the process 
as seamlessly as we can.
    Dr. Kizer. If I might make two comments, one just to 
amplify a little bit on what Vice Admiral Mateczun said, that 
at least when I was a naval officer 30 years ago or so, the 
nature of my work was such that I not infrequently was assigned 
to both Army and Air Force units and had the opportunity to 
delve into all these. And I would say that there are very 
different cultures in the services, and integrating into a 
single joint Armed Forces medical culture is not an easy task, 
and we recognize the challenges here.
    The second point I would make is the Congress is very 
clear, and the Department certainly agrees, that the facility 
should be world-class, but the Congress did not provide much 
operational definition for what world-class should be taken to 
mean. So much of the work of the subcommittee that I chaired 
and the report that we issued actually had to do with defining 
in operational and functional terms what world-class would 
mean. And there are many pages detailing that in 6 different 
domains and 18 conditions.
    But perhaps, if I might just state in perhaps a different 
way than what was said earlier, I think the subcommittee views 
a world-class medical facility as one that goes above and 
beyond compliance with the professional accreditation and 
certification standards, where there is a palpable commitment 
to excellence.
    A world-class facility is one in which highly skilled 
professionals work together with precision and passion as 
practice teams within an environment of inquiry and discovery 
and in one that creates an ambience or an atmosphere that 
inspires trust and communicates confidence.
    I think a world-class facility constantly envisions what 
could be and goes beyond the best-known medical practices to 
advance the frontiers of knowledge and to pioneer. Improved 
processes appear so that the extraordinary becomes ordinary, 
and the exceptional becomes routine. So perhaps that is a 
different way of operationalizing or thinking about this 
concept of world-class.
    Dr. Fleming. Sure. I know I am out of time, but I don't 
know how much--I would like to follow, if I could, one other 
question, Mr. Chairman?
    Mr. Ortiz. Go ahead.
    Dr. Fleming. The issue of electronic medical records (EMR), 
which is a wonderful thing--it is a wonderful--I am a strong 
believer as a physician myself. My medical clinic had an EMR 
since 1997. I am also very familiar with the challenges, and 
certainly a worldwide system that then has to integrate with 
the Veterans Affairs (VA) system is an unbelievable challenge. 
But I do hear complaints about the functionality of the system.
    Obviously, as you integrate and you have more jointness and 
all these things, that is going to become even more critical. 
Do you have plans to improve that? Or I understand that the 
platform is really an old platform which may limit how much you 
can improve it. Can you elaborate any on those points?
    Admiral Mateczun. Yes, Dr. Fleming, thank you. It is a 
great challenge. You know, we have probably one of the world's 
largest databases for the Military Health System in the central 
data repository, where we have tremendous amounts of 
information, so we do have some expertise. Our platform is 
sometimes not user-friendly. We are working at changing that.
    We are committed to arriving at the Administration's 
mandate for interoperability between the VA and the DOD. 
Particularly, we are working right now on an inpatient system 
to cross over the two systems and then interoperability between 
the two platforms, which are Armed Forces Health Longitudinal 
Technology Application (AHLTA) and Veterans Health Information 
Systems and Technology Administration (VistA) that are out 
there today.
    Mr. Middleton. If I could help there, too, as you know, 
sir, we have our system. The VA has their system. We have a 
mandate from the Administration to put together the virtual 
lifetime electronic record for our veterans, a huge challenge.
    The VA system, and I know Dr. Kizer knows it as well as 
anyone in this room, also has its challenges in its old 
architecture and things like that. We recognize that in our 
own. We and the Department are working on the way ahead for a 
new architecture. We are in the process of that now, actually 
picking folks to be part of that team to move forward with 
that.
    We have a commitment from the Department to help us in that 
endeavor in terms of not only the expertise, but in some 
resources as well. So we think we are on our way to a different 
place with electronic health record. That is not to say that 
the health record we have today hasn't served us very well for 
a number of years, but it is time for a change.
    And as I am sure you are familiar, we now also have the 
national standards, the National Health Information Network 
(NHIN) standards that are evolving. We are going to do some 
programs, some pilot programs, perhaps with some civilian 
activities, to see if we can share information between the 
Departments as well as civilian activity. So there's a lot of 
exciting things coming in electronic health record, but it is a 
huge challenge--absolutely, sir.
    Dr. Fleming. Thank you.
    I yield back, Mr. Chairman.
    Mr. Ortiz. Thank you.
    Mr. Middleton, you know, I find it troubling that we have 
programmed $2.5 billion for the realignment of Walter Reed, but 
we still have so many fundamental issues outstanding. We have 
programs that will cost almost another $5 billion in other 
medical centers.
    And do you think that our inability to manage the Capital 
Region will also have an impact at other locations in the 
United States? And how do we ensure that lessons learned are 
incorporated to other sites? And I think somebody questioned on 
Brooke Medical Center in San Antonio. So how are we going to 
implement some of those lessons learned today and through this 
process of realigning Walter Reed and Bethesda?
    Mr. Middleton. Thank you, sir. I think the first is to 
articulate some of the lessons that we have learned. I think 
that is an important issue. And, of course, those lessons are 
always ongoing.
    One key area is acquisition strategy. There's multiple ways 
in which you get buildings acquired. One of those is design-
build. One is integrated design-bid-build. We are actually 
testing that out. Frankly, the way we are doing it in Bethesda 
has allowed us to actually meet these timelines. Had we gone 
through some traditional methodologies, we would have been 
struggling. So we have been fortunate in that.
    I think we have to learn the lesson of how we deal with our 
agents, the Corps of Engineers and the Naval Facilities 
Engineering Command (NAVFAC) in an effective way. We have, I 
think, built a strategy. What we learned in Bethesda is how we 
can sit down with the I&E, Dr. Robyn's staff, our staff, JTF 
CAPMED staff, to make sure that we are identifying the 
requirements as early as we can.
    We have over the last couple of years built a series of 
criteria for evidence-based design, which is sort of the 
buzzword for the kinds of facilities that we want to build. And 
so back in 2007, we put together a package that articulated 
what those design features ought to be.
    And we held a conference in 2008 with civilian activities 
to articulate those kinds of world-class facilities issues 
around evidence-based design--things like natural light and 
enhanced privacy for infection control, as Mr. Wilson talked 
about in single rooms, patient safety features that are built-
in, the way in which we observe the patients in the rooms, and 
the way in which hand cleaning has occurred, and the kinds of 
technology that we can advance.
    All of those are part of where we go in the future, so 
everything that we do at Fort Belvoir particularly, because it 
was a greenfield site, are things that we tend to want to 
extrapolate, so when we go to build the new Fort Hoods of the 
world and the Fort Blisses of the world or the new Air Force 
base hospitals, where we are building those new design features 
into that, and we are learning that based on what we are 
learning in Bethesda.
    We have seen also there are some negative lessons. We know 
how difficult it is to build and operate the facility at the 
same time. You know, this is much akin to the old analogy of 
flying the airplane while you are fixing it, only we are doing 
it at hypersonic speed. And that is a big lesson.
    So where we don't have to do that in the future, that may 
be a lesson that we want to learn as well--how difficult this 
