[Senate Hearing 111-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2010

                              ----------                              


                       WEDNESDAY, MARCH 18, 2009

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:30 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Daniel K. Inouye (chairman) 
presiding.
    Present: Senators Inouye, Murray, Cochran, and Bennett.

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF LIEUTENANT GENERAL ERIC B. SCHOOMAKER, 
            M.D., Ph.D., SURGEON GENERAL, U.S. ARMY 
            MEDICAL COMMAND


             OPENING STATEMENT OF SENATOR DANIEL K. INOUYE


    Chairman Inouye. I'd like to welcome all of the witnesses 
today as we review the Department of Defense (DOD) medical 
programs. There'll be two panels this morning. First we'll hear 
from the service surgeon generals: General Eric Schoomaker, 
Vice Admiral Adam Robinson, Jr., General James Roudebush. Then 
we'll hear from our chiefs of the Nurse Corps: General Patricia 
Horoho, Rear Admiral Christine M. Bruzek-Kohler, and General 
Kimberly Siniscalchi. Did I get it correct?
    I'd like to welcome back all of the three surgeon generals 
to our subcommittee once again. I look forward to continuing 
our work together to ensure the future of our military medical 
programs and personnel.
    As you may have noted, this is the first defense hearing 
that the subcommittee will be holding this year. We 
deliberately selected the medical programs as our inaugural 
topic to underscore the importance that this issue has to our 
subcommittee. Our surgeon generals and the chiefs of the Nurse 
Corps have been called upon to share their insight on what is 
working and what is not working.
    Military medicine is a critical element in our defense 
strength. Our ability to care for our wounded soldiers on the 
modern battlefield is a testament both to the hard work and 
dedication of our men and women in uniform and to the 
application of the new technology which is a hallmark of the 
U.S. armed forces, and so to our medical programs' demonstrated 
commitment to provide for our servicemembers and their 
families, which is unsurpassed in any other military. It is a 
vital component in our military compensation package, one that 
is necessary to sustain the all-volunteer force, a force, I 
might add, which by all measurement is the finest in the world.
    This is a unique medical hearing because we have not 
received the details of the fiscal year 2010 DOD budget, nor 
have we received the remaining fiscal year 2009 supplemental 
request. While we may not be able to discuss detailed budget 
issues, we'll focus on various medical personnel and medical 
technology issues facing the Department, our servicemembers and 
their families.
    On a personal note, when I was in the Army some time ago 4 
percent of the men in my regiment were married, just 4 percent. 
I think that was about the average in the United States Army. 
Now 56 percent of the Army, 54 percent of the Navy, and 45 
percent of the Marine Corps, and 59 percent of the Air Force 
are married. This completely alters the dynamic of the service 
I remember to the one you see today.
    Not only that, but the demographics of our servicemembers 
have drastically changed. We also have more than a few dual-
service parents and couples, both of which deploy to theater.
    We've all read about the rising rates of suicide, divorce, 
substance abuse in our military. This is not something that can 
only be addressed with the service member. This must be 
approached with the service member, their family, their fellow 
soldiers, sailors, marines, and airmen. The solutions are not 
one size fits all or one service fits all. Instead, all ideas 
must be on the table for everyone to consider. What works for 
the Army may not necessarily work for the Navy.
    In addition, we need to take a unified approach to medical 
research in areas directly tied to the warfighter that we are 
currently tackling and those that could be right around the 
corner. This coordinated approach should cross the entire 
Federal Government, utilizing the resources and expertise of 
the Department of Veterans Affairs, the National Institutes of 
Health, Department of Homeland Security, and the Substance 
Abuse and Mental Health Services Administration, just to name a 
few.
    The Department stands at a very pivotal juncture in its 
efforts to modernize the medical technology enterprise 
architecture. I'm certain each one of you can share a story or 
two about the various versions of the Department's medical 
health records and how challenging it can be, at the least. Now 
you are tasked to both modernize the system and make it 
interoperable with the Veterans Administration (VA) to 
facilitate seamless transitions for our servicemembers and to 
enable joint DOD-VA locations to care for both veterans and 
servicemembers.
    These are not simple tasks and I know that there are many 
challenges ahead. These are some of the issues we'll face in 
the years ahead. We continue to hold this valuable hearing with 
the service surgeon generals and the chiefs of the Nurse Corps 
as an opportunity to raise and address these and many other 
issues.
    I look forward to your statements and note that your full 
statements will be made part of the record.
    Before we proceed with witnesses, may I call upon the vice 
chairman of the subcommittee, Senator Cochran.


                   STATEMENT OF SENATOR THAD COCHRAN


    Senator Cochran. Mr. Chairman, thank you very much. I'm 
pleased to join you in welcoming our two panels of witnesses 
today, the service surgeon generals and the chiefs of the Nurse 
Corps. We have an important duty to provide for the medical 
needs of our active, Guard, and Reserve personnel. The joint 
approach in managing the military medical programs has been 
very important in supporting our soldiers, sailors, airmen, and 
marines, especially during wartime.
    The men and women of the medical service corps deserve our 
thanks for their services they've provided and continue to 
provide. I'm pleased to join the chairman in being here to 
receive your testimony and working with you as we try to 
identify the priorities that need special attention in the 
funding cycle that we are approaching.
    Thank you very much.
    Chairman Inouye. Thank you very much.
    I am especially pleased to have with us in the subcommittee 
this morning Senator Bennett of Utah. He's our newest member. 
Welcome, sir. Would you like to make a statement?
    Senator Bennett. Your being pleased is only exceeded by my 
being pleased at the opportunity to be here. Thank you for your 
welcome.
    Chairman Inouye. Thank you very much.
    May I call upon the first witness, Lieutenant General Eric 
B. Schoomaker. He's a doctor, a Ph.D. He's also the Surgeon 
General of the U.S. Army.
    General Schoomaker. Thank you, sir. Chairman Inouye, Vice 
Chairman Cochran, Senator Bennett: Thank you for providing all 
of us here a forum for discussing our service medical programs 
and to allow me to discuss Army medicine and the defense health 
program (DHP).
    As you mentioned earlier, sir, I'm joined by our Chief of 
the Army Nurse Corps, Major General Patty Horoho, and the 
Commander of the Western Regional Medical Command at Madigan 
Army Medical Center at Fort Lewis, Washington.
    Also, in recognition of the Army's having declared 2009 as 
the year of the NCO, the noncommissioned officer, I'm joined 
today by my senior--the senior enlisted medic in the Army, who 
is my command sergeant major, Althea Dixon. She is one of the 
finest soldiers and leaders with whom I have had the pleasure 
to serve and is an invaluable member of my command team. 
Command Sergeant Major Dixon has been my battle buddy and my 
conscience and my unwavering standardbearer throughout these 
last three commands and through some of the most difficult 
challenges that Army medicine has faced. We've traveled 
together throughout the United States, especially throughout 
the southeast United States when we worked together in the 
Southeast Regional Medical Command, but also in Europe and in 
Kenya, Thailand, Korea, and most recently in Afghanistan and in 
Iraq.
    She embodies really the ethos of the noncommissioned 
officer. She's the person to whom I turn for unvarnished truth 
about my command and my effectiveness as a commander. She's my 
constant reminder of what is one of the most distinguishing and 
powerful features of our Army, which is our noncommissioned 
officer corps.
    For my oral statement today I'd like to highlight just a 
handful of key points that I raise in my written testimony. 
First I'd like to thank the Congress and this subcommittee in 
particular for the very generous and much appreciated funding 
support that you provided for the military health system and 
for Army medicine over the last year. Congress has been 
attentive to the needs we have in military medicine, 
particularly in our sustainment, restoration, and modernization 
(SRM) funding, SRM funding for facilities, and our research and 
development funds for research.
    Our sustainment, restoration, and modernization funding 
really gets put to great use by our facilities managers who 
keep our facilities operating safely and reliable. Some of our 
older hospitals are not ideal for practicing a 21st century 
form of medicine, but our SRM funding has really allowed us to 
keep them in good shape and running safely and smoothly.
    Our research and development dollars are going toward some 
very promising research. I think the chairman alluded to that 
earlier. It's aimed at saving and improving the lives of 
soldiers on future battlefields. Frankly, although I use the 
term ``soldiers'' to describe the recipients of these efforts, 
increasingly we conduct our research programs really as a joint 
effort among my three colleagues here, so that all warriors--
soldiers, sailors, airmen, marines, coast guardsmen, and other 
Federal agency partners--as well as the public at large are 
beneficiaries of our work.
    Examples are biomarkers for traumatic brain injury, tissue 
re-engineering, interventions to build resilience and prevent 
psychiatric hazards--just a few examples of where innovative 
research initiatives that were funded through our fiscal year 
2009 core medical research budget are working. I eagerly await 
the outcomes of these and other research efforts that can 
better the lives of our soldiers and other warriors.
    Next I'd like to briefly mention the latest developments in 
our warrior care and transition program. This is probably one 
of the most important advances that we've made over the last 
several years. In our first year of standing up the warrior 
care and transition program through the Army medical action 
plan, we heavily invested in the structure of our units. We 
focused on proper ratios of care providers and cadre that 
oversee our warriors in transition. That's what we call our 
soldiers who are in these programs. They are transitioning into 
uniform, back into uniform, or into civilian life, or into 
continued care in the private sector or in the VA.
    Now in our second year, we're directing our efforts at 
optimizing the transition for our soldiers and families. In 
March 2008 we launched a comprehensive transition plan 
initiative for our warriors in transition. Instead of focusing 
solely on their injury or illness, the comprehensive transition 
plan fosters an holistic approach to a warrior's rehabilitation 
and transition. These are the lessons which wounded, ill, and 
injured soldiers from former wars, such as the chairman himself 
and Senator Dole, general retired, now Secretary, Shinseki, and 
general retired Fred Franks, have told us were the most 
important lessons to be gained from their own experiences in 
recovery and rehabilitation.
    This is accomplished through a collaboration of a 
multidisciplinary team of physicians, of case managers, 
specialty care providers, occupational therapists, and others. 
Together with a soldier and the family, we develop an 
individually tailored set of goals, emphasize the transition 
phase to civilian life or return to duty. I'm confident that 
this is really where we need to be doing that and it's going to 
come up with the right outcomes for our folks.
    An even newer Army program that I have high expectations 
for is our comprehensive soldier fitness program. The Army 
Chief of Staff, General George Casey, has established a vision 
of an Army comprised of balanced, healthy, self-confident 
soldiers and families and Army civilians whose resilience and 
total fitness enable them to thrive even in this area of high 
operational tempo and persistent conflict and engagement.
    To achieve this ambitious vision, he's instituting a 
comprehensive soldier fitness program. The intent of this 
program is to increase the resilience of soldiers and families 
by developing the five dimensions of strength: physical, 
emotional, social, spiritual, and family.
    It's currently in development. It's under the leadership of 
Brigadier General Rhonda Cornum, an Army Medical Department 
physician. I expect this program to have a positive effect and 
a profound effect upon our soldiers, their families, and our 
Army civilians.
    Last, I wanted to share with you a copy of our new combat 
medic handbook. Our combat medics, which we call 68-Whiskeys, 
68-Ws, are the best trained battlefield medics in the world, 
alongside our Navy and Air Force colleagues of course. As the 
Army and the joint force have labored to provide better body 
armor and protection from ballistic and burn and blast injury 
and have altered the tactics, techniques, and procedures in a 
complex urban terrain to reduce combat casualties and improve 
on our killed in action rates, that is survival from the 
initial wounding incident, our medics have enhanced these 
improvements and have further contributed to a historically low 
died of wound rates despite more destructive weapons that are 
wielded by our enemies.
    The medics of this 68-Whiskey generation are trained to 
perform advanced airway skills, hemorrhage control techniques, 
shock management, and evacuation. Examples are: Sergeant First 
Class Nadine Kahla and Sergeant First Class Jason Reisler, who 
are 68-Whiskey NCOs assigned to the Army Medical Department 
Center and School in San Antonio, Texas. They are 
representatives of the other 17 68-Whiskey NCO authors that 
contributed to this new advanced fieldcraft combat skills 
textbook, a state-of-the-art manual for combat medics. This 
delineation of combat medic skills is newly published. It'll be 
issued to every graduating new combat medic beginning this 
month. It's an incredible resource developed by some truly 
incredible NCOs.
    In closing, I wanted to thank the subcommittee for the 
terrific support that you have given to the defense health 
program and to Army medicine. I greatly value the insight of 
this subcommittee and I look forward to working with you 
closely over the next year.
    I also want to salute our noncommissioned officers for 
their professionalism, competence, and leadership. They're 
truly the backbone of the Army and of Army medicine.


                           PREPARED STATEMENT


    Thank you for holding this hearing. Thank you for your 
continued support of Army medicine and the warriors and 
families that we're most honored to serve. Thank you, sir.
    Chairman Inouye. Thank you very much, General Schoomaker.
    [The statement follows:]

  Prepared Statement of Lieutenant General Eric B. Schoomaker, M.D., 
                                 Ph.D.

    Chairman Inouye, Vice Chairman Cochran, and distinguished members 
of the Subcommittee, thank you for providing me this forum to discuss 
Army Medicine and the Defense Health Program. I appreciate this 
opportunity to talk with you today about some of the very important 
work being performed by the dedicated men and women--military and 
civilian--of the U.S. Army Medical Department (AMEDD) who personify the 
AMEDD value ``selfless service.'' In recognition of 2009 being ``The 
Year of the NCO'', throughout my testimony I will highlight the 
contributions of the AMEDD's Non-Commissioned Officer Corps, the 
backbone of Army Medicine. Non-Commissioned Officers comprise 18 
percent of the Army Medical Department and play critical roles in every 
aspect of the organization. I am joined today by the senior enlisted 
medic in the Army, my Command Sergeant Major Althea Dixon, one of the 
finest Soldiers and leaders with whom I have had the privilege to serve 
and an invaluable member of my command team.
    As the Commander of the U.S. Army Medical Command (MEDCOM), I 
oversee with the assistance of Command Sergeant Major Dixon a $10 
billion international healthcare organization staffed by 70,000 
dedicated Soldiers, civilians, and contractors. We are experts in 
medical research and development, medical logistics, training and 
doctrine, the critical elements of public health--health promotion and 
preventive medicine, dental care, and veterinary care--in addition to 
delivering industry-leading healthcare services to 3.5 million 
beneficiaries around the world. But central to everything we do in Army 
Medicine is the warfighter--we exist as a military medical department 
to support the warfighter. I am happy to report that we are 
accomplishing that mission phenomenally well. I can say this with great 
confidence after spending the first week of this month with the U.S. 
Central Command (CENTCOM) Surgeon at the Multi-National Force/Multi-
National Corps--Iraq Surgeon's Conference in Iraq. Seeing first hand 
the care and civil-military medical outreach from Brigade and Division 
to Corps and Theater was a clear demonstration of the Joint Medical 
Force providing top-notch medical support across the full-continuum of 
care and nation building.
    To determine how successful we are at executing our mission, Army 
Medicine uses the Balance Scorecard (BSC) approach developed in the 
1990s by Harvard's Doctors Robert Kaplan and David Norton. Simply put, 
the BSC serves as an organizational strategic management system which 
can help improve organizational performance while remaining aligned to 
our strategy. The MEDCOM began BSC implementation in 2001 under LTG 
(Ret) James Peake's leadership. Since then, we have continued to refine 
the BSC to grow and direct our dynamic organization. I use the enclosed 
Army Medicine Strategy Map (published in April 2008 and revised in 
January 2009) and Scorecard as the principal tool by which to guide and 
track the Command to improve operational and fiscal effectiveness, and 
better meet the needs of our patients, customers, and stakeholders. The 
BSC communicates to our MEDCOM workforce and drives top-to-bottom 
organizational understanding and alignment, focusing our day-to-day 
efforts to ensure we execute our Mission successfully.

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            Army Medicine Balanced Scorecard (BSC) Overview
Purpose
    The Balanced Scorecard strategic management framework has been and 
continues to serve as the centerpiece of the Army Medicine's 
enterprise-wide Strategic Management System. The first AMEDD strategy 
map was approved by LTG James B. Peake on April 2001 and the framework 
has continued through today with LTG Eric B. Schoomaker's January 2009 
strategy map. The BSC is used to drive top-to-bottom organizational 
understanding and alignment, focus day-to-day efforts, and ensure that 
we are executing our Mission.
Overview
    The BSC is a concept introduced by Doctors Robert Kaplan and David 
Norton in 1992. The BSC is a framework to translate the organization's 
strategy into terms that can be easily understood, communicated, and 
acted upon (measurable action).
    The foundation and main driver of a BSC is the organization's 
Mission and Vision. Four perspectives then define the organization: 
Patient/Customer/Stakeholder (Ends), Internal Processes (Ways), 
Learning and Growth (Means), and Resource (Means). The April 2008 
strategy map (one page schematic) describes Army Medicine's strategy 
via the strategic objectives (located in the bubbles on the strategy 
map) in each perspective. Behind each strategic objective is a detailed 
objective statement that clearly defines the meaning of the strategic 
objective and measure, which will drive behavior to accomplish each 
objective. Each measure will have a target and supporting initiatives 
that will drive the change required to allow the organization to move 
closer to its intended outcomes (ends).
    The BSC is a dynamic, living document that will be refined due to 
mission and priority changes, organizational learning, as well as when 
targets are met. Periodic reviews are conducted to ensure proactive 
change.
Organizational Cascading and Alignment
    To ensure enterprise-wide alignment to the Army Medicine BSC, Major 
Subordinate Command Commanders and Corps Chiefs are required to build a 
supporting BSC and conduct an alignment brief with TSG.
Additional Information
    Detailed information, to include the Army Medicine BSC, is located 
at https://ke2.army.mil/bsc.
Contacts
    Mr. Randy Randolph, Director Strategy and Innovation, commercial 
(703) 681-3015 or DSN 761-3015 [email protected].
    LTC Rex Berggren, Strategic Planning Officer, commercial (703) 681-
5683 or DSN 655-5683 [email protected].
    Ms. Sylvia Pere, Strategic Planner, commercial (210) 221-7172 or 
DSN 471-7172 [email protected].

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    The Army Medicine BSC measures and improves organizational 
performance in four ``balanced'' Strategic Perspectives: ``Resources'' 
and ``Learning and Growth'' which are the ``Means''; ``Internal 
Processes'' which is the ``Ways''; and ``Patients, Customers and 
Stakeholders'' which is the ``Ends'' by which we show best value in 
products and services. These ``Ends'' are how I've organized my 
statement in order to best communicate the significant and varied 
accomplishments of Army Medicine over the last year.
    The Six Army Medicine ``Ends'': Improved Healthy and Protected 
Families, Beneficiaries, and Army Civilians; Optimized Care & 
Transition of Wounded, Ill, and Injured Warriors; Improved Healthy and 
Protected Warriors; Responsive Battlefield Medical Force; Improved 
Patient and Customer Satisfaction; and Inspire Trust in Army Medicine.

   IMPROVED HEALTHY AND PROTECTED FAMILIES, BENEFICIARIES, AND ARMY 
                               CIVILIANS

    Improve the health of beneficiaries thru cost-effective evidence-
based care, proactive disease management, demand management, and public 
health programs.
    Use of HEDISR Measures.--The Healthcare Effectiveness 
and Data Information Set (HEDISR) is a tool used by more 
than 90 percent of America's health plans (> 400 plans) to measure 
performance on important dimensions of care. The measures are very 
specifically defined, thus permitting comparison across health plans. 
The DOD is not a member of the HEDIS program, but uses the HEDIS 
methodology to measure and compare its performance to the HEDIS 
benchmarks. The Military Health System (MHS) Population Health Portal 
takes administrative data and electronic health record data and 
provides reports on the status of our beneficiaries on each measure. 
Currently, we track 9 measures and compare our performance to HEDIS 
benchmarks. In October 2008, the Army was in the 90th percentile 
compared to HEDIS health plans for 2 of 9 measures. We are in the 50th 
to 90th percentile for 6 measures and below the HEDIS 50th percentile 
for one measure. Marked improvement is seen in colorectal cancer 
screening which improved 8.9 percent (October 2005 to October 2008) and 
approaches the HEDIS 90th percentile. In addition, the Army has very 
high compliance with Pneumovax, the vaccine against pneumococcal 
pneumonia, for our enrolled patients over age 65. Since 2007, we've 
been providing financial incentives to our hospitals for superior 
compliance in key HEDIS measures. The Army was the pioneer for what the 
Assistant Secretary of Defense for Health Affairs is now terming Pay-
for-Performance. We have shown that these incentives work to change 
behavior and achieve desired outcomes in our system.
    MEDCOM Reorganization.--The MEDCOM is engaged in a phased 
reorganization designed to optimize the delivery of healthcare to our 
Army and to support a deploying force. With the support of senior Army 
leadership, I approved phase one of this reorganization which aligns 
CONUS Regional Medical Commands (RMCs) with their supporting TRICARE 
regions. MEDCOM is restructuring in order to be better aligned and 
positioned to support our transforming Army. Command Sergeant Major 
Matthew T. Brady was instrumental in developing the structure and 
functions for the newly designed Western RMC headquarters--his 
contributions are emblematic of the significant role played by NCOs 
across the MEDCOM in our restructuring efforts.
    Healthcare support today is outstanding and it must remain so for 
our Army to succeed during an era of persistent conflict. As the Army 
changes its structures, relationships and organizational designs 
through transformation and other initiatives to better support our 
Nation in the 21st Century, the AMEDD must adapt to ensure it remains 
reliable and relevant for our Army. The main restructuring is from 4 
CONUS RMCs to 3 CONUS RMCs. While reorganizing RMCs, we intend to 
further integrate healthcare resources, capabilities and assets to 
foster greater unity of effort and synergy of our healthcare mission. 
The restructuring will posture us to better provide the best support 
for Army Force Generation (ARFORGEN) and improve readiness through 
enhanced health care services for our Soldiers, their Families, and 
Army units.
    Clinical Information Systems.--The AMEDD has long recognized a need 
for an information system to help us grow as a knowledge-driven 
organization. The AMEDD energetically assumed lead for the DOD during 
the implementation of the Composite Health Care System I (CHCS I), now 
known as AHLTA. Unfortunately, AHLTA has not always kept pace with 
expectations at the user-level or at the corporate level for data 
mining and other uses. The Army has taken significant steps to leverage 
the data from AHLTA and other clinical information systems to improve 
clinical quality and outcomes as well as patient safety. To address 
identified shortcomings with AHLTA at the provider level, the AMEDD has 
invested in the MEDCOM AHLTA Provider Satisfaction (MAPS) initiative. 
This includes investment in tools like Dragon MedicalTM and 
As-U-Type, individualized training and business process re-engineering 
led by clinical champions, and use of wireless and desktop 
virtualization. At the Heidelberg Health Center in Germany, Staff 
Sergeant Kenneth M. Melick is the workhorse who took the physician 
vision for business process reengineering from construction to final 
implementation and ensured success. MAPS is beginning to show 
significant improvements in provider usability and satisfaction. Direct 
interviews with providers and staff reveal that MAPS implementation has 
generated a dramatic change in attitude among our staff.
    The most recent version of AHLTA has presented us with challenges, 
but it is showing improvements and gaining provider acceptance. AHLTA 
provides significant benefit to beneficiaries, especially in the areas 
of patient safety, security, improved clinical and readiness outcomes, 
and global availability of records. In addition, a new enterprise 
architecture for the MHS will likely result in a significant 
improvement in managing our information systems. The next update to 
AHLTA (3.3) is being deployed and its additional functionality and 
improved speed is well-liked by the providers who have tested it.
    Force Health Protection and Public Health Programs.--The U.S. 
Army's Center for Health Promotion and Preventive Medicine (CHPPM) is a 
subordinate command of the MEDCOM that affects the lives of Soldiers 
and Families everyday. Its mission is to provide worldwide technical 
support for implementing preventive medicine, public health, and health 
promotion/wellness services into all aspects of America's Army and the 
Army community. The CHPPM team supports readiness by keeping Soldiers 
fit to fight, while also promoting wellness among their Families and 
the Federal civilian workforce. CHPPM integrates public health efforts 
to develop and export primary prevention based products by using 
epidemiologic data of disease and injury to identify the best 
prevention programs to implement for overall population health 
improvement. One member of the CHPPM team--Sergeant Kerri Washington--
made a notable impact on the health and safety of our U.S. Army and 
Iraqi Forces in the Multi National Division--Baghdad area of 
responsibility. Sergeant Washington deployed as a Preventive Medicine 
(PM) Specialist with the 61st Medical Detachment (PM) and applied his 
preventive medicine skills, leadership ability, and unique health 
surveillance training to enhance Soldier health and disease prevention.
    CHPPM is establishing a Public Health Management System to evaluate 
the programs and policies developed to promote optimal health in the 
Army community which will use the public health process to provide 
metrics indicating the success or lack of success in these endeavors. 
This will allow leaders to make informed decisions on effective or 
ineffective public health issues in the Army. Army veterinarians play a 
key role in public health as well, ensuring the safety of food and 
water and the prevention of animal-borne diseases. As part of the 
MEDCOM Reorganization addressed earlier, I have directed my staff to 
assess the feasibility and benefits of establishing a Public Health 
Command which better synchronizes and integrates the efforts of all 
AMEDD members who contribute to public health programs. This will 
enhance comprehensive health and wellness and optimize delivery of 
public health support to the Army.