can be to operate a really first-class medical facility at the 
same time you are trying to renovate it and enhance it at the 
same time.
    So all those will be built into our building strategy, our 
acquisition strategy, our world-class strategy. And I think 
where the Defense Health Board Subcommittee has helped to 
articulate those other six domains, not just the core 
infrastructure, we do need to talk about the leadership 
processes of care, and we need to talk about performance, how 
we are doing knowledge management.
    And to that end we are having our conference. Our main 
Health and Human Services (HHS) conference in January is going 
to--basically, the theme is going to be knowledge management, 
how we share information, because we don't want Bethesda to 
become--we want it to be a center of excellence, but we don't 
want it to become an island of excellence. That is not the only 
place where excellence needs to occur. Many years ago I 
commanded a small hospital in South Dakota, and I want that 
place to be as excellent as well for the care that they can 
provide at that facility. So those are all the lessons that we 
are trying to learn to build the future, sir.
    Mr. Ortiz. Chairwoman Davis.
    Mrs. Davis. Thank you, Mr. Chairman.
    I wanted to ask about one of the issues that I think Dr. 
Kizer raised about the kind of invisible structure and the 
concern, I think, that there may not have been or--and part of 
my question is is there an ongoing process for clinician input 
into the communities of interest, essentially, that occur 
within hospitals?
    And one of the concerns is with--the amputee community 
today I know is together, and that provides, you know, some 
great benefits that I think that a number of the clinicians 
think is a good idea. We also know for breast cancer patients, 
for example, that they are also together.
    It is my understanding that some of the organization, and 
there are different philosophies about that, you know, whether 
it is more related to acuity or it is more related to the 
particular kind of issues that patients are working with and 
perhaps have an ability to share.
    So what are we seeing within that structure? And have we 
resolved all those issues? Is there still opportunity for 
clinicians to be able to present their points of view around 
that? Where are we?
    Admiral Mateczun. Chairwoman Davis, on that, a couple of 
examples just on end-user input into design, we are still 
accepting some of that. As recently as two weeks ago, we were 
at meeting on some of the rooms at Fort Belvoir. And we can't 
do big design changes, but we are working still with end-user 
input to make sure that we are able to on the design phase do 
as much as we can.
    In terms of the delivery of care, there are differences of 
opinion on organization. When we made a move towards a 
comprehensive cancer center, there were a number of desirable 
attributes of that form of care--for instance, the 
consolidation of cosmetic services, the consolidation of 
psychological counseling for cancer members that sometimes 
seemingly conflicted with the independent provision, for 
instance, of breast care centers.
    And so we have been working with the clinicians about that. 
They are still providing input. And we are continuing to do 
that. We have got a meeting coming up with all of the cancer 
chiefs, where we will be continuing to work with those 
questions about organization to make sure that they feel they 
are able to provide the best care, but that our patients are 
getting integrated care across the system.
    One of the problems that we have is that as we focus in an 
individual lane like breast care, then we sometimes lose focus 
on the integrated delivery of care for the other problems they 
may or may not have. So we are struggling with that, and I 
think we will come up with a good model.
    Mrs. Davis. All right. I would appreciate that, because I 
think that certainly the people that have created what we know 
is to be an exceptional care for our wounded warriors 
particularly, we need to continue to have that kind of input, I 
think.
    Admiral Mateczun. The amputee care will be organized 
exactly as it is today so that that whole part of the 
organization is getting imported. And one of the questions I 
frequently get is, well, is that an Army structure? Actually, 
it is a tri-service structure today. So it will come over 
intact. The way that they deliver care will be preserved.
    Mrs. Davis. Thank you. I wanted--two quicker questions to 
just pick up on a few issues that were raised. One of those 
have to do with Section 1635 of the FY 2008 NDAA. It required 
the interoperability between the DOD and the VA. And Health 
Affairs had briefed our staff--I guess this is to Mr. 
Middleton--that you have fulfilled the requirements of 1635, 
and yet we just heard today that it sounds like it is, you 
know, a work in progress.
    Mr. Middleton. I think there's two things. I think there is 
meeting the requirements, which is the interoperability, our 
ability to transfer information. I am sure we have been over 
and talked before about bi-directional information and one-
directional information with the Veterans Administration. I 
think we have articulated and can prove that we can do that.
    I think the bigger question that I alluded to before is 
what is the backbone like? What does the architecture look like 
going forward, as both departments have to modernize their 
facility? And we have come a long way from the architecture 
that we built this with many, many years ago.
    Modern technology, the Internet, there's all kinds of 
things now that afford us an opportunity to make it better and 
make it even more interoperable. And I think that is what I 
wanted to make sure that you understood is that we think we 
meet the requirements of your--but we need to do better.
    I mean we could, for example, we can push a lot more 
information right now than the Veterans Administration can 
absorb at one time because of some architectural issues within 
their system. So we need to solve that collectively. We don't 
necessarily have to have the same system. We have to be able to 
make sure that a larger system is more interoperable, and I 
think that is where we want to go, as well as modernize our own 
system.
    Mrs. Davis. Thank you.
    Admiral Mateczun, you mentioned earlier that funds had been 
identified to address and fix the concerns of the independent 
review, and I just wanted to turn to Mr. Middleton and Dr. 
Robyn. And is that true? I mean as far as you know, have those 
funds been identified that can address the concerns of the 
review?
    Admiral Mateczun. Let me clarify, Madam Chairwoman. The 
funds that are identified were with the ongoing construction. 
For anything that required new construction in the master plan, 
those funds have not been identified. So all of the 
deficiencies within the current construction are certainly 
there. Things like single patient rooms and achieving those or 
new ORs, should they be needed, funds have not been identified.
    Mrs. Davis. Funds have not been identified for those. All 
right. You would agree with that. All right. Thank you.
    Mr. Ortiz. I think we have had some wonderful testimony 
today, and me personally, I think I have learned a lot from 
your testimony. And we need to stay ahead of the curve. If we 
do send--the President recommended that we send 30,000 soldiers 
to Afghanistan, which means that--and I pray to God that we 
don't have any more casualties or, you know, young men and 
women coming back with injuries.
    And we are just going to have to be ready for whatever 
comes between now and then. And I know that, you know, you and 
I and this committee, we have huge obligations and 
responsibilities to our warriors. They have done a great job. 
Some of them just came back from Landstuhl this last week, and 
we visited some of the soldiers deploying from Italy and 
Germany back at their--who are there now, because they left two 
or three days ago.
    But I know that all of us mean well. I mean we are a team 
sitting in different locations, but we want the best for our 
warriors. I just want to thank each and every one of you for 
your testimony today. And hearing no more questions, this joint 
hearing we had today stands adjourned. Thank you so much.
    [Whereupon, at 11:30 a.m., the subcommittees were 
adjourned.]
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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                            December 2, 2009