  OPTIMIZED CARE AND TRANSITION OF WOUNDED, ILL, AND INJURED WARRIORS

    Warrior Care and Transition Program.--The transformation of U.S. 
Army Warrior Care began in April 2007 with the development of the Army 
Medical Action Plan (AMAP), which outlined an organizational and 
cultural shift in how the Army cares for its wounded, ill, and injured 
Soldiers. Over the past 22 months, the AMAP has evolved into the Army 
Warrior Care and Transition Program (WCTP), fully integrating Warrior 
Care into institutional processes across the Army, and is achieving 
many of the Army's goals for enhancing care and improving the 
transition of wounded warriors back to duty or into civilian life as 
productive veterans. At the heart of the Warrior Care and Transition 
Program is the successful establishment of 36 Warrior Transition Units 
(WTUs) at major Army installations worldwide, and nine Community Based 
Warrior Transition Units (CBWTUs) located regionally around the United 
States. These units replace the Medical Holdover (MHO) system of the 
past and provide holistic care and leadership to Soldiers who are 
expected to require 6 months of rehabilitative treatment, and/or need 
complex medical case management.
    Comprehensive Transition Plan.--In our first year of Warrior Care 
and Transition, we heavily invested in the structure of our units and 
support systems. Now in our second year, we recognize that our focus 
needs to be on optimizing the transition for our Soldiers. In March 
2008, MEDCOM launched the Comprehensive Transition Plan initiative for 
Warriors in Transition. Instead of focusing solely on the injury or 
illness, the Comprehensive Transition Plan fosters a holistic approach 
to a Warrior's rehabilitation and transition. This is accomplished 
through the collaboration of a multidisciplinary team of physicians, 
case managers, specialty care providers, and occupational therapists. 
Together with the Soldier, they develop individually tailored goals 
that emphasize the transition phase to civilian life or return to duty. 
Goals are set and the transition plan developed within one month of the 
Soldier's arrival at the WTU.
    Physical Disability Evaluation System.--The Medical Evaluation 
Board (MEB) and Physical Evaluation Board (PEB) processes have been 
streamlined and paperwork requirements reduced to more efficiently move 
a Soldier's disability package through the adjudication process. 
Additionally, collaboration between the DOD and the Department of 
Veterans Affairs (VA) ensures that Warriors in Transition have priority 
processing by the Veterans Health Administration (VHA) and Veterans 
Benefits Administration (VBA) 60 to 180 days prior to separating so 
that they can receive their VA benefits and health care immediately 
upon discharge. General Frederick M. Franks, Jr., USA Ret. has been 
leading an Army task force to research and recommend improvements to 
the MEB/PEB process. His findings, recently delivered to the Secretary 
of the Army, recommended that DOD and VA eliminate dual adjudication 
from the current system and ``transition to a comprehensive process 
focusing on rehabilitation and transition back to either uniformed 
service or civilian life that promotes resilience, self-reliance, re-
education, and employment, while ensuring enduring benefits for the 
Soldier and Family.'' This finding reaffirms the importance of the 
Comprehensive Transition Plan.
    Warrior Satisfaction.--Over the past 2 years, the Army has made 
tremendous progress in transforming how it provides healthcare to its 
Soldiers, with improvements impacting every aspect of the continuum of 
care. Over this period, overall Soldier and Family satisfaction with 
the care and support they have received as a result of the efforts of 
the Warrior Care and Transition Program has increased significantly. 
Two years ago, only 60 percent of those in the legacy medical hold 
units were satisfied with the care they received. Today, that number 
has increased to 80 percent of Soldiers and Families who now receive 
the focused and comprehensive care and support provided by WTUs. 
Considering that over 20,000 Soldiers, along with their Families, have 
transitioned through the Warrior Care and Transition Program over that 
time, this represents a significant number of ``satisfied'' customers. 
A key element of increased satisfaction has been the availability of a 
robust ombudsman program staffed primarily with retired NCOs. An 
ombudsman works at each of our WTUs on behalf of the Warriors in 
Transition and their Families to fix problems and cut through 
bureaucratic entanglements. It is a great example of our dedicated 
senior NCOs continuing to serve Soldiers even after they've taken off 
the uniform.

                IMPROVED HEALTHY AND PROTECTED WARRIORS

    Improve the health of service members through full spectrum health 
services to optimize mission readiness, health and fitness, and 
resiliency before, during, and after deployment.
    Evidence Based Practices.--The theme of evidence based practices 
runs through everything we do in Army Medicine and is highlighted 
throughout our Balanced Scorecard. Evidence based practices mean 
integrating individual clinical expertise with the best available 
external clinical evidence from systematic research. Typical examples 
of evidence based practice include implementation of clinical practice 
guidelines and dissemination of best practices. I encourage my 
commanders and subordinate leaders to be innovative, but across Army 
Medicine we must balance that innovation with standardization so that 
all of our patients are receiving the best care and treatment 
available.
    Comprehensive Soldier Fitness.--The Army Chief of Staff has 
established a vision of an Army comprised of balanced, healthy, self-
confident Soldiers, Families and Army Civilians whose resilience and 
total fitness enable them to thrive in an era of high operational tempo 
and persistent conflict. To achieve this ambitious vision, he is 
instituting the Comprehensive Soldier Fitness Program. General Casey 
identified several shortcomings in his own Army experience. For 
example, the Army does not routinely assess all the elements of 
wellness, fitness, and optimal human performance, other than physical. 
Resilience, life skills, and mental coping techniques are not fully 
trained across the Army. The Army does not always link available life 
skills and performance programs and interventions with Soldiers and 
Families until the need has been demonstrated by a negative behavior. 
And the Army does not teach Soldiers about the potential for Post 
Traumatic Growth (PTG), nor give Soldiers the opportunity to validate 
their post traumatic growth during Post Deployment assessments. The 
intent of the Comprehensive Soldier Fitness Program is to increase the 
resiliency of Soldiers and Families by developing the five dimensions 
of strength--physical, emotional, social, spiritual, and family. This 
program is in early development, but under the leadership of Brigadier 
General Rhonda Cornum, an AMEDD physician, and with the commitment of 
passionate non-commissioned officers like her Non-Commissioned Officer 
in Charge, Master Sergeant Richard Gonzales, I expect this program to 
have a profound positive effect on the lives of Soldiers, Families, and 
Army Civilians.
    Brain Health.--Commanders and leaders are responsible for the 
mental and physical well-being and care of Soldiers. They play a 
critical role in encouraging Soldiers to seek prompt medical care for 
traumatic brain injuries (TBI). This responsibility begins on the 
battlefield, as close as possible in time and space to the injury. The 
AMEDD is developing the best process to evaluate and treat every 
Service member involved in an event that may result in TBI. Commanders 
and medics throughout theater are emphasizing early recognition of 
brain injuries followed by examinations and care rendered in accordance 
with clinical practice guidelines developed by the AMEDD in conjunction 
with the CENTCOM Surgeon. The Army is also working closely with the 
National Guard to implement a personnel tracking instrument that 
provides identification of individuals who may have been involved in a 
blast and require screening.
    In coordination with the VA and the Defense Center of Excellence 
for Psychological Health and Traumatic Brain Injury, the Army continues 
to expand resources dedicated to TBI research and treatment. The 
Defense Centers of Excellence (DCoE), directed by Army Brigadier 
General Loree Sutton, lead a collaborative effort toward optimizing 
psychological health and TBI treatment for all Service members. The 
DCoE establishes quality standards for: clinical care; education and 
training; prevention; patient, family and community outreach; and 
program excellence. The DCoE mission is to maximize opportunities for 
warriors and families to thrive through a collaborative global network 
promoting resilience, recovery, and reintegration for psychological 
health and TBI.
    Fort Campbell's Warrior Resiliency and Recovery Center for mild TBI 
is showing very promising results in the identification and treatment 
of mild TBI. The post concussive syndrome appears to exist in these 
Soldiers with a natural clinical history separate from that of Post 
Traumatic Stress Disorder (PTSD) or other psychiatric conditions. The 
syndrome is effectively treated with an intensive and comprehensive 
interdisciplinary approach. Early data indicate significant improvement 
in all treated cases and complete return to duty recovery in over 77 
percent of treated Soldiers.
    Battlemind Training.--One validated evidence-based practice that 
reduces the impact of post traumatic stress is the Battlemind Training 
System (BTS). The Battlemind Training System (BTS) reflects a strength-
based approach, using buddy aid and focusing on the leader's role in 
maintaining our Warriors' mental health. The BTS targets all phases of 
the deployment cycle as well as the Warrior life cycle and medical 
education system. BTS includes training modules designed for Warriors, 
Leaders, and military spouses. Key teaching points about PTSD and 
concussion were recently incorporated into the deployment cycle and 
life cycle Battlemind modules.
    RC Dental Readiness.--Maintaining dental readiness in the Reserve 
Components (RC) has been challenging. During the past year, new program 
developments have provided an integrated Army solution for RC dental 
readiness throughout the ARFORGEN cycle. The Army Dental Command 
(DENCOM) executes First Term Dental Readiness (FTDR) at Initial Entry 
Training (IET) installations, and focuses on examining and treating 
dental conditions in recruits that could otherwise render a Soldier 
non-deployable. Upon graduation from IET, RC Soldiers return to their 
units where the Army Selected Reserve Dental Readiness System (ASDRS), 
initiated in September of 2008, maintains RC Soldier dental readiness 
throughout the three ARFORGEN phases. If the RC Soldier is mobilized, 
they are validated for their deployment dental readiness by DENCOM-
operated facilities and if found to be deficient, are examined and 
treated to a deployable status by dedicated AC and RC dental personnel 
such as Sergeant First Class Dexter Leverett, a USAR NCO mobilized 
since 2004, who has managed RC mobilization and demobilization dental 
operations at both Fort Hood and Camp Shelby, MS--two sites which have 
processed over 26,000 RC Soldiers in the past 5 months alone. Upon 
return from deployment, DENCOM resets RC Soldier dental readiness by 
conducting a Demobilization Dental Reset (DDR) which provides a dental 
exam and readiness care that can prudently be completed during the 
abbreviated demobilization process. Since July 2008 we have dentally 
reset 88 percent of RC Soldiers demobilizing from overseas. I expect 
this integrated approach to generate improved RC dental readiness.
    Armed Forces Health Surveillance Center.--The new Armed Forces 
Health Surveillance Center (AFHSC), a DOD Executive Agency supported by 
CHPPM, performs comprehensive medical surveillance and reporting of 
rates of diseases and injuries among DOD service members. AFHSC's main 
functions are to analyze, interpret, and disseminate information 
regarding the status, trends, and determinants of the health and 
fitness of U.S. military (and military-associated) populations and to 
identify and evaluate obstacles to medical readiness. AFHSC is the 
central epidemiological resource for the U.S. Armed Forces providing 
regularly scheduled and customer-requested analyses and reports to 
policy makers, medical planners, and researchers. It identifies and 
evaluates obstacles to medical readiness by linking various databases 
that communicate information relevant to service members' experience 
that has the potential to affect their health.

                  RESPONSIVE BATTLEFIELD MEDICAL FORCE

    Ensure health service assets of all three components are trained, 
modular, strategically deployable, and can support full spectrum 
operations and joint force requirements.
    Pre-deployment Trauma Training.--Adhering to the policy that no one 
should be initially exposed to a medical challenge while on deployment 
or on the battlefield, pre-deployment trauma training is now mandatory 
for individual providers and medical units to improve survival rates. 
It is a critical link between standard medical care and the intense 
battlefield environment Soldiers face in the current conflicts. By 
recreating the high-stress situations medics will face in Iraq and 
Afghanistan, this training allows for the refinement of advanced trauma 
treatment skills and sensitization to hazardous conditions which allow 
medics to increase their confidence and proficiency in treatment. This 
training includes a surgical skills laboratory, the principles of 
International Humanitarian Law, and mild TBI and Combat Stress 
identification. Returning Soldiers cite this as the best training they 
have ever received.
    Medical Simulation Training Centers.--The Medical Simulation 
Training Center (MSTC) grew from an Army Chief of Staff directive to 
create and quickly implement medical simulation training to prepare 
combat medics for the battlefield. Command Sergeant Major David 
Litteral and Sergeant First Class William Pilgrim were active in the 
early development of the MSTC program, and are two of the many NCOs 
instrumental in the program's success. In fiscal year 2008 the 14 
stateside MSTCs provided training to 27,136 Combat Medics and non-
medical Soldiers in the Tactical Combat Casualty Care (TC\3\) and Medic 
sustainment courses. Also in fiscal year 2008, at four locations within 
the CENTCOM Area of Responsibility (AOR), 26,132 Medics and Soldiers 
validated their TC\3\ skills and received just in time training. This 
success has carried into fiscal year 2009 as 20,235 Medics and Soldiers 
have passed through the now 16 stateside MSTCs and four CENTCOM 
locations for training and or validation of critical battlefield 
lifesaving skills.
    Joint Forces Combat Trauma Medical Course (JFCTMC).--This is a 5-
day trauma training course developed by the AMEDD Center and School and 
designed for providers deploying to Level III (Combat Support Hospital) 
medical missions. The course is a series of lectures with breakout 
sessions by specialty, which include laboratory sessions. JFCTMC 
prepares deploying providers to care for patients with acute war-
related wounds and incorporates lessons learned from Operation Iraqi 
Freedom and Operation Enduring Freedom. Sergeant First Class Theresa 
Smith, Sergeant First Class Pearell Tyler, Sergeant First Class David 
Estrada, Sergeant First Class Robert Lopez, and Staff Sergeant Cedric 
Griggs conduct the much-praised Emergency Surgical Procedures portion 
of this course and provide Point of Wounding training. That's right--
non-commissioned officers training physicians and other health care 
providers.
    Combat Development.--AMEDD NCO Combat Developers, like Master 
Sergeant (MSG) Christian Reid and Sergeant First Class Raymond Arnold, 
have been front and center in product improvements of the Mine 
Resistant Ambush Protected (MRAP) ambulance, Army Combat Helmet, Combat 
Arms Ear Plugs, Improved Outer Tactical Vest, and Fire Retardant Army 
Combat Uniform. Additionally, MSG Reid has been pivotal in the 
development of the Improved First Aid Kit (IFAK) from concept to 
fielding in 6 months and the Warrior Aid and Litter Kit (WALK) of which 
more than 25,000 have been procured to support current combat 
operations. The MRAP-Ambulance provides increased protection to our 
crews and patients. To make the MRAP-Ambulance the most capable ground 
ambulance in the Army today, we integrated ``spin-out'' technology from 
the Future Combat System (FCS) Medical Vehicles. The combat medic is 
now able to leave the Forward Operating Bases to conduct medical 
evacuation missions and can provide world class en-route care to 
wounded soldiers. The AMEDD also developed Casualty Evacuation Kits 
(CASEVAC) for both the MRAP and HMMV ambulances to increase capability. 
These efforts provided the combat medic with field ambulances built for 
survivability in the challenging environment of asymmetric warfare.
    Fresh Blood Distribution.--Recognizing that fresher blood has been 
associated with increased survival on massively transfused patients, 
the Armed Services Blood Program Office (for which Army maintains 
oversight as Executive Agent) has been working with the Services to 
decrease the time it takes for blood to arrive in theater with the 
overall goal of getting 80 percent of the units in theater by day 
seven. The average age of red blood cells arriving in theater prior to 
November 2008 was 13.3 days. Sergeant First Class Peter Maas and others 
in the Blood Program Office identified 13 action items necessary to 
improve blood collection, manufacture, and distribution to the CENTCOM 
AOR. Since implementing these action items in November, 2008, the 
average age of red blood cells arriving in theater has dropped to 9.2 
days. The most recent shipment had an average age of 5.6 days. In the 
last month, we have managed to bypass blood delivery to Bagram and are 
shipping blood directly to Kandahar from Qatar. This has resulted in 
blood reaching Kandahar that is 2-3 days fresher than before. In 
addition to delivering fresher blood to theater, we are actively and 
aggressively pursuing new blood technologies that should lead to 
improved warrior care on the battlefield in the near future.
    Armed Forces Institute of Regenerative Medicine.--The U.S. Army 
Medical Research and Materiel Command (USAMRMC) in partnership with the 
Office of Naval Research, the U.S. Air Force, the National Institutes 
of Health, and the VA established the Armed Forces Institute of 
Regenerative Medicine (AFIRM) in March 2008. The AFIRM is a multi-
institutional, interdisciplinary network working to develop advanced 
treatment options for our severely wounded servicemen and women. The 
AFIRM is made up of two civilian research consortia working with the 
U.S. Army Institute of Surgical Research (USAISR) in Fort Sam Houston, 
Texas. One consortium is led by Wake Forest University Baptist Medical 
Center and the McGowan Institute for Regenerative Medicine in 
Pittsburgh and one is led by Rutgers, the State University of New 
Jersey, and the Cleveland Clinic. Each of these civilian consortia is 
itself a multi-institutional network.
    Regenerative medicine, which has achieved success in the 
regeneration of human tissues and organs for repair or replacement, 
represents great potential for treating military personnel with 
debilitating, disfiguring, and disabling injuries. Regenerative 
medicine uses bioengineering techniques to prompt the body to 
regenerate cells and tissues, often using the patient's own cells 
combined with degradable biomaterials. Technologies for engineering 
tissues are developing rapidly, with the ultimate goal of delivering 
advanced therapies, such as whole organs and engineered fingers and 
limbs.
    Joint Theater Trauma System and Joint Trauma Analysis and 
Prevention of Injury in Combat.--The Joint Medical Force continues to 
show great improvements in battlefield care as a consequence of linking 
all information from Level 2 and 3 care thru the entire continuum of 
care via the Joint Theater Trauma System (JTTS). The JTTS, coordinated 
by the Institute for Surgical Research of the USAMRMC, provides a 
systematic approach to coordinate trauma care to minimize morbidity and 
mortality for theater injuries. JTTS integrates processes to record 
trauma data at all levels of care, which are then analyzed to improve 
processes, conduct research and development related to trauma care, and 
to track and analyze data to determine the long term effects of the 
treatment that we provide. The JTTS also plays an active role as a 
partner in the Joint Trauma Analysis and Prevention of Injury in Combat 
(JTAPIC) program, another MRMC asset under the DOD Executive Agency for 
Blast Injury Research.
    The JTAPIC Program links the DOD medical, intelligence, 
operational, and materiel development communities with a common goal to 
collect, integrate, and analyze injury and operational data in order to 
improve our understanding of our vulnerabilities to threats and enable 
the development of improved tactics, techniques, and procedures (TTPs), 
and materiel solutions that will prevent or mitigate traumatic 
injuries. The JTAPIC Program has already made a difference in the way 
we protect our Warfighters from combat injuries as illustrated in the 
following key accomplishments:
  --Provided actionable information which has led to modifications and 
        upgrades to vehicle equipment and protection systems, such as 
        seat design, blast mitigating armor, and fire suppression 
        systems;
  --Established a near-real time process for collecting and analyzing 
        combat incident data that confirmed the presence of threat 
        weapons of interest;
  --Analyzed combat incident data to identify vulnerabilities in 
        operational procedures, and rapidly conveyed those 
        vulnerabilities to commanders in theater;
  --Established a process for collecting and analyzing damaged personal 
        protective equipment (PPE), such as body armor and combat 
        helmets, to provide PPE developers with the information they 
        need to develop enhanced protection systems.
    The JTAPIC Program received the 2008 Department of the Army 
Research and Development Laboratory of the Year Award for Collaboration 
Team of the Year in recognition of its accomplishments.
    Combat Medic Skills Textbook.--Our combat medics (68W) are the best 
trained battlefield medics in the world. The historically low ``died of 
wounds'' rate is evidence of their enhanced skills. The medics of the 
68W generation are trained to perform advance airway skills, hemorrhage 
control techniques, shock management, and evacuation. Sergeant First 
Class Nadine Kahla and Sergeant First Class Jason Reisler are 68W NCOs 
assigned to the AMEDD Center & School. They are representative of the 
17 other 68W NCO authors that contributed to the new 68W Advanced Field 
Craft Combat Medic Skills Textbook, a state of the art training manual 
for the combat medic. This delineation of combat medic skills is newly 
published and will be issued to every graduating combat medic beginning 
this month. We are currently looking at ways to distribute this 
textbook to every medic in the force--Active, National Guard, and Army 
Reserve.

               IMPROVED PATIENT AND CUSTOMER SATISFACTION

    Improve stakeholder satisfaction by understanding, managing, and 
exceeding their expectations.
    Improved Infrastructure.--On behalf of the Army Medical Department 
team, I want to thank the Congress for listening to our concerns about 
military medical infrastructure and taking significant action to help 
us make needed improvements to our facilities. Funding provided for 
military hospitals in the fiscal year 2008 supplemental bill and in the 
American Recovery and Reinvestment Act of 2009 will positively impact 
the quality of life of thousands of Service Members, Family Members, 
and Retirees as we build new state of the art facilities in places like 
Fort Benning, Georgia, Fort Riley, Kansas, and San Antonio, Texas. 
Additional funding provided by Congress for Sustainment, Restoration, 
and Modernization of our facilities has been put to great use and 
allowed us to make some valuable improvements that have been noted by 
our staff and patients.
    The Army requires a medical facility infrastructure that provides 
consistent, world class healing environments that improve clinical 
outcomes, patient and staff safety, staff recruitment and retention, 
and operational efficiencies. The quality of our facilities--whether 
medical treatment, research and development, or support functions--is a 
tangible demonstration of our commitment to our most valuable assets--
our military family and our MHS staff. The environment in which we work 
is critical to staff recruitment and retention in support of our All 
Volunteer Force. Not only are these facilities the bedrock of our 
direct care mission, they are also the source of our Generating Force 
that we deploy to perform our operational mission. To support mission 
success, our current operating environment needs appropriate platforms 
that support continued delivery of the best healthcare, both preventive 
and acute care, to our Warfighters, their Families and to all other 
authorized beneficiaries. I am currently working closely with the 
Assistant Secretary of Defense for Health Affairs, Dr. S. Ward 
Casscells, and the leadership of the DOD to determine the level of 
investment our medical facilities will need. I respectfully request the 
continued support of DOD medical construction requirements that will 
deliver treatment and research facilities that are the pride of the 
Department.
    Access to Care.--Army leadership and MEDCOM are decisively engaged 
in improving access to care for our Soldiers and their Families. These 
efforts will result in markedly improved access and continuous 
situational awareness at each medical treatment facility. Access means 
that patients are seen by the right provider, at the right time, in the 
right venue; and this applies equally to the Direct Care System & 
Purchased Care System (TRICARE). Key elements identified for improving 
access to care include: Aligning treatment facility capacity with the 
number of beneficiaries; enhancing provider availability; reducing 
friction at key points of access; managing clinic schedules; and 
leveraging technology.
    We have developed a campaign plan to improve access by giving 
hospital commanders the tools they need along with the responsibility 
and accountability to generate results.
    Sustainable Cost of Operations.--While focusing on quality 
outcomes, the MEDCOM is also concerned with ensuring that we maintain a 
sustainable cost of operation for the AMEDD. Our efforts to improve 
access are coupled with initiatives to improve efficiency. Our 
Performance Based Adjustment Model (PBAM) provides financial incentives 
for improving efficiency, patient satisfaction, and quality. PBAM and 
other incentive programs have resulted in the Army being the only 
Service to achieve planned workload gains every year since 2003. A key 
author of PBAM is Master Sergeant (now retired) Richard Meyer.
    Disseminating Best Practices.--The MEDCOM has embraced the Lean Six 
Sigma approach to sustaining improved performance. As an example, a 
Lean Six Sigma project to improve the telephone appointing process was 
initiated at Carl R. Darnall Army Medical Center (CRDAMC), the largest 
telephone appointing call center in the MEDCOM. The call center was 
plagued with high call volume, low patient satisfaction, long process 
cycle time, and high variation. The project sought to decrease process 
cycle time and the call abandon rate to improve patient satisfaction. 
By the conclusion of the project, the overall average hold time was 
reduced to 33 seconds (a 6-fold improvement); the call abandon rate was 
reduced to 3 percent (a 10-fold improvement); calls handled increased 
from 4,700 to 7,300 per week; and call agent turnover was reduced. 
Today the mean hold time at CRDAMC is 3 seconds. This project's 
successful action plan and metrics have been disseminated across the 
command as a best practice.