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              RESPONSE TO QUESTION SUBMITTED BY MR. TAYLOR

    Admiral Mateczun. Each of the Military Services has programs to 
provide wounded, ill, or injured Service members who remain in the 
military opportunities for meaningful work. At the Office of the 
Secretary of Defense level, the Operation Warfighter program helps 
connect recovering wounded warriors with meaningful employment 
activities outside of the hospital environment. Operation Warfighter 
allows wounded warriors to explore employment interests, develop job 
skills, build a resume, and gain valuable work experience as interns 
with Federal agencies in the National Capital Region. It provides 
valuable assistance to wounded warriors transitioning back to the 
military or into the civilian community and workplace. [See page 21.]
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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                            December 2, 2009

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                    QUESTIONS SUBMITTED BY MR. ORTIZ

    Mr. Ortiz. Walter Reed Army Medical Center (WRAMC) was essentially 
closed by Base Realignment and Closure (BRAC) 2005 and the functions 
principally realigned to Bethesda, MD, and Fort Belvoir, VA. BRAC-
related costs have increased significantly and the Department will be 
challenged to meet the September 2011 BRAC deadline. What steps is the 
Department pursuing to limit cost and schedule growth? Will the 
Department be able to meet the BRAC statutory deadline of September 
2011? What are the biggest challenges that will need to be addressed in 
order to meet the BRAC statutory deadline?
    Mr. Middleton. The Department utilizes a well established vetting 
and approval process to limit cost and schedule growth. The Deputy 
Secretary of Defense is the final approval authority. As a result, the 
Department is on schedule to meet the BRAC statutory deadline. The 
biggest challenges facing the Joint Task Force, National Capital Region 
Medical (JTF CAPMED) and the Department are not related to construction 
but include governance, financial management, potential workforce 
attrition, and transition to the new facilities.
    The scope of the transformation in National Capital Region (NCR) 
Medical has evolved since the original BRAC recommendations. Per the 
Naval Facilities Engineering Command and the Army Corps of Engineers, 
the Department is currently on schedule to complete the NCR Medical 
BRAC transfer of functions by the September 15, 2011 deadline. As such, 
there is minimal schedule risk left in the construction at Bethesda and 
Fort Belvoir. JTF CAPMED, via its Project Management Office, is 
overseeing the Walter Reed transition and has awarded the Initial 
Outfitting & Transition contract for both hospitals as well. This 
contract brings together the industry leaders to ensure that outfitting 
the buildings and transition of patients and staff will occur safely by 
September 15, 2011. To maintain schedule, the Department is working 
with the contractors to find efficiencies so it can mitigate potential 
delays should they occur.
    The Department is putting to bear all its available resources to 
mitigate inherent operating risks both WRAMC and the National Naval 
Medical Center (NNMC) pose during BRAC. At WRAMC, it will be important 
to maintain the civilian workforce to preserve current capability and 
to staff both of the new hospitals. The Department has identified a 
military force mix for Walter Reed National Military Medical Center 
(WRNMMC) and Fort Belvoir Community Hospital (FBCH). It is also working 
to finalize the manning document to make notifications to employees of 
their locations in the end state by spring 2010. At NNMC, the Navy must 
continue to provide healthcare while renovations require the relocation 
of many functions. During the actual movement of patients from WRAMC to 
WRNMMC and FBCH, direct care system patients will be appropriately 
transferred to the private sector or other military hospitals 
temporarily to allow for the transition.
    Bethesda--The Department continues to apply a wide range of 
acquisition and construction strategies, tactics, and techniques to 
limit cost and schedule growth while performing complex construction 
and renovation work on the active Bethesda campus. Significant customer 
input was collected both during concept development and early in the 
Design-Build process to create the schedule which supports the BRAC 
statutory deadline. The dialogue with end-users is still being 
maintained throughout each design stage and the ongoing construction 
phases. Once the requirements were determined, agreements were 
developed with all stakeholders to maintain the aggressive schedule, 
and to control cost for fixed scopes of work. The Defense Contract 
Audit Agency was used to perform contractor audits, which established 
reasonable market rates for design and construction needed to meet 
customer requirements. While maximizing patient safety, construction 
phasing for the renovation areas was organized to temporarily relocate 
functions, coordinate patient versus construction boundaries, and 
reduce the number of phases. All these Department efforts have 
maximized efficiency by reducing cost and shortening the schedule.
    Fort Belvoir Community Hospital--The FBCH was contracted under the 
fast track, Integrated Design Bid Build process. This method operates 
in a cost-reimbursable mode during design development and is then 
converted to a firm, fixed price once the design is substantially 
completed. The design is complete and the Department is currently in 
negotiations with the contractor to make the contract definite.
    During the design phase of the project, risk of cost and schedule 
growth was significantly higher than it currently is. During the design 
period, the project team spent an extensive amount of energy and time 
coordinating with the Army's Health Facilities Planning Agency, JTF 
CAPMED, and Assistant Secretary of Defense for Health Affairs to ensure 
optimal design incorporating evidence-based design components and met 
the needs of the medical mission by providing a ``world-class'' medical 
facility. Since the design is now complete, the risk of additional cost 
and schedule growth beyond what has already been identified is 
significantly reduced. However, the entire project team must remain 
vigilant to minimize changes to the final design so the risk of 
additional costs and delays are minimized. In the event a change to the 
final design is identified, it will be scrutinized by management of all 
major stakeholder organizations to assure that it is absolutely 
essential and steps will be taken to mitigate cost and schedule impacts 
to the greatest extent practicable. To ensure that the Department is 
paying a fair-market price for this facility, it has engaged Defense 
Contract Audit Agency early in the project and is currently auditing 
the Contractor's proposal to assure all costs identified by the 
contractor are allowable and allocatable.
    Evolution to World Class--The Department is committed to achieving 
world-class standards, as defined and directed under the law, at 
Bethesda and Fort Belvoir Community Hospital. However, completion of 
NCR Medical BRAC projects and the evolution to world class standards at 
Bethesda are two separate and necessarily sequential efforts. The 
Department is developing an NCR Medical Comprehensive Master Plan, as 
required by Section 2714 of the National Defense Authorization Act for 
Fiscal Year 2010, which will synchronize both of these efforts to 
maximize the effective use of resources while maintaining patient 
safety.
    Mr. Ortiz. Much progress has been made to improve the diagnosis and 
treatment of the so-called ``silent wounds of war''--traumatic brain 
injury (TBI) and post-traumatic stress disorder (PTSD). However, 
medical practitioners at the National Naval Medical Center (NNMC) 
currently use somewhat different tools and approaches for the detection 
and treatment of TBI and PTSD compared to their counterparts at the 
Walter Reed Army Medical Center (WRAMC). What measures will be needed 
to reconcile diagnostic and treatment differences for these conditions? 
To what extent will findings from the Defense Centers of Excellence for 
TBI and PTSD be relied upon to standardize the diagnosis and treatment 
for TBI and PTSD at the NNMC? To a large extent, the NNMC and WRAMC 
have become specialized in different medical disciplines--the NNMC in 
brain injury and neurosurgical procedures and WRAMC in amputation and 
physical rehabilitation. In the future at a merged NMMC, will the Navy 
and Army largely continue to maintain these specializations? If so, how 
will this affect the organization, staffing, and management of medical 
treatment at the NMMC?
    Mr. Middleton. In the future, world-class medical care in each of 
these specialties will be available at the new facility. Clinical 
expertise in the Navy's brain injury and neurosurgical procedures and 
the Army's amputee care and rehabilitation programs will be merged and 
integrated at the new Walter Reed National Military Medical Center 
(WRNMMC). The complexity of TBI and psychological health requires 
specialized care that crosses a multitude of specialties. Unified 
leadership across these specialized services will ensure comprehensive 
holistic care throughout the continuum of care within the military and 
veterans' health care system. The TBI services will soon become one 
integrated service combining the concept of operation and assets from 
both the NNMC and the WRAMC. Access to TBI services will be at a single 
site in the clinical building at WRNMMC. There, the clinical screening 
teams, case managers, and multidisciplinary treatment teams will meet 
the patients and family members in one defined location. With a fully 
integrated staff, all members of the WRNMMC staff required in the 
management of patients with TBI will be appropriately trained and 
utilized regardless of their Service affiliation.
    Amputee care and physical rehabilitation will be available as part 
of the Orthopedic and Rehabilitation Department. Space allocations and 
personnel resources have been dedicated to support all of these 
programs. Medical, nursing, and support staff will be fully integrated, 
appropriately trained, and utilized in the management of amputee care 
and rehabilitation regardless of their service affiliation.
    Mr. Ortiz. Congress has appropriated more than $5 billion to 
support ongoing construction and renovation over the past three years. 
What are the current lessons learned from the ongoing realignment of 
Walter Reed? How will the lessons learned be incorporated into future 
military construction contracts at other ongoing construction 
locations? Will elements of a world-class and premier military 
treatment facility be incorporated into future designs? What is the 
goal of Department of Defense (DoD) Health Affairs in military 
construction?
    Mr. Middleton. At this point, it is premature to fully evaluate the 
success of the different acquisition strategies utilized at Bethesda 
and Fort Belvoir. A full assessment of both will be conducted in 
conjunction with the U.S. Army Corps of Engineers and the Naval 
Facilities Engineering Command upon completion of both projects. The 
assessment will not be limited to simply cost and schedule metrics, but 
will also evaluate the degree to which key stakeholders, including 
patients, families, and staff, feel these new facilities provide 
patient-centric healing environments. The aggressive design/build and 
integrated design/bid/build strategies utilized by the design/
construction agents were necessary and allow the Department to achieve 
the Base Realignment and Closure deadline set by law. The standard 
design/bid/build process would not have done so. Lessons learned will 
be incorporated into future military construction contracts at other 
locations where appropriate. This will be done through updates to 
current DoD Directives and adjustments to acquisitions strategies by 
our design/construction agents.
    The key tenets of ``world-class'' infrastructure identified by the 
Defense Health Board are already included in current DoD guidance for 
hospital design and construction and are being incorporated into future 
designs.
    The goal of OASD (Health Affairs) in military construction is to 
design and build health facilities that meet the tenets of ``world-
class'' and promote a patient-centric healing environment while 
employing evidence-based design principles.
    Mr. Ortiz. Wide discretion is provided to the Department to 
implement design standards. However, this leads to a significant 
disparity in the quality of facilities and in the case of the Bethesda 
Naval Medical Center, a significant difference between the new 
construction and the rest of the medical center.