                     INSPIRE TRUST IN ARMY MEDICINE

    Increase stakeholder support of Army Medicine by inspiring trust, 
building confidence, and instilling pride.
    Improving civilian medical practices.--The implementation of 
tactical combat casualty care (TC\3\) principals for point of injury 
treatment on the battlefield has changed long-standing hemorrhage 
control protocols in the civilian Emergency Medical Services (EMS) 
community. The nation's EMS community has altered long-standing 
treatment protocols that formerly considered tourniquet use a last 
resort. The use of tourniquets, based on the success of their 
application by military medics in theater, is now not only seen as safe 
by our nation's healthcare providers, but as the intervention of choice 
for control of severe hemorrhage. Hemorrhage control is the leading 
cause of death in trauma. The change in philosophy regarding tourniquet 
use will result in more lives saved in both urban and rural areas of 
our country.
    Establishing Successful Interservice Partnerships (San Antonio 
Military Medical Center).--Wilford Hall Medical Center (WHMC) and 
Brooke Army Medical Center (BAMC) are quickly evolving towards the San 
Antonio Military Medical Center (SAMMC) which is an integrated 
healthcare platform in which patient care is delivered in two 
facilities operating under one organizational structure. The SAMMC 
organizational structure has been operational for over 1 year. The 
organizational structures of BAMC and WHMC were both realigned to form 
a functional organization for delivery of healthcare, maintenance of 
our readiness and deployment platforms, sustainment of training of all 
levels of healthcare providers, and promotion of research. Many 
physical moves of medical services have already occurred across the 
SAMMC platform. SAMMC is planning for the migration of the two military 
level one trauma centers in San Antonio to one military level one 
trauma center, capable of handling the same patient care volume that is 
being delivered today in the two centers. Planning and coordination 
with the City of San Antonio have been an integral part of this process 
to ensure continued trauma support in the city. SAMMC enjoys strong 
collaborations with both the University of Texas Health Science Center, 
local government leaders, and the Audie Murphy Veterans Memorial 
Hospital in support of the large tri-service beneficiary population in 
the San Antonio community.
    Establishing Successful Interagency Partnerships (Behavioral and 
Social Health Outcomes).--CHPPM resources are partnered with civilian 
academia, the VA and HHS (including the Centers for Disease Control and 
Prevention, and the National Institute of Mental Health) to work in the 
mitigation of rising rates of suicide, depression, PTSD and other 
adverse behavioral and social health outcomes in our Families, 
Retirees, Active Duty, Reserve and National Guard Soldiers. MEDCOM is 
working with other key organizations to build a robust public health 
capability in the area of Behavioral and Social Health outcomes (to 
include suicides and homicides). This effort includes the construction 
of an Army-level relational database that draws critical information 
from numerous sources to enable comprehensive analysis of adverse 
outcomes in Army organizations and communities.
    Establishing Successful Interagency Partnerships (National 
Interagency Biodefense Campus).--Fort Detrick, Maryland hosts and is 
intimately involved in the development of the National Interagency 
Biodefense Campus (NIBC) to fill gaps in national biodefense and 
integrate agencies for a whole of government approach to national 
security. As a charter member of the National Interagency Confederation 
for Biological Research (NICBR), a collaboration of the National Cancer 
Institute along with the NIBC partners, the Army is breaking ground in 
building on a model for interagency cooperation at Fort Detrick. During 
2008, members of the NICBR/NIBC were involved in developing national 
policy on biodefense and biotechnology as well as collaborating on 
research. Research includes work on developing vaccines, diagnostics, 
forensics, and therapeutics. While focusing on protecting people from 
disease and bioterrorism, members of the NICBR/NIBC participated in 
multiple national assessments to prioritize and focus biodefense 
missions, all while continuing united scientific discovery. During 
2009, the NICBR/NIBC will continue to work with Congress and others to 
define and scope gaps and seams in our Nation's biodefense posture.
    In closing, I want to thank this Committee for their terrific 
support of the Defense Health Program and Army Medicine. I greatly 
value the insight of this Committee and look forward to working with 
you closely over the next year. I also want to salute our non-
commissioned officers for their professionalism, competence, and 
leadership--they are truly the backbone of Army Medicine. Thank you for 
holding this hearing and thank you for your continued support of the 
Army Medical Department and the Warriors and Families that we are most 
honored to serve.

    Chairman Inouye. May I now call upon Vice Admiral Robinson.

STATEMENT OF VICE ADMIRAL ADAM M. ROBINSON, JR., 
            SURGEON GENERAL OF THE NAVY, UNITED STATES 
            NAVY
    Admiral Robinson. Thank you very much, Chairman Inouye, 
also Vice Chairman Cochran, Senator Murray, and Senator 
Bennett, and other distinguished members of the subcommittee.
    Since I last testified, we have seen the emergence of 
impressive changes and unique challenges to this Nation and the 
global community. A historic presidential election has made 
significant national and international political impact, a war 
effort sustained with military troops deploying into hostile 
areas, and an increasing military medicine presence playing a 
key role to support the humanitarian civil assistance mission.
    We are seeing uncertainty, change, and fluctuation in our 
economy that will impact all of us, including military 
medicine. Navy medicine continues on course because our focus 
has been and will always be providing the best healthcare to 
our sailors, marines, and their families, all while supporting 
our Nation's maritime strategy.
    In response to our most critical demand to support the 
Marine Corps, we are realigning medical capabilities to 
emerging theaters of operation. As the Marine Corps forces 
shift their efforts to Afghanistan, Navy medicine will support 
them and sustain our efforts in medicine, in trauma medicine, 
and surgery capabilities.
    The Navy's maritime strategy calls for proactive 
humanitarian assistance and disaster response efforts, and 
these are now preplanned engagements. These missions deploy 
from sea-based, land-based, or expeditionary platforms and aim 
to meet a great spectrum of medical needs. Our Nation's 
humanitarian efforts serve as a unique opportunity for medical 
diplomacy to positively impact the perception of the United 
States by other nations.
    In addition, these missions have become another avenue for 
improved recruiting and retention of Navy medicine healthcare 
providers. Filling vacancies in our medical department corps is 
critical to meeting our mission of maintaining medical 
readiness of the warfighter and providing healthcare to all 
eligible beneficiaries. The Chief of Naval Personnel and I have 
worked together on this issue, making medical recruiting a 
continued priority for fiscal year 2009.
    In spite of successes in the health professions scholarship 
program (HPSP), medical and dental corps recruitment, meeting 
our direct accession mission still remains a challenge. I 
anticipate increased demand for medical service corps 
personnel, in particular to better meet our increasing 
requirements. From individual augmentation requirements to 
planned humanitarian assistance missions and unexpected 
disaster relief missions, as well as to meet the growing needs 
of a Marine Corps that is, in fact, growing, these demands will 
impact medical service corps specialties linked to mental, 
behavioral, and rehabilitative health and operational support.
    Consistent with increased operational demand signals, as 
well as to compensate for prior shortfalls in recruiting, the 
overall recruiting goals for uniformed medical service corps 
officers have nearly doubled since fiscal year 2007. The Navy 
has been successful during the past year recruiting and 
retaining Nurse Corps officers using a combination of 
accession, retention, and loan repayment incentives. For the 
first time in over 5 years, Navy Nurse Corps officers gains in 
2008 outpaced losses. The Chief of the Navy Nurse Corps, Rear 
Admiral Chris Bruzek-Kohler, is here and will follow up in her 
statement and testimony.
    Our graduate medical education is a critical part of the 
foundation for Navy medicine's ongoing success. Despite the 
demands on faculty and staff for operational support, our Navy 
GME programs continue to be highly rated by the Accreditation 
Council for Graduate Medical Education, and our program 
graduates continue to pass their board certification 
examinations at rates significantly higher than the national 
average in almost every specialty.
    More importantly, Navy-trained physicians continue to prove 
themselves to be exceptionally well prepared to provide care in 
austere settings ranging from the battlefield to humanitarian 
assistance and disaster relief efforts.
    Over the last year Navy medicine expanded services so that 
wounded warriors would have access to timely, high quality 
medical care. In 2008, we consolidated all wounded, ill, and 
injured warrior healthcare support, with the goal of 
establishing global policy implementation guidance and 
oversight in order to deliver the highest quality customer-
focused, comprehensive and compassionate care to servicemembers 
and their families.
    As of March 2009, 161 medical care case managers were 
assigned to 45 medical treatment facilities and ambulatory care 
clinics, caring for approximately 1,500 Operation Iraqi 
Freedom/Operation Enduring Freedom (OIF-OEF) casualties. The 
medical care case managers collaborate with Navy Safe Harbor 
and Marine Corps Wounded Warrior Regiment, both line programs, 
in working directly with wounded warriors, their families, 
caregivers, and multidisciplinary medical teams.
    We work diligently to coordinate the complex services 
needed for improved healthcare outcomes and to ensure that 
servicemembers return closer to home as soon as possible.
    Navy and Marine Corps liaisons at medical treatment 
facilities aggressively ensure that orders and other 
administrative details, such as extending reservists, are 
completed. Last year, we established a centralized operational 
stress control program and coordinator who is working in 
conjunction with our line leadership to indoctrinate mental 
health stigma reduction into the broader Navy-Marine Corps 
culture. Over 11,000 sailors have received operational stress 
control training to date, and formal curriculum will be 
introduced in the fall 2009 at key points throughout the 
careers of sailors--from accession to flag officer.
    Also, to anticipate emerging mental health threats, Navy 
medicine actively conducts real-time in-country surveillance 
and assessment of the mental health of our troops.

                           PREPARED STATEMENT

    Chairman Inouye, Vice Chairman Cochran, I want to express 
my gratitude on behalf of all who work for Navy medicine, 
uniformed, civilian, contractor, and volunteer personnel, who 
are committed to meeting and exceeding the healthcare needs of 
our beneficiaries. I would also like to thank you and the 
members for your continued support of Navy medicine and of the 
military health system.
    Thank you.
    Chairman Inouye. Thank you very much, Admiral Robinson.
    [The statement follows:]