      In determining the construction/renovation criteria of a 
construction contract, does the Department seek to obtain the latest 
construction standard or does the amount of funding determine the scope 
of construction?

      What is being done to ensure adequate housing and support 
services for the families of patients receiving extended inpatient and 
outpatient care at the National Military Medical Center? In addition, 
are there plans to improve the accommodations of Mercy Hall at NNMC to 
the level now found at the Malogne House on the WRAMC campus?

    Dr. Robyn. [The information was not available at the time of 
printing.]
    Mr. Ortiz. DUSD (I&E) has indicated their intent to limit further 
BRAC investments and defer further renovation investments until after 
BRAC so that Service O&M funds can be obtained.

      Will the strategy of limiting Service O&M investments 
until after BRAC achieve the vision of a world-class medical center?

      Does the current construction plan require BRAC 
appropriations to renovate the remaining Bethesda campus? Will the 
responsible services then be required to renovate these areas again 
using Operation and Maintenance appropriations?

    Dr. Robyn. [The information was not available at the time of 
printing.]
    Mr. Ortiz. According to the Defense Health Board report: ``The BRAC 
funding process entails a number of constraints and limitations that do 
not support the creation of a comprehensive plan and construction 
strategy, particularly for renovation of existing facilities. These 
limitations have been, and continue to be, a major impediment to 
designing the new WRNMMC to be a world-class medical facility. The BRAC 
2005 appropriation limits use of these funds.'' Later on the report 
states that there is no need to halt construction of the new facilities 
if a plan can be developed to accomplish backfill renovations in a 
timely manner.
    However, there has been some discussion between DOD and the Defense 
Health Board about whether or not to halt construction while a master 
plan is developed and whether or not the BRAC law and funding process 
would permit development of a Master Plan using BRAC funds.

      Is the Defense Health Board recommending a halt to 
construction while a master plan is developed? If so, how likely is DOD 
to meet the statutory deadline of September 15, 2011 for completion of 
this BRAC recommendation?

      What is the timeline for DOD to create a comprehensive 
facility master plan?

      How will development of a master plan affect DOD's 
ability to complete construction by the September 15, 2011 deadline?

    Dr. Robyn. [The information was not available at the time of 
printing.]
    Mr. Ortiz. The Army and the Navy's approach to support to wounded 
warriors and their service members vary significantly. With this merger 
of these two cultures at the militaries premier medical center, there 
has been a clash of military cultures.

      What is being done to ensure adequate housing and support 
services for the families of patients receiving extended inpatient and 
outpatient care at the National Military Medical Center? In addition, 
are there plans to improve the accommodations of Mercy Hall at NNMC to 
the level now found at the Malogne House on the WRAMC campus?