          Prepared Statement of Vice Admiral Adam M. Robinson

    Chairman Inouye, Senator Cochran, distinguished members of the 
committee, since I testified last spring we have seen the emergence of 
impressive changes and unique challenges to this nation and the global 
community. A historic Presidential election which has made significant 
national and international political impact, a war effort sustained 
with military troops deploying into hostile areas; and an increasing 
military medicine presence playing a key role to support the 
humanitarian civil assistance mission. We are seeing uncertainty, 
change and fluctuation in our economy that will impact all of us, 
including military medicine.
    Navy Medicine continues on course, because our focus has been, and 
will always be providing the best healthcare for our Sailors, Marines, 
and their family members while supporting the CNO's Maritime Strategy. 
We are focused on strengthening Navy Medicine today, and are 
proactively planning to meet future healthcare requirements.
    Navy Medicine is built on a solid foundation of proud traditions 
and a remarkable legacy of Force Health Protection. Our focus has not 
changed and every day in Navy Medicine we are preparing healthy and fit 
Sailors and Marines to protect our nation and be ready to deploy.
    Navy Medicine is playing a major part in supporting the Maritime 
Strategy. You will find us at home and around the world providing 
preventive medical care; health maintenance training and education; 
direct combat medical support; medical intelligence; and operational 
planning mission support. Our Navy Medicine teams are flexible enough 
to perform a Global War on Terror mission, a homeland security mission, 
a humanitarian assistance mission, and a disaster relief mission; while 
at the same time provide direct healthcare to our nation's heroes and 
their family members at home and overseas.
    In spite of all of the missions we are currently prepared to 
participate in, we are continuously making the necessary changes and 
improvements to meet the requirements of the biggest consumer of our 
operational support efforts--the Marine Corps. Currently, we are 
realigning medical capabilities to support operational forces in 
emerging theaters of operation. We are working on enhancing our 
strategic ability, operational reach, and tactical flexibility. As 
Marine Corps forces shift their efforts to Afghanistan, Navy Medicine 
stands prepared to make the necessary adjustments to provide the 
highest quality combat medical support. Since the global operations to 
combat terrorism began, Navy Medicine's combat medical support has 
proven exceptionally successful at bringing wounded service member's 
home. We hope, through our ability to remain agile and flexible, to 
sustain those efforts--like the record-high survivability rates--and 
improve them wherever possible.
    The Navy's Maritime Strategy calls for proactive humanitarian 
assistance and disaster response efforts. These missions have been 
taking place since 1847, and have come a long way since then. The 
Navy's Humanitarian Civil Assistance missions are now pre-planned 
engagements deployed from sea-based, land-based or expeditionary 
platforms to meet a great spectrum of medical needs. From basic medical 
evaluation and treatment, to optometry, to general surgery, and 
immunizations, our physicians, nurses, dentists, ancillary healthcare 
professionals, and hospital corpsmen are ready.
    Our efforts have continued to grow and this year, the U.S. Southern 
Command will sponsor four multi-service Medical Readiness Training 
Exercises (MEDRETEs). These missions will visit Jamaica, Honduras, the 
Dominican Republic and Guyana and will include a Navy Medicine Reserve 
Component. These two-week deployments will provide primary care in 
remote locations in conjunction with the Ministry of Health of each 
host nation. The medical services provided will include preventive 
medicine education, pediatrics, primary medical care, immunizations, 
pharmacy services, and dental care.
    Over 400 Navy Medicine personnel are ready to provide humanitarian 
civil assistance later this year in two ship-based missions. In April, 
the USNS COMFORT (TAH 20) will deploy for a 120-day mission to South 
and Central America as part of Continuing Promise 09. Later in 2009, 
the USS DUBUQUE (LPD 8) will deploy for a 125-day mission as part of 
Pacific Partnership 09.
    Our nation's humanitarian efforts serve as a unique opportunity to 
positively impact the perception of the United States by other nations. 
These often joint missions serve as examples of how increased 
collaboration between the other services, other government agencies, 
and non-governmental organizations can maximize available resources in 
order to improve worldwide response capability. From our experience, we 
have developed a successful model of healthcare education and training 
for host country providers. This will lead to local sustainable 
activities that will provide long-lasting benefits to help overcome 
healthcare barriers in resource poor countries. Furthermore, these 
missions have become another avenue for improved recruiting and 
retention of Navy Medicine healthcare providers.
    While our humanitarian civil assistance missions provide us with 
some amazing opportunities as providers of medical care, Navy Medicine 
is acutely aware and incredibly proud of our operational commitment to 
the United States Marine Corps. We continue to fine tune our deployable 
medical capabilities to support every Marine who deploys to emerging 
theaters of operation. We never stop improving our strategic ability, 
operational reach, and tactical flexibility. As the Marine Corps forces 
shifts their efforts to Afghanistan, Navy Medicine will be there 
providing the highest quality combat medical support from the corpsmen 
who stand by their Marines on the battlefield, to fleet hospitals, to 
the care provided at a military hospital and world-class restorative 
and rehabilitative care facilities in the continental United States.
    We continue to make improvements to meet the needs of Sailors and 
Marines who may become injured--while serving in theater or training at 
home. Over the last year, Navy Medicine significantly expanded services 
so that wounded warriors would have access to timely, high-quality 
medical care. Our response is two-tiered, first to uncompromisingly 
increase specialized multidisciplinary teams, and second, to expand 
sharing with other government agencies and the private sector of 
clinical resources, research and expertise.
    In addition, Navy Medicine's Concept of Care is always patient and 
family focused. We never lose our perspective in caring for all our 
beneficiaries--everyone is a unique human being in need of 
individualized, compassionate, and professionally superior healthcare. 
At our military treatment facilities (MTFs), we recognize and embrace 
the military culture and incorporate that into the healing process. 
Based on the progress in a patient's care and healing, from initial 
care to rehabilitation and life long medical needs, we determine the 
best clinical location and treatment plan for that patient. Families 
are a critical part of the healthcare delivery team, and we integrate 
the family's needs into the healing process as well.
    In 2008, the Bureau of Medicine and Surgery (BUMED), Headquarters 
for Navy Medicine, consolidated all wounded, ill and injured warrior 
healthcare support, with the goal of establishing global policy, 
implementation guidance, and oversight in order to deliver the highest 
quality customer-focused, comprehensive and compassionate care to 
service members and their families.
    As of March 2009, 161 Medical Care Case Managers were assigned to 
45 MTFs and ambulatory care clinics caring for approximately 1,500 OIF/
OEF casualties. The Medical Care Case Managers collaborate with Navy 
Safe Harbor and Marine Corps Wounded Warrior Regiment in working 
directly with wounded warrior, family, caregivers and the multi-
disciplinary medical team to coordinate the complex services needed for 
improved health outcomes.
    The BUMED Wounded Warrior Regiment Medical Review team and the 
Returning Warrior Workshop support Marines and Navy Reservists, and 
their families by focusing on key issues faced by reservists during 
their transition from deployment to home. Navy and Marine Corps 
Liaisons at MTFs aggressively ensure that orders and other 
administrative details, such as extending reservists, are completed.
    Traumatic Brain Injury (TBI) is considered the signature wound of 
OIF/OEF, due to the proliferation of improvised explosive devices 
(IED). Navy Medicine continues to improve ways to identify and treat 
TBI. The traumatic stress and brain injury programs at National Naval 
Medical Center (NNMC) Bethesda, Naval Medical Center San Diego (NMCSD), 
Naval Hospital Camp Pendleton (NHCP), and Naval Hospital Camp Lejeune 
(NHCL) are collaborating to identify and treat service members who have 
suffered blast exposure. Navy Medicine has partnered with the Navy and 
Marine Corps community to identify specific populations at risk for 
brain injury such as front line units, SEALS, and Navy Explosive 
Ordinance disposal units. Navy Medicine also expanded social work 
assets to provide clinical mental health support in theater, at Navy 
MTFs and regional treatment centers.
    Much attention has been focused on ensuring service members' 
medical conditions are appropriately addressed on return from 
deployment. The Pre-Deployment Health Assessment (Pre-DHA) is one 
mechanism that is used to identify physical and psychological health 
issues prior to deployment. The Post Deployment Health Assessment 
(PDHA) and the Post Deployment Health Re-Assessment (PDHRA) identify 
deployment related healthcare concerns on return to home station and 
90-180 days post deployment.
    Navy Medicine's innovative Deployment Health Centers--currently 17 
in high Fleet and Marine Corps concentration areas--support the 
deployment health assessment process and serve as easily accessible 
non-stigmatizing portals for mental healthcare. The centers are staffed 
with primary care and mental health providers to address deployment-
related health issues such as TBI, Post Traumatic Stress Disorder 
(PTSD), and substance misuse. Approximately 15 percent of Navy and 
Marine Corps Post Deployment Health Assessments result in a medical 
referral, while the PDHRA medical referral rate is approximately 22 
percent for both Active and Reserve Component service members.
    Navy Medicine's partnership with the Department of Veterans Affairs 
(VA) medical facilities is evolving into a mutually beneficial 
partnership. This coordinated care for our warriors who transfer to or 
are receiving care from a VA facility ensures their needs are met and 
their families concerns are addressed. Full-time VA staff members are 
located at several Navy MTFs where they focus on the healthcare needs 
of service members and their families.
    Filling vacancies in the Medical, Dental, Nurse and Medical Service 
Corps of the Active and Reserve Components is critical in meeting our 
mission of maintaining medical readiness of the warfighter and 
providing healthcare to all eligible beneficiaries. My goal is to 
maintain the right workforce to deliver medical capabilities across the 
full range of military operations through the appropriate mix of 
accession, retention, education and training incentives. As a result, 
the Chief of Naval Personnel and I have worked together on this issue 
making medical recruiting a continued priority for fiscal year 2009.
    Navy Medicine not only equips and trains our current healthcare 
professionals; we also prepare our future reliefs for the challenges 
ahead. To build the future force for Navy Medicine we must reach out to 
America's students and young professionals. We must invite them to our 
hospitals, our classrooms, and our research facilities so they can see 
what we do and they can ask career-making questions.
    Congress has been very generous and attentive to the Special Pay 
and Bonus authorities. The Services are implementing those new 
programs--in some cases with limited success. An example of this is 
that the Critical Wartime Skills Accession Bonus offered to physicians 
and dentists as an incentive to directly access trained specialists was 
not effective in fiscal year 2008. Multi-Year Retention pays and 
Bonuses have historically provided the highest return for obligated 
service, but we thought it was important to try new authorities 
provided by Congress.
    Navy Medicine offers one of the most generous and comprehensive 
scholarships in the healthcare field. The Armed Forces Health 
Professions Scholarship Program (HPSP) provides tuition assistance for 
up to 4 years of school. In addition all professional school required 
fees and expenses, books and equipment are paid for by the Navy. The 
value of this program could be well over $200,000 during the course of 
a 4 year professional school program. Graduates join the Navy's active 
duty healthcare team as commissioned officers. During fiscal year 2008, 
the Navy Medical and Dental Corps met its HPSP goal for the first time 
in several years.
    In spite of the successes in HPSP Medical and Dental Corps 
recruitment, meeting our direct accession mission may remain a 
challenge. The Medical Services Corps is our most diverse Corps with 31 
specialties under three general groupings consisting of clinicians, 
healthcare administrators, and research scientists.
    I anticipate increased demand for Medical Service Corps personnel 
with respect to Individual Augmentation missions supporting the present 
course in Iraq and the anticipated role the military in Afghanistan, 
planned Humanitarian Assistance and unexpected disaster relief 
missions, as well as to meet the needs of Marine Corps manning 
increases and the many wounded warrior programs they support. These 
demands will impact Medical Service Corps specialties linked to mental, 
behavioral and rehabilitative health and operational support; Clinical 
Psychologists, Social Workers, Occupational Therapists, Physician 
Assistants and Physical Therapists to name a few.
    While it is anticipated that the Assistant Secretary of Defense, 
Health Affairs guidance for recruiting and retention incentives for 
Clinical Psychologists, Social Workers, and Physician Assistants will 
be released this fiscal year, similar incentives may need to be 
expanded to other specialties where limited incentives currently exist. 
Consistent with increased operational demand signals, as well as to 
compensate for prior shortfalls in recruiting, the overall recruiting 
goals for uniformed Medical Services Corps officers have nearly doubled 
since fiscal year 2007.
    The Navy has been successful during the past year recruiting and 
retaining Nurse Corps officers using a combination of accession, 
retention, and loan repayment incentives. Over 4,000 active duty and 
reserve Navy nurses are serving in operational, humanitarian, and 
traditional missions at home and overseas. These men and women are 
essential to Navy Medicine's Force Health Protection mission. Navy 
nurses, in particular the wartime nursing specialties of mental health, 
nurse anesthesia, critical care, family nurse practitioners, emergency 
medicine, preoperative and surgical care, have been exemplary in all 
theaters of operations and healthcare settings.
    For the first time in over 5 years, Navy Nurse Corps officer gains 
in 2008 outpaced losses. Despite the growing national nursing shortage 
and the civilian nursing community proving to be recession resistant, 
the recruitment and retention of nurses continues to improve. 
Additional requirements will be placed on the recruiting and retention 
efforts of the Nurse Corps in the near future as nursing billets are 
restored due to changes in the Military to Civilian Conversion program. 
Future success in the recruitment and retention of nurses will continue 
to be dependent on incentive packages that are competitive with the 
civilian sector.
    Like recruiting and retention, our Graduate Medical Education (GME) 
is a critical part of the foundation for Navy Medicine's ongoing 
success. Navy Medicine provides world-class graduate medical education 
at nine sites with 60 programs involving over 1,000 trainees. Despite 
the demands on faculty and staff for operational support, our Navy GME 
programs continue to be highly rated by the Accreditation Council for 
Graduate Medical Education. Navy program graduates continue to pass 
their board certification examinations at rates significantly higher 
than the national average in almost every specialty. More importantly, 
Navy-trained physicians continue to prove themselves to be 
exceptionally well prepared to provide care in austere settings ranging 
from the battle field to humanitarian assistance and disaster relief 
efforts.
    Along with our successes, Navy GME is facing challenges. Advances 
in medicine and technology are resulting in longer and in some case 
completely new types of training which stress the fixed number of 
funded positions available. Additionally, we did not meet medical 
student accession goals 3 and 4 years ago, and this is beginning to 
impact our current GME programs. The lower number of uniformed 
graduates will challenge our ability to support our operational 
healthcare mission while placing an adequate number of graduates into 
training to meet our need for specialists in the future.
    Navy Medicine scientists conduct basic, clinical, and field 
research directly related to current and future military requirements 
and operational needs. In today's unsettled world, we face not only the 
medical threats associated with conventional warfare, but also the 
potential use of weapons of mass destruction and terrorism against our 
military forces and our citizens at home and overseas and our allies. 
Navy Medicine's research efforts focus on finding solutions to 
traditional battlefield medical problems such as bleeding, Traumatic 
Brain Injury, combat stress, and naturally occurring infectious 
diseases; as well as the health problems associated with non-
conventional weapons including thermobaric blast, biological agents, 
and radiation.
    The DOD Center for Deployment Health Research at the Naval Health 
Research Center reported that 8.7 percent of U.S. troops who were 
deployed and exposed to combat duty in Iraq or Afghanistan reported 
symptoms of PTSD on a screening survey. We anticipate that this ongoing 
research will prove helpful in identifying populations at especially 
increased risk of PTSD from combat, and lead to improved diagnosis and 
prevention strategies.
    The Naval Institute for Dental and Biomedical Research helped to 
prove the military utility of a new product ``Dent Stat,'' a temporary 
dental filling material used in treating dental emergencies in all 
forward deployed settings. This user-friendly temporary restorative 
material helps stabilize and reduce pain from fractured teeth and lost 
or broken fillings so warfighters can quickly return to their units.
    The Navy Medical Research Center developed an updated vaccine 
against Japanese encephalitis (JE) allowing for U.S. Food and Drug 
Administration licensure. The JE vaccine should prevent this mosquito-
borne potentially fatal brain infection, and will save lives of 
military personnel who deploy to the Asia-Pacific region, and also 
civilian travelers to JE-endemic regions.
    These are just a few examples of how Navy Medicine's biomedical and 
dental research, development, testing and evaluation, including 
clinical investigations, will protect and improve the health of those 
under our care.
    It is important to recognize the unique challenges before Navy 
Medicine at this particularly critical time for our nation. Growing 
resource constraints for Navy Medicine are real, as is the increasing 
pressure to operate more efficiently without compromising healthcare 
quality and workload goals. The Military Healthcare System (HMS) 
continues to evolve, and we are taking advantage of opportunities to 
modernize management processes that will allow us to operate as a 
stronger innovative partner within the MHS.
    Integration of care between the military direct care and our 
civilian network, and across the services, has implications related to 
both the quality and cost of care. The National Capital Area and the 
San Antonio military markets have become pilots for a ``joint'' 
healthcare system. While the models are different, the end goal is the 
same: a single approach to healthcare. With the current economic 
situation driving the need for cost effectiveness, movement toward a 
Unified Medical Command construct will likely accelerate. Identifying 
those functions that can be joint--along with those that need to remain 
service specific--is a critical component of the success of the 
project. Bringing the direct care system and the TRICARE Management 
Activity under a single command structure offers significant advantages 
and might be the next best step as military healthcare evolves. Navy 
Medicine supports and is actively engaged in these efforts.
    Chairman Inouye, Ranking Member Cochran, I want to express my 
gratitude on behalf of all who work for Navy Medicine--uniformed, 
civilian, contractor, volunteer personnel--who are committed to meeting 
and exceeding the healthcare needs of our beneficiaries. Thank you 
again for providing me this opportunity to share with you Navy 
Medicine's mission, what we are doing today, and our plans for the 
future. It has been my pleasure to testify before you today and I look 
forward to answering any of your questions.

    Chairman Inouye. May I now call upon Lieutenant General 
Roudebush.