    Dr. Robyn. [The information was not available at the time of 
printing.]
    Mr. Ortiz. Bethesda National Military Medical Center Transition. 
The Joint Task Force has advocated for the transition of the Walter 
Reed Army Medical Center to occur after all construction is complete 
and during an abbreviated timeline of a few days in August 2011. This 
timeline raises the risk to maintaining patient care and has the 
potential for inducing a significant disruption. Will patient care 
suffer during the accelerated transition period?
    Admiral Mateczun. While the NCR Medical BRAC construction and 
initial outfitting & transition (IO&T) timeline for Bethesda and Fort 
Belvoir is aggressive, the Department, through integrated program and 
project management, has developed comprehensive milestone schedules and 
a transition of operational plans as part of its Master Transition Plan 
(MTP) for the Walter Reed transition. JTF CAPMED's BRAC Transition 
Program Management Office (PMO) is coordinating transition planning 
across all three facilities (Walter Reed Army Medical Center, National 
Naval Medical Center and Dewitt Army Community Hospital) and developing 
risk management plans to ensure patient safety and patient care is 
maintained during all phases of the transition. In addition, firms in 
the private sector retain hospital transition activities as a core 
competency and the IO&T contract that JTF CAPMED just awarded will 
leverage that competency.
    Patient care will not suffer during an accelerated transition 
period. This notion is supported by industry standards from world-class 
institutes such as UCLA, which transitioned all hospital services over 
14 day time period, including 342 patients which were moved in a five 
hour period.
    The key to maintaining patient care and ensuring patient safety 
during all phases of the BRAC transition is proactive and comprehensive 
transition planning. The Department provided its initial MTP to 
Congress on September 30, 2009, as part of its response to section 
1674(a) of the National Defense Authorization Act (NDAA) for Fiscal 
Year 2008. The MTP, an iterative document, explained in February 2009, 
the Joint Task Force, National Capital Region Medical (JTF CAPMED) held 
a Transition War Game to commence the initial transition planning among 
the NCR Medical stakeholders. At this War Game, group consensus was 
services should not transition from Walter Reed Army Medical Center 
(WRAMC) to Walter Reed National Military Medical Center (WRNMMC) and 
Fort Belvoir Community Hospital (FBCH) until all critical activities 
are completed at the Bethesda campus or appropriate mitigation 
strategies have been instituted. One key trigger activity is ensuring 
all essential clinical and supporting services are in place and fully 
functional. Several facilities, including clinics, staff parking 
garages and the Warrior Transition Center Complex, are not expected to 
be ready for occupancy until late summer 2011. The consensus of the 
group was that it is an unnecessary risk to attempt to transition 
patients and staff when the necessary facilities may not be fully 
operational. Following completion of these critical activities, the 
Department is prepared to execute a well orchestrated, consolidated 
transition of staff and patients from WRAMC will occur.
    To ensure industry standards and best practices are incorporated 
into our transition plans, JTF CAPMED conducted an in-depth study on 
seven major medical centers that have relocated to new facilities in 
the past three years. The findings of this study support the Transition 
War Game recommendation for transitioning inpatients over a 
consolidated period of time, as was done at major tertiary care 
facilities such as Catholic Health Initiatives: St. Joseph's Medical 
Center in Reading, PA. This 200 bed teaching hospital relocated eight 
miles with all in-patients transferred in six hours. The key to a 
successful move with patient safety maintained is assembling a 
transition team to develop a move plan, ensure training and orientation 
of staff prior to the relocation, and executing a phased move of all 
non-patient essential functions early when space permits.
    The Department maintains that conducting a well-planned, 
abbreviated transition is the least risky option for it patients.
    Mr. Ortiz. The Army incorporated a single-patient room standard at 
Fort Belvoir. The Navy has elected to retain the vast majority of 
patient rooms at two per room. The Independent Design Review panel has 
indicated that a single-patient room standard is general practice for 
most medical facilities. Why did the Department include different 
patient room standards at Bethesda and Fort Belvoir? What is the 
industry standard? Did costs limit the ability of the Department to 
implement a consolidated standard? Why does the Department provide such 
latitude in construction standards?
    Admiral Mateczun. The American Institute of Architects guidelines 
mandate single-patient rooms only for new hospital construction. There 
is no mandate to retrofit existing facilities, although application of 
this standard will be considered when undertaking major renovations of 
existing facilities. The Department's standard mirrors that of the 
industry and is being applied to all new hospital construction in the 
Department. As a result, Fort Belvoir includes all single-patient rooms 
and Bethesda does not. The Department did provide additional funds to 
incorporate single-patient rooms for our Wounded Warriors at Bethesda, 
so cost was not a factor in that decision. The Department will consider 
the need for additional single-patient rooms post Base Realignment and 
Closure as part of the ongoing master planning effort at the Bethesda 
campus.
    Mr. Ortiz. It has been reported that the Joint Task Force is not 
accepting any additional clinician input into the design process. Will 
the Department continue to accept clinician input into the design and 
construction process? Will these suggestions result in changes into the 
overall layout?
    Admiral Mateczun. Clinician as well as patient input has been 
integral to ensuring the design of the new Walter Reed National 
Military Medical Center, and the Fort Belvoir Community Hospital will 
meet all future mission requirements and provide an unparalleled 
standard of care for this Nation's most deserving patients. However, as 
the construction process moves forward and in some portions of the 
project nears completion, there is less flexibility in adjusting 
designs without significantly delaying delivery of the buildings, 
incurring an unacceptable increase in cost, or violating contractual 
agreements.
    Regardless of these obstacles the Department continues to evaluate 
clinician and patient input. Also, where it is prudent to preserve the 
safety and quality of patient care, it has sought additional funding to 
incorporate these changes. Some of these changes have significantly 
changed the interior designs of the wards and clinics but have not 
impacted the exterior design of the buildings. The revised design of 
the Cancer Center and the improved design of the Optometry Clinic are 
indicative of the changes the Department has made during the 
construction process.
    The Department continues to compile inputs from clinicians to 
appropriately implement in the non-BRAC projects that the Department 
identifies are required to achieve ``world-class'' standards, as 
defined under section 2714 of the National Defense Authorization Act 
for fiscal year 2010.
    Mr. Ortiz. Medical Care and Facilities Merging. The impending 
merger has produced a high degree of anxiety among many medical and 
non-medical staff. Some staff report that they have been informed that 
their positions will be terminated; some have been told that staffing 
plans have been changed and that they will be retained after all; some 
are in limbo. What is being done to ensure adequate housing and support 
services for the families of patients receiving extended inpatient and 
outpatient care at the National Military Medical Center? In addition, 
are there plans to improve the accommodations of Mercy Hall at NNMC to 
the level now found at the Malogne House on the WRAMC campus?
    Admiral Mateczun. Medical Centers within the Department of Defense 
are always constructed to meet current and future mission requirements 
by using the most up-to-date standards. All medical projects at Walter 
Reed National Military Medical Center (WRNMMC) and at Fort Belvoir are 
designed based upon standards as described in the Unified Facilities 
Criteria (UFC) 4-510-01, ``Design: Medical Military Facilities'' issued 
by the Department of Defense. The UFC is developed and maintained by 
DoD medical engineering and design experts based upon the ``best 
practices'' in industry. As such, DoD medical projects have always been 
required to meet, if not exceed, industry standards. Currently, the 
Department is developing a Comprehensive Master Plan for the NCR 
Medical that will identify the requirements to achieve ``world-class'' 
standards, as defined and directed under section 2714 of the National 
Defense Authorization Act for fiscal year 2010, at Bethesda.
    The Department is utilizing existing assets and construction 
donated by private entities to provide housing for families of patients 
receiving extended inpatient and outpatient care at the WRNMMC. 
Currently, existing Navy Lodge, Fisher Houses, and Visiting Officer 
Quarters are available to provide temporary housing for families of 
patients. Those facilities will be augmented by three (3) new Fisher 
Houses which are currently under construction and will provide an 
additional 60 family suites. At present, there are no plans for 
additional renovation of Mercy Hall. Mercy Hall was built in 1968 and 
renovated to current Americans with Disabilities Act (ADA) standards in 
2008, providing 98 fully ADA compliant single occupancy rooms. The Hall 
is sited near inpatient and certain administrative services for wounded 
warriors and has proven to be an excellent facility in which to house 
wounded warriors that require close proximity to these services and 
require additional supervision to function as an outpatient. There is 
no intention to use Mercy Hall as temporary family accommodations. 
However, the Department is working diligently to define additional 
temporary housing requirements for the families of patients that will 
receive care at the new WRNMMC.
    Regarding support services, there are already plans in place to 
expand support services on the Bethesda Campus. The Navy Exchange (NEX) 
will start construction of its new facility in Calendar Year 2010. The 
new NEX will be more than triple the size of the current NEX and will 
allow the NEX to carry a broader array of goods tailored to meet the 
needs of wounded warriors and their families. The Department will also 
provide a great number of services for Warriors in Transition (WIT) to 
include a physical fitness center that will be sized to properly 
accommodate the space and access requirements of the WRNMMC WIT 
population and allow them to exercise alongside other Warriors and 
caregivers. This will support integration and re-integration of WITs 
into their community, and the reestablishment of the warrior/athlete 
ethos. Additionally, Commander Navy Installations Command (CNIC) is 
proactively seeking to significantly expand child care services. These 
services are not currently available on the Campus.
    Mr. Ortiz. Medical Care and Facilities Merging. The impending 
merger has produced a high degree of anxiety among many medical and 
non-medical staff. Some staff report that they have been informed that 
their positions will be terminated; some have been told that staffing 
plans have been changed and that they will be retained after all; some 
are in limbo. What is being done to facilitate a successful merger of 
the NNMC and WRAMC personnel? What is being done to maintain morale 
before, during, and following the merger? In addition, what are the 
current and planned post merger staffing by department or function at 
NNMC and WRAMC? If changes are planned post merger, why are these 
changes needed and what will be the impact on the provision of needed 
medical care?
    Admiral Mateczun. At Walter Reed Army Medical Center (WRAMC), it 
will be important to maintain the civilian workforce to preserve 
current capability and to staff both of the new hospitals. Extensive 
planning has been accomplished to implement the Department mandated 
Guaranteed Placement Program (GPP) for WRAMC hospital personnel and to 
effectively merge Army and Navy employees into a single workforce of 
civilians at the new Walter Reed National Military Medical Center 
(WRNMMC). Leadership representatives from the four National Capital 
Region hospitals are members of the Civilian Human Resources Council, a 
group chartered to ensure placement of employees who remain at WRAMC 
through closure. In order to meet the dual goals of the GPP commitment 
and the creation of a ``world-class'' workforce, the Council will 
identify Service best practices to develop the new National Capital 
Region Medical culture of the future. The Council members are working 
collaboratively to modify current position management and hiring 
processes at WRAMC and the National Naval Medical Center (NMMC) in 
order to maximize the placement of WRAMC employees in their location of 
choice in 2011. The Department plans to begin notifying individuals of 
their work locations in the end-state in Spring/Summer 2010, after the 
final validation of the new hospital staffing plans is complete.
    The Department's civilian workforce is a center of gravity. It 
strives to maintain morale by communicating updates on the BRAC 
Integration and Transition progress to employees using venues such as 
monthly Town Hall meetings, electronic, and print media. This type of 
communication will continue after the BRAC integration to facilitate 
ongoing dialogue needs of employees. A detailed plan has been developed 
to guide the transition and integration of employees from WRAMC to 
WRNNMC and Fort Belvoir Community Hospital (FBCH). Beginning with the 
approval of a Joint Table of Distribution (JTD), it seeks to align the 
current workforce using workforce planning techniques that optimize the 
assignment of employees, coordinate efforts by civilian Human Resources 
Specialists (HR), and establish standardized policies/processes that 
will ensure quality HR support in the future.
    Mr. Ortiz. What recommendations can be offered to ensure that the 
construction designs obtain a world-class standard?
    Dr. Kizer. The National Capital Region Base Realignment and Closure 
Health Systems Advisory Subcommittee (NCR BRAC HSAS) of the Defense 
Health Board has made many specific recommendations for what needs to 
be done for the design of the new Walter Reed National Military Medical 
Center (WRNMMC) to more likely achieve world class status. These 
recommendations were detailed in our report last June, copies of which, 
I understand, were provided to the House Armed Services Committee by 
the Department of Defense last July.
    In viewing our recommendations it should be remembered that this is 
not a static process and that as design changes and renovations are 
made additional concerns or issues may arise. Also, as noted in our 
report and in my testimony, the facility design and construction will 
not in and of itself make the new WRNMMC a world class medical 
facility, although it may prevent it from achieving such a level of 
excellence. Most of what will make the new WRNMMC a world class medical 
facility will be its ``invisible architecture''--i.e., its values, 
culture, leadership, staff morale and processes of care.
    As noted in our report and in my testimony, the three most urgent 
needs in this regard are to: (1) resolve the authority issue; (2) align 
funding sources; and (3) rapidly develop a master plan.
    Mr. Ortiz. If changes are implemented in the renovation effort, 
could they be implemented and still obtain the September 2011 BRAC 
deadline?
    Dr. Kizer. It will be very difficult. If this deadline is to be 
met, then substantive work on the master plan and changes in the 
renovation effort must begin immediately. The likelihood of meeting the 
deadline diminishes every day that progress is not made in addressing 
the identified needs.
    Mr. Ortiz. In your estimate, what is the risk associated with 
moving the Walter Reed functions to Bethesda/Fort Belvoir by September 
2011? What are the consequences (in terms of patient care)?
    Dr. Kizer. If the NCR BRAC HSAS recommendations are addressed and 
implemented then there should be little risk. If they are not 
adequately addressed, then the consequences will depend on what 
problem(s) is/are not addressed, among other factors.
    Depending on what specific problem(s) is/are not addressed, then 
care could be compromised in multiple ways, including patient safety, 
infection control, patient and family comfort, staff morale, confusion 
in way finding, physician and nurse productivity, and provision of 
critical services, to name some.
                                 ______
                                 