STATEMENT OF LIEUTENANT GENERAL JAMES G. ROUDEBUSH, AIR 
            FORCE SURGEON GENERAL, UNITED STATES AIR 
            FORCE
    General Roudebush. Mr. Chairman, Mr. Vice Chairman, Senator 
Murray, Senator Bennett: Thank you for this opportunity to 
share our issues, our concerns, but also our accomplishments 
with you this morning.
    I believe your comments frame it very appropriately and 
very correctly in terms of the importance of what we bring both 
individually and collaboratively to the care of the men and 
women who have raised their right hand and sworn to support and 
defend and go into harm's way for our Nation. It's important 
that we do care for them, and it's important that we work with 
each one, one by one, as they transition perhaps to care within 
the Department of Veterans Affairs, to assure that that 
transition is as smooth, effortless, and user-friendly as it 
can be.
    So I think your comments set this up very, very well. Thank 
you, sir. And thank you and the subcommittee for your 
unwavering support in our endeavors in this regard. We simply 
could not do it without you, and we truly appreciate that.
    This morning, sir, I'd like to talk a bit about Air Force 
medicine, understanding that Air Force medicine is part of a 
joint capability, and we keep that issue very clearly in mind. 
Air Force medicine contributes significant capability to the 
joint warfight in combat casualty care, wartime surgery, and 
aeromedical evacuation.

                       AIR FORCE THEATER HOSPITAL

    On the ground, at both the Air Force theater hospital at 
Balad and Craig Joint Theater Hospital in Bagram we are leading 
numerous combat casualty care initiatives that will positively 
impact combat and peacetime medicine for years to come. Air 
Force surgeons laid the foundation for the state-of-the-art 
intervascular operating room at Balad, the only DOD facility of 
its kind, and their use of innovative technology and surgical 
techniques has greatly advanced the care of our joint 
warfighter and coalition casualties, and their work within the 
joint theater trauma system, collaborative joint work, their 
work within this joint system, has literally rewritten the book 
on the use of blood in trauma resuscitation.
    To bring our wounded warriors safely and rapidly home, our 
critical care aeromedical transport teams, or CCATs, provide 
unique intensive care unit (ICU) care in the air within DOD's 
joint en route medical care system. We continue to improve the 
outcomes of CCAT wounded warrior care by incorporating lessons 
learned into clinical practice guidelines and modernizing the 
equipment we use to support this important mission.

       MEDICAL LIFESAVING OPERATIONS--HURRICANES KATRINA AND RITA

    But it's important to note that this Air Force-unique 
expertise also pays huge dividends back home. When Hurricanes 
Katrina and Rita struck in 2005, Air Force active duty, Guard, 
and Reserve medical personnel were in place conducting 
lifesaving operations. Similarly, hundreds of members of this 
total force team were in place September 1, 2008, when 
Hurricane Gustav struck the Louisiana coast and when Hurricane 
Ike battered Galveston, Texas, less than 2 weeks later.
    During Hurricane Gustav, Air Mobility Command coordinated 
the movement of more than 8,000 evacuees, including 600 
patients. Air crews transported post-surgical and intensive 
care unit patients from Texas-area hospitals to Dallas 
principally. I'm extremely proud of this incredible team 
effort.
    The success of our Air Force mission, however, directly 
correlates with our ability to build and maintain a healthy and 
fit force at home station and in theater. Always working to 
improve our care, our family health initiative establishes an 
Air Force medical home. This medical home optimizes healthcare 
practice within our family healthcare clinics, positioning a 
primary care team to better accommodate the enrolled population 
and streamline the processes for care and disease management. 
The result is better access, better care, and better health.

                   PSYCHOLOGICAL HEALTH OF OUR AIRMEN

    The psychological health of our airmen is critically 
important. To mitigate their risk for combat stress symptoms 
and possible mental health problems, our program known as 
Landing Gear takes a proactive approach, with education and 
symptom recognition both pre- and post-deployment. We educate 
our airmen that recognizing risk factors in themselves and 
others, along with a willingness to seek help, is the key to 
effectively functioning across the deploying cycle and 
reuniting with their families. Likewise, we screen carefully 
for traumatic brain injury at home and at our forward deployed 
medical facilities.
    To respond to our airmen's needs, we have over 600 active 
duty and 200 civilian and contract mental health providers. 
This mental health workforce has been sufficient to meet the 
demand signal that we have experienced to date, but, that said, 
we do have challenges with respect to active duty psychologists 
and psychiatrists recruiting and retention and we're pursuing 
special pays and other initiatives to try to bring us closer to 
100 percent staffing in these two very important specialties.
    For your awareness, over time we are seeing an increasing 
number of airmen with post-traumatic stress disorder (PTSD). 
1,759 airmen have been diagnosed with PTSD within 12 months of 
returning from deployment from 2002 to 2008. As a result of our 
efforts at early post-traumatic stress identification and 
treatment, the majority of these airmen continue to serve with 
the benefit of treatment and support.
    Also, understanding that suicide prevention lies within and 
is integrated into the broader construct of psychological 
health and fitness, our suicide prevention program, a 
community-based program, provides the foundation for our 
efforts. Rapid recognition, active engagement at all levels, 
and reducing any stigma associated with help-seeking behaviors 
are hallmarks of our program. One suicide is too many and we're 
working hard to prevent the next.

                SUSTAINING THE AIR FORCE MEDICAL SERVICE

    Sustaining the Air Force medical service requires the very 
best in education and training for our professionals. In 
today's military that means providing high-quality programs 
within our system as well as strategically partnering with 
academia, private sector medicine, and the Department of 
Veterans Affairs to ensure that our students, residents, and 
fellows have the best training opportunities possible.
    While the Air Force continues to attract many of the finest 
health professionals in the world, we still have significant 
challenges in recruiting and retention. We're working closely 
with our personnel and recruiting communities using accession 
and retention bonus plans to ensure full and effective staffing 
with the right specialty mix to perform our mission. At the 
center of our strategy is the health professions scholarship 
program. HPSP is our most successful recruiting tool. But we're 
also seeing positive trends in retention from our other 
financial assistance programs and pay plans. Thank you for your 
unwavering support in this critical endeavor.
    In summary, Air Force medicine is making a difference in 
the lives of airmen, soldiers, sailors, marines, family 
members, coalition partners, and our Nation's citizens. We are 
earning their trust every day. As we look forward to the way 
ahead, I see a great future for the Air Force medical service 
built on a solid foundation of absolutely top-notch people, 
outstanding training programs, and strong partnerships. It's an 
exciting, challenging, and rewarding time to be in Air Force 
and military medicine. I couldn't be more proud of this joint 
team.

                           PREPARED STATEMENT

    We join our sister services in thanking you for your 
enduring support, and I look forward to your questions.
    Chairman Inouye. I thank you very much, General Roudebush.
    [The statement follows:]

   Prepared Statement of Lieutenant General (Dr.) James G. Roudebush

    Mr. Chairman and esteemed members of the Committee, it is my honor 
and privilege to be here today to talk with you about the Air Force 
Medical Service. Our Air Force medics work directly for the Line. To 
that end, we too are focused on reinvigorating the Air Force nuclear 
enterprise; partnering with the joint and coalition team to win today's 
fight; developing and caring for Airmen and their families; modernizing 
our Air and Space inventories, organizations, and training, and 
recapturing acquisition excellence.
    In support of our Air Force priorities, our Air Force Medical 
Service (AFMS) is on the cutting edge of protecting the health and 
well-being of our Service men and women everywhere. Our experience in 
battlefield medicine is shaping America's healthcare for the 21st 
century and beyond. We are actively enhancing readiness; ensuring a 
fit, healthy force, and building/sustaining the model health system for 
DOD. In short, it's a great time to be in Air Force medicine!

                       ADVANCEMENTS IN READINESS

    Air Force medics contribute significant capability to the joint 
warfight in aeromedical evacuation, combat casualty care and wartime 
surgery. Our advancements in these areas are unparalleled in previous 
combat experience.
    Our Critical Care Air Transport Teams (CCATTs) provide unique ``ICU 
care in the air'' within DOD's joint enroute medical care system. We 
continue to improve the outcomes of CCATT wounded warrior care by 
incorporating lessons learned into clinical practice guidelines and 
modernizing equipment to support the mission. For example, we are 
developing a joint electronic in-flight patient medical record to 
ensure effective patient care documentation and record availability. We 
are working to improve CCATT equipment, such as mobile oxygen storage 
tanks and airborne wireless communication systems, and continuing to 
evaluate existing equipment to ensure safety for our patients.
    On the ground, at both the Air Force Theater Hospital at Balad, 
Iraq and Craig Joint Theater Hospital at Bagram, Afghanistan, Air Force 
medics lead numerous combat casualty care initiatives that will 
positively impact combat and peacetime medicine for years to come. The 
Air Force surgeons garnered invaluable experience in the field of 
vascular surgery that laid the foundation for a state-of-the-art 
endovascular operating room at Balad--the only DOD facility of its 
kind. The inaugural use of diagnostic angiography and vena caval 
filters, along with coil embolization and stent grafts in select 
vascular surgeries in-theater have truly modernized care of our joint 
warfighter and coalition casualties. Colonel (Dr.) Jay Johannigman, the 
332nd Expeditionary Medical Operations Squadron lead trauma surgeon, 
said, ``Our Joint combat hospitals, be they Army, Navy, or Air Force, 
are all beginning to think alike and do things similarly. These efforts 
help us improve and speed the care to the patient.''
    Working with the Armed Services Blood Program Office, Air Force 
medics have improved the supply of crucial life-saving blood products 
in-theater, supplementing fresh blood with a new frozen red blood cell 
product with an extended shelf life. An in-theater apheresis center was 
established to collect fresh platelets needed to support aggressive 
treatment of trauma patients requiring massive transfusions.
    The ability to collect and analyze data is critical to our success 
in combat casualty care. The Joint Theater Trauma Registry (JTTR), 
established in 2004, has made significant strides in these efforts. 
Their work led to major changes in battlefield care, including 
management of extremity compartment syndromes, burn care resuscitation, 
and blood transfusion practices. Their results are setting military-
civilian benchmarking standards. The JTTR is truly a joint effort, with 
full participation of the Air Force. An Air Force physician is the JTTR 
system deputy director, and our critical care nurses are key players in 
the in-theater JTTR team. Through the JTTR we're capturing and 
implementing best practices for management of the extensive trauma 
cases seen.
    Air Force-unique expertise pays dividends back home, as well as in 
theater, and is saving lives. Many Americans who have become victims of 
natural disasters benefited from our humanitarian support. When 
Hurricanes Katrina and Rita struck in 2005, Air Force Active Duty, 
Guard, and Reserve medics were in place conducting lifesaving 
operations. Similarly, hundreds of members of this Total Force team 
were in place September 1, 2008 when Hurricane Gustav struck the 
Louisiana coast and when Hurricane Ike battered Galveston, Texas, less 
than 2 weeks later. During Hurricane Gustav, Air Mobility Command 
coordinated the movement of more than 8,000 evacuees, including 600 
patients. Aircrews transported post-surgery/post-intensive care unit 
patients from Galveston area hospitals to Dallas medical facilities. I 
am extremely proud of this incredible team effort.