                  QUESTIONS SUBMITTED BY MS. BORDALLO

    Ms. Bordallo. Section 722 the National Defense Authorization Act 
for Fiscal Year 2008 called for the establishment of a Joint Pathology 
Center as a successor to the current Armed Forces Institute of 
Pathology. The legislation established a mandate to perform at least 
for core minimum functions:

    1.  Diagnostic pathology consultation services in medicine, 
dentistry, and veterinary sciences;

    2.  Pathology education, to include graduate medical education, 
including residency and fellowship programs, and continuing medical 
education;

    3.  Diagnostic pathology research; and

    4.  Maintenance and continued modernization of the Tissue 
Repository and, as appropriate, utilization of the Repository in 
conducting the activities described in paragraphs (1) through (3).

    Notwithstanding this mandate, the Defense Health Board has on two 
separate occasions criticized the concept of operations for the Joint 
Pathology Center as insufficient to carry out the its mandate. 
Furthermore, in light of the National Defense Authorization Act for 
Fiscal Year 2010's mandate to create a master plan that will ``ensure 
the delivery of world class military medical facilities across the 
National Capital Region'', what concrete actions is the Department of 
Defense taking to ensure that the Joint Pathology Center will meet that 
world class standard?
    Mr. Middleton. Section 722 of the National Defense Authorization 
Act (NDAA) for Fiscal Year (FY) 2008 mandated a Joint Pathology Center 
(JPC) be established in to function as the reference center in 
pathology for the Federal Government. Is stated that the JPC should 
provide at a minimum:

      Diagnostic pathology consultation in medicine, dentistry, 
and veterinary services;

      Pathology education, to include graduate medical 
education, including residency and fellowship programs;

      Diagnostic pathology research

      Maintenance and continued modernization of the Tissue 
Repository

    Additionally, the JPC must be established consistent with BRAC law.
    The Department of Defense (DoD) chartered a JPC work group in April 
2008, that included senior leadership from the Armed Forces Institute 
of Pathology (AFIP), Uniformed Services University of the Health 
Sciences (USUHS), Military Services, Department of Veterans Affairs, 
and Department of Health and Human Services to develop options for a 
JPC within the Department. The JPC Working Group was instrumental in 
developing the initial Concept of Operations (CONOPS) to meet the 
mandate under Section 722 of the NDAA for FY 2008. Based on the initial 
CONOPS, the Department chose to establish the JPC under the Joint Task 
Force, National Capital Region Medical (JTF CAPMED).
    Upon delegation of the JPC mission to JTF CAPMED in December 2009, 
an interim director was appointed. Prior to this, JTF CAPMED took the 
lead in establishing an inter-organizational Implementation Team 
consisting of members from the three Services, VA, USUHS, AFIP, OASD 
(Health Affairs), and Office of the Army Surgeon General to carefully 
review the concept of operations, identify gaps in proposed services, 
and develop an expanded concept of operations and implementation plan. 
As a result of this analysis, several critical services were identified 
and additional personnel requirements to appropriately staff the JPC 
were also identified. A detailed concept of operations and 
implementation that includes these critical services and personnel 
requirements is being finalized. Additionally, the JPC is working 
closely with AFIP to finalize a phased implementation plan for the JPC 
to enable the proper transfer of function to the JPC without loss of 
continuity of clinical care while appropriately balancing and 
addressing civilian personnel considerations.
    The Defense Health Board (DHB), in its advisory role to the 
Department, reviewed the initial JPC CONOPS, which was not a detailed 
implementation plan. The implementation plan under development by the 
JPC Implementation Team addresses the concerns of the DHB and will meet 
the recommendations of the DHB review with the exception of JPC 
oversight being provided by a Board of Governors. Based on the JPC's 
mission set, the Department recommends a Federal Board of Advisors 
comprised of primary stakeholders.
    The depth and scope of clinical services provided by the JPC 
include, but are not limited to the list below. In some areas, the 
services will be more robust than those provided by AFIP.

      The JPC will provide full-spectrum, comprehensive, expert 
secondary pathology consultation to the federal government utilizing 
state-of-the-art immunohistochemical and molecular diagnostic studies.

      The JPC will be one of the few centers in the country 
offering full-service muscle biopsy analysis and comprehensive Depleted 
Uranium testing and imbedded fragment analysis in support of our 
wounded warrior population and operations in-theater and will provide 
full-spectrum pathology support for the critical Armed Forces Medical 
Examiner mission.

      The JPC will continue and expand the AFIP mission of 
providing telemedicine expert consultation (telepathology) to remote 
hospitals and in support of pathology services in theater and overseas.

      The JPC will continue the AFIP mission of providing a 
one-of-a-kind comprehensive Veterinary Pathology service to the 
Department and several other federal government agencies that includes 
Veterinary Pathology Consultation, research, education to veterinarians 
worldwide, and a Veterinary Pathology Residency Training Program for 
the Department.

      The JPC will leverage state-of-the-art and evolving 
technology in providing its education mission through robust online 
educational opportunities to government physicians worldwide and will 
provide graduate medical education in support of government residency 
and fellowship programs nationwide.

      The JPC will support critical clinical research missions 
such as the Combat Wound Initiative and Traumatic Brain Injury 
initiatives.

      JTF CAPMED recognizes that the Tissue Repository is an 
invaluable asset that, if appropriately utilized, could be the leading 
Tissue Biorepository and greatly advance medical knowledge and 
technology. The JPC will partner with leaders in medical research and 
biorepository management to carefully develop a comprehensive plan to 
fully utilize the vast Tissue Repository in support of medical research 
throughout the federal government and in partnership with civilian 
academic institutions.

    Ms. Bordallo. Some members of the community surrounding the current 
Bethesda Naval Hospital have raised concerns about the level of 
interagency cooperation specifically between Navy, Army and NIH. In 
particular, there is significant concern about the impact to traffic in 
the area. The stretch of Wisconsin Avenue that is impacted greatest by 
the realignment is already extremely congested during peak travel 
hours. A recent GAO report on the Guam military build-up reiterated the 
need for the convening of a meeting of the Economic Adjustment 
Committee to better coordinate all federal government resources. Would 
a meeting of the Economic Adjustment Committee better help facilitate 
an improved federal government interagency process to address the 
``outside the fence'' impacts at Bethesda Naval Hospital?
    Dr. Robyn. [The information was not available at the time of 
printing.]
                                 ______
                                 
                  QUESTIONS SUBMITTED BY MR. LOEBSACK

    Mr. Loebsack. How will you assure that patients receive the 
absolute best care in specialties such as pain care, mental health, TBI 
care, and prosthetic care at the new Walter Reed facility in Bethesda? 
Particularly on the pain care issue--Walter Reed is a leader in this 
specialty amongst the military medical facilities. How will this care 
be maintained and enhanced in the new facility? Are there specific 
issues that must be taken into account for specialties such as pain 
care and physical therapy that are being incorporated into the design 
plans for the new campus?
    Mr. Middleton. The Department will continue to provide absolute 
best care to patients at the new Walter Reed National Military Medical 
Center (WRNMMC). The Army's capabilities at WRAMC with amputee care are 
leading transformations in prosthetics and rehabilitation and the 
Navy's expertise in open Traumatic Brain Injury (TBI) at NNMC is 
renowned world-wide. The integrated clinical chiefs of all the current 
departments within the National Naval Medical Center (NNMC) and the 
Walter Reed Army Medical Center (WRAMC) are dedicated to preserving the 
tradition of excellence that distinguishes both healthcare providers 
today.
    Pain Management--WRAMC has become a center of clinical expertise 
for the art and science of advanced regional anesthesia techniques and 
acute pain management. This has become invaluable in the management of 
pain in both the austere environment of war and in the civilian 
clinical setting. Since this clinical advancement plays such a 
significant role in current and future operations, dedicated clinical 
space and personnel have been committed for both regional anesthesia 
and chronic pain management clinics planned for the Walter Reed 
National Military Medical Center. In Building 9, 8,500 sq. ft. of space 
is dedicated to the Pain Care Center of Excellence which will maintain 
the ``world-class'' expertise and training capabilities currently 
available at WRAMC.
    Mental Health--Psychological health issues have become one of the 
most prominent injuries of the current conflicts. The Department has 
increased capacity to address these issues commensurate with the 
mission requirements. The new organizational structure will include 
both psychiatry and psychology as separate departments with personnel 
assigned that match these needs. In the new outpatient clinic, 45,000 
sq. ft. of space primarily on the sixth level of Building A is 
dedicated to outpatient behavioral health. A robust partial 
hospitalization program to decrease the demand for inpatient beds has 
been designed in line with the current program at WRAMC and the Defense 
Veterans Brain Injury Center (DVBIC) clinical component. There will be 
two new inpatient psychiatry wards (27,000 sq. ft. in Building 10) with 
a total bed capacity of 28. An additional 12 inpatient beds and partial 
hospitalization capabilities are designed for the new Fort Belvoir 
Community Hospital (FBCH).
    Traumatic Brain Injury (TBI)--Treatment for Traumatic Brain Injury 
will include a six bed specialty inpatient ward and a highly functional 
multi-disciplinary clinical group that includes clinical neurologists, 
psychiatrists, psychologists, orthopedists, physical and occupational 
therapists, neuropsychometrists, and other traumatic brain injury 
specialists. These programs will transition and integrate available 
expertise from both NNMC and WRAMC programs. All clinical expertise 
will be in close proximity to the new National Intrepid Center of 
Excellence at Bethesda that is dedicated to research, diagnosis and 
treatment of military personnel and veterans suffering from traumatic 
brain injury and psychological health issues.
    Prosthetic Care--Military beneficiaries (active duty, retirees and 
dependants) with upper and lower extremity amputations currently 
receive the best medical care in the world. Nearly one whole floor in 
the new outpatient clinic addition (Building A) will be dedicated to 
physical medicine modalities with additional services and diagnostic 
support provided on two other floors. Over 115,000 sq. ft. is dedicated 
to Physical Therapy, Physical Medicine and Rehabilitation, Occupational 
Therapy, Amputee Center, Orthotics, Prosthetics, Chiropractic Services, 
Orthopedics, Podiatry, and a satellite Laboratory, Radiology, and 
Pharmacy on the first three floors of the new outpatient clinic. This 
represents the largest physical medicine footprint in all of the 
Department of Defense and will continue to provide WRAMC's current 
capabilities in the care of amputees and the manufacture and adjustment 
of state-of-the-art upper and lower extremity prosthetics.
    Physical Therapy--Physical therapy plays a major role in the 
rehabilitation of amputees, traumatic brain injured, and 
psychologically injured patients. Clinical space in the new clinical 
building outlined above and in the inpatient areas have been designed 
to offer the best medical care to these injured patients. Appropriate 
personnel have been designated on the current manpower document to 
complete the mission in these areas.
    Mr. Loebsack. How will you assure that patients receive the 
absolute best care in specialties such as pain care, mental health, TBI 
care, and prosthetic care at the new Walter Reed facility in Bethesda? 
Particularly on the pain care issue--Walter Reed is a leader in this 
specialty amongst the military medical facilities. How will this care 
be maintained and enhanced in the new facility? Are there specific 
issues that must be taken into account for specialties such as pain 
care and physical therapy that are being incorporated into the design 
plans for the new campus?
    Dr. Robyn. [The information was not available at the time of 
printing.]
    Mr. Loebsack. How will you assure that patients receive the 
absolute best care in specialties such as pain care, mental health, TBI 
care, and prosthetic care at the new Walter Reed facility in Bethesda? 
Particularly on the pain care issue--Walter Reed is a leader in this 
specialty amongst the military medical facilities. How will this care 
be maintained and enhanced in the new facility? Are there specific 
issues that must be taken into account for specialties such as pain 
care and physical therapy that are being incorporated into the design 
plans for the new campus?
    Admiral Mateczun. The Department will continue to provide absolute 
best care to patients at the new Walter Reed National Military Medical 
Center (WRNMMC). The Army's capabilities at WRAMC with amputee care are 
leading transformations in prosthetics and rehabilitation and the 
Navy's expertise in open Traumatic Brain Injury (TBI) at NNMC is 
renowned world-wide. The integrated clinical chiefs of all the current 
departments within the National Naval Medical Center (NNMC) and the 
Walter Reed Army Medical Center (WRAMC) are dedicated to preserving the 
tradition of excellence that distinguishes both healthcare providers 
today.
    Pain Management--WRAMC has become a center of clinical expertise 
for the art and science of advanced regional anesthesia techniques and 
acute pain management. This has become invaluable in the management of 
pain in both the austere environment of war and in the civilian 
clinical setting. Since this clinical advancement plays such a 
significant role in current and future operations, dedicated clinical 
space and personnel have been committed for both regional anesthesia 
and chronic pain management clinics planned for the Walter Reed 
National Military Medical Center. In Building 9, 8,500 sq. ft. of space 
is dedicated to the Pain Care Center of Excellence which will maintain 
the ``world-class'' expertise and training capabilities currently 
available at WRAMC.
    Mental Health--Psychological health issues have become one of the 
most prominent injuries of the current conflicts. The Department has 
increased capacity to address these issues commensurate with the 
mission requirements. The new organizational structure will include 
both psychiatry and psychology as separate departments with personnel 
assigned that match these needs. In the new outpatient clinic, 45,000 
sq. ft. of space primarily on the sixth level of Building A is 
dedicated to outpatient behavioral health. A robust partial 
hospitalization program to decrease the demand for inpatient beds has 
been designed in line with the current program at WRAMC and the Defense 
Veterans Brain Injury Center (DVBIC) clinical component. There will be 
two new inpatient psychiatry wards (27,000 sq. ft. in Building 10) with 
a total bed capacity of 28. An additional 12 inpatient beds and partial 
hospitalization capabilities are designed for the new Fort Belvoir 
Community Hospital (FBCH).
    Traumatic Brain Injury (TBI)--Treatment for Traumatic Brain Injury 
will include a six bed specialty inpatient ward and a highly functional 
multi-disciplinary clinical group that includes clinical neurologists, 
psychiatrists, psychologists, orthopedists, physical and occupational 
therapists, neuropsychometrists, and other traumatic brain injury 
specialists. These programs will transition and integrate available 
expertise from both NNMC and WRAMC programs. All clinical expertise 
will be in close proximity to the new National Intrepid Center of 
Excellence at Bethesda that is dedicated to research, diagnosis and 
treatment of military personnel and veterans suffering from traumatic 
brain injury and psychological health issues.
    Prosthetic Care--Military beneficiaries (active duty, retirees and 
dependants) with upper and lower extremity amputations currently 
receive the best medical care in the world. Nearly one whole floor in 
the new outpatient clinic addition (Building A) will be dedicated to 
physical medicine modalities with additional services and diagnostic 
support provided on two other floors. Over 115,000 sq. ft. is dedicated 
to Physical Therapy, Physical Medicine and Rehabilitation, Occupational 
Therapy, Amputee Center, Orthotics, Prosthetics, Chiropractic Services, 
Orthopedics, Podiatry, and a satellite Laboratory, Radiology, and 
Pharmacy on the first three floors of the new outpatient clinic. This 
represents the largest physical medicine footprint in all of the 
Department of Defense and will continue to provide WRAMC's current 
capabilities in the care of amputees and the manufacture and adjustment 
of state-of-the-art upper and lower extremity prosthetics.
    Physical Therapy--Physical therapy plays a major role in the 
rehabilitation of amputees, traumatic brain injured, and 
psychologically injured patients. Clinical space in the new clinical 
building outlined above and in the inpatient areas have been designed 
to offer the best medical care to these injured patients. Appropriate 
personnel have been designated on the current manpower document to 
complete the mission in these areas.

                                  