                    ENSURING A FIT AND HEALTHY FORCE

    The success of our medical readiness mission directly correlates 
with our ability to build and maintain a fit and healthy force at home 
station and in-theater. One way we do this is through optimization of 
health care delivery. Our Family Health Initiative, our Air Force 
``medical home,'' optimizes health care practice within our family 
health clinics, increasing the number of medical technicians on the 
family health teams to better accommodate the enrolled population and 
streamlining the processes for care and disease management.
    We achieve a fit and healthy force by measuring our health care 
outcomes. The AFMS has used the Healthcare Effectiveness Data and 
Information Set measures for more than 8 years to assess the care we 
deliver. Our outcome measures for childhood immunization delivery, 
asthma medication management, LDL cholesterol control in diabetics, and 
screening for Chlamydia all exceed the 90th percentile in comparison to 
civilian benchmarks. We also compare very highly with civilian hospital 
care for all 40 of our measures developed by the Agency for Healthcare 
Research and Quality, which evaluates patient safety, inpatient 
quality, pediatric care quality, and prevention-related quality for our 
hospital services. We recently began measuring 30-day mortality rates 
for myocardial infarction, pneumonia and congestive heart failure, and 
found that the AFMS is well below the national benchmark in all three 
measures. In 2009, we will implement measurement of well-child visits 
and follow-up after mental health hospitalization. While this is all 
good news, we must remain vigilant in analyzing and evaluating the 
effectiveness of our healthcare delivery--our patients deserve the very 
best.
    The exposure of our Airmen to battlefield trauma puts psychological 
health at the forefront of our health and fitness mission. To mitigate 
their risk for combat stress symptoms and possible mental health 
problems, our Landing Gear program takes a proactive approach with 
education and symptom recognition, both pre- and post-deployment. We 
educate our Airmen that recognizing risk factors in themselves and 
others, along with a willingness to seek help, is the key to 
effectively functioning across the deployment cycle and reuniting with 
their families.
    We have over 600 Active Duty and over 200 civilian and contract 
mental health providers. This includes 97 additional contract Mental 
Health providers we added in 2007 to manage increased workload. This 
mental health workforce has been sufficient to meet the demand signal 
that we have experienced to date. That said, we do have challenges with 
respect to Active Duty psychologist and psychiatrist recruiting and 
retention, and we are pursuing special pays and other initiatives to 
try to bring us closer to 100 percent staffing in those two 
specialties. We continually assess and reassess the demand based on 
mission requirements as well as the need for clinical services. We are 
seeing a gradual increase in the incidence of post-traumatic stress 
disorder (PTSD) in our Airmen and we are also seeing a persistent 
demand at the 1:2 dwell rate for mental health providers in the 
deployed environment. This demand is not likely to decrease, and could 
well increase over time. We are tracking this demand closely to ensure 
that we have the resources to meet tomorrow's demand.
    With regard to what we are doing about PTSD, we address post-
traumatic stress (PTS) in our Airmen by combining resilience training 
with frequent screening and ready access to mental healthcare. 
Resilience training is conducted via an Air Force developed program 
Landing Gear, where Airmen learn what to expect while deployed, and 
when and how to get help for stress symptoms. Screening occurs before 
deployment, at the end of deployment, 90-180 days post-deployment and 
annually via the Physical Health Assessment. Each screening asks about 
PTS and other psychological symptoms. Healthcare providers fully assess 
all symptoms noted on the screening, and refer to mental health 
providers for further care as needed. We also train frontline 
supervisors and have positioned mental health personnel in our primary 
care clinics in order to increase access and reduce stigma. Quality 
healthcare for our Airmen requires our mental health providers to have 
the best tools available to treat PTS. To that end, we have sent 490 of 
our mental health providers to 2 and 3-day workshops conducted by 
civilian subject matter experts on the two widely recognized methods of 
PTSD treatment. All our providers, mental health and primary care, are 
trained and follow nationally/Veterans Affairs (VA) approved clinical 
practice guidelines to assure that all treatment for PTSD is state of 
the art and meets the highest standards.
    For your awareness, 1,758 Airmen have been diagnosed with PTSD 
within 12 months of return from deployment (fiscal year 2002-fiscal 
year 2008). The vast majority of these Airmen continued to serve with 
the benefit of treatment and support. Of these Airmen, 255 have been 
enrolled in our Wounded Warrior program secondary to PTSD, and are not 
expected to be returned to duty. Our efforts at early PTS 
identification and treatment strive to maximize the number of Airmen we 
are able to return to full duty and health. As noted, however, we are 
seeing an increase over time in the number of our Airmen with diagnosed 
PTSD.
    Understanding that suicide prevention lies within and is integrated 
into the broader construct of psychological health and fitness, we 
continue to aggressively work our eleven suicide prevention 
initiatives, which include frontline supervisor training and suicide 
risk assessment training for mental health providers. We have mental 
health providers in our family health units to provide the full 
spectrum of care for both our active duty and family members. This 
allows us to approach issues in a way conducive to quick recognition 
and resolution, while reducing any perceived stigma associated with 
visits to mental health clinics. Suicide prevention requires a total 
Air Force community effort, using all tools available. We are expanding 
our ability to identify, track and treat Airmen dealing with PTSD, 
Traumatic Brain Injury (TBI), or other mental health problems to ensure 
no one is left behind who needs help. We have the resources, the 
opportunity, and clearly the need to better understand, and care for 
these injuries.
    Current treatment/management for TBI is based on Defense and 
Veterans Brain Injury Center (DVBIC) TBI Clinical Guidance. The Air 
Force TBI treatment is done by a multidisciplinary team guided by 
comprehensive brain injury and mental health assessment tools. All TBI 
patients receive education on TBI symptoms and management as well as 
appropriate referrals for occupational therapy, physical therapy, 
speech and language, pharmacy, audiology and optometry. Cognitive 
rehabilitation is initiated after medical issues have subsided and the 
patient's pain is managed. In fiscal year 2009, video teleconferencing 
equipment will be installed in all mental health clinics to allow 
direct consult with the DVBIC.
    We have also taken the lead in DOD with diabetes research and 
community outreach. We have a very productive partnership with the 
University of Pittsburgh Medical Center (UPMC) and the Army. Wilford 
Hall Medical Center (WHMC), Lackland AFB, Texas, is designated as the 
initial DOD roll-out site for diabetes initiatives developed at UPMC. 
Major Mark True, an endocrinologist, is the WHMC project lead and 
director for the Air Force diabetes program. He established a Diabetes 
Center of Excellence (DCOE) program and, in August 2007, introduced 
several inpatient diabetes protocols and initiatives in the hospital, 
including an intravenous insulin protocol that substantially improved 
glucose control in critical care units. We are working to open an 
outpatient regional DCOE that will impact clinical outcomes across a 
regional population. This will be supported by the Mobile Diabetes 
Management with Automated Clinical Support Tools project beginning this 
year, which will demonstrate improved diabetic management through cell 
phones and web-based technology use.

               BUILDING AND SUSTAINING A PRE-EMINENT AFMS

    Sustaining the AFMS as a premiere organization requires the very 
best in education and training for our professionals. In today's 
military, that means providing high quality programs within our system, 
as well as strategically partnering with academia, private sector 
medicine and the VA to assure that our students, residents and fellows 
have the best training opportunities possible.
    With the ongoing demand for well trained surgeons in our trauma 
care mission, we have focused on Surgical Care Optimization. This 
initiative identified eleven medical treatment facility (MTF) platforms 
to provide the capacity necessary to keep critical wartime medics 
proficient in battlefield trauma care. It also seeks to increase MTF 
recapture of DOD beneficiary specialty care by optimizing operating 
room access and efficiency.
    Our Graduate Medical Education programs consistently graduate 
residents fully prepared to provide excellent clinical care in the 
inpatient, outpatient and deployed settings. The outstanding 
performance of our residents on board certification exams is just one 
marker of the success of our numerous training programs, many of which 
are partnered with leading civilian institutions throughout the 
country, including Wright State and Cincinnati University in Ohio; 
Saint Louis University in Missouri, and the Universities of 
Mississippi, Texas, Nevada and California.
    We partner with local civilian medical facilities to support the 
Sustainment of Trauma and Resuscitation Skills Program, enabling home-
station clinical currency rotations in private sector level one trauma 
centers. Our Centers for Sustainment of Trauma and Resuscitation Skills 
is an immensely successful partnering endeavor that provides immersion 
trauma skills training with some of the great trauma centers in the 
Nation--R. Adams Cowley Shock Trauma Center in Baltimore, Maryland; 
University Hospital in Cincinnati, Ohio; and St. Louis University 
Medical Center, Missouri. Nearly 800 physicians, nurses and technicians 
completed this training in 2008; many of them deployed soon after and 
reported being very well prepared for their roles in combat medicine.
    Working closely with our Department of Veterans Affairs partners, 
we continuously strive to streamline the system for all our personnel 
to include our wounded, ill and injured Airmen. A major success in this 
partnership is our joint ventures. The Air Force has four of the eight 
existing DOD/VA joint venture sites--Elmendorf AFB, Alaska; Kirtland 
AFB, New Mexico; Nellis AFB, Nevada; and Travis AFB, California. Three 
additional sites are under consideration or in development at Keesler 
AFB, Mississippi; Buckley AFB, Colorado; and Eglin AFB, Florida. These 
joint ventures offer optimal healthcare delivery capabilities for both 
our patient populations, while also serving to make the most of 
taxpayer dollars.
    The Disability Evaluation System pilot program is a joint effort 
that resulted from the Commission on Care for America's Returning 
Wounded Warriors. The goal is to simplify healthcare and treatment for 
injured Service members and veterans and to deliver benefits as quickly 
as possible. Malcolm Grow Medical Center at Andrews AFB, Maryland was 
one of the initial three military medical treatment facilities in the 
National Capital Region to participate. The pilot streamlined and 
increased transparency of both the medical examination board process 
and the VA disability and compensation processes. In the pilot, both 
processes now occur concurrently, provide more information for the 
member during the process, and supply comprehensive information 
regarding entitlements from both agencies at the time of the 
separation. Continued evaluation of the study is slated to occur at 19 
more military installations, to include Elmendorf AFB, Alaska.
    Cutting-edge research and development initiatives are critical to 
building the future AFMS. The Virtual Medical Trainer is a continuation 
of existing efforts to develop advanced distributed learning. This 
project focuses on the development of training for disaster 
preparedness and medical care contingencies, addressing such areas as 
equipment, logistics, and war readiness skills training. Extensive work 
has been done to increase simulation in all of our hospitals and trauma 
training centers. Shared simulation with our university partners 
improves care and patient safety for both civilian and military 
patients. Virtual or simulation capabilities are a very cost-effective 
way to train and prepare our medics to do a variety of missions.
    Keesler AFB, Mississippi is studying advanced technologies to 
include robotic microscopy and virtual (whole slide) imaging. Eight 
MTFs have the robotic microscopes, and efforts are underway to obtain 
connectivity between MTFs and the VA Medical Center at Omaha, Nebraska. 
Once fully operational, this system allows general clinicians remote 
access to expert advice, diagnosis, and mentoring, and provides high 
quality standard of care independent of location.
    Similarly, telemedicine is vastly expanding the capabilities of our 
existing resources. Wright-Patterson AFB, Ohio radiologists and 
clinicians are successfully providing consultation services across the 
Air Force, and this year the project is slated to extend to Landstuhl 
Army Medical Center, Germany, and RAF Lakenheath, England. Automated 
Identification and Data Collection, a new business process study at 
Keesler AFB, Mississippi will identify opportunities for radiofrequency 
identification and barcode technologies in military medicine. We are 
exploring how to improve clinical and administrative processes in 
medical equipment management and repair, patient flow analysis and 
management, bedside services, medication administration, and surgical 
tray management.
    Successfully building and sustaining the AFMS requires continued 
focus on the physical plants we occupy to perform our mission. We 
greatly appreciate the tremendous support you have provided to 
recapitalize Air Force aging medical infrastructure. We're excited 
about our plans to improve facility restoration and sustainment and to 
move forward with sorely needed medical military construction (MILCON) 
projects.
    Green design initiatives and energy conservation continue to be 
high priorities for the Air Force. We are incorporating these into AFMS 
MILCON and restoration projects for our MTFs. We use the nationally 
accepted benchmark--Leadership in Energy and Environmental Design--to 
design and construct buildings with sustainable design elements. I'm 
pleased to share some recent examples, such as exterior solar shading 
panels used in Keesler AFB's Base Realignment and Closure (BRAC) Tower 
and Diagnostic Imaging Center projects. A grey water system 
incorporated into Tinker AFB, Oklahoma MILCON recycles treated 
wastewater generated from MTF hand-washing for use in toilets or 
irrigation systems, decreasing or eliminating the amount of fresh water 
used for those purposes. Our projected fiscal year 2010 Air Force 
MILCON projects will incorporate enhanced day lighting concepts 
allowing more natural light into buildings and office spaces. Our 
energy optimization efforts are both environmentally and fiscally 
beneficial and enable us to better serve military members and their 
families.
    Our most critical building block for the future is our people. With 
these unprecedented advances in training and research, it is 
understandable that the Air Force continues to attract many of the 
finest health professionals in the world. In fiscal year 2008, the Air 
Force Medical and Dental Corps exceeded their Health Professions 
Scholarship Program (HPSP) recruiting goals. HPSP is our most 
successful recruiting tool, and we are seeing positive early trends in 
retention from our other financial assistance programs and pay plans. 
We are working closely with our personnel and recruiting communities at 
targeting accession and retention bonus plans to ensure full and 
effective staffing with the right specialty mix to perform our mission.

         BUILDING A JOINT AND EFFECTIVE MILITARY HEALTH SYSTEM

    The AFMS is committed to working with our Sister Services to 
support joint medical capabilities and leverage common operating 
platforms such as logistics, research and development and information 
management/information technology. We are well on the way to bringing 
BRAC plans to fruition. The Joint Task Force National Capital Region 
Medical, or JTF CapMed, is moving forward with plans to combine the 
Army, Navy, and Air Force assets into the new Walter Reed National 
Military Medical Center. Malcolm Grow Medical Center at Andrews AFB, 
Maryland is our component to JTF CapMed and serves as an important care 
delivery platform in the NCR as the east coast hub for aeromedical 
evacuation. Since late 2001, Andrews AFB has welcomed home and cared 
for more than 33,000 patients arriving from Operations Enduring Freedom 
and Iraqi Freedom, U.S. Central Command, U.S. European Command and U.S. 
African Command.
    The BRAC plans are also moving forward in San Antonio, Texas, to 
integrate Army and Air Force MTFs into the new San Antonio Military 
Medical Center (SAMMC), creating the largest inpatient facility in DOD. 
SAMMC has integrated nearly all clinical activities and has led the way 
in bringing the Air Force and Army together in an integrated platform 
that meets the Air Force, Army, and joint mission requirements all the 
while maximizing the use of existing resources.
    Also in San Antonio is the Medical Education and Training Campus 
(METC). This is an important step toward what leaders are calling the 
largest consolidation of training in the history of the Department of 
Defense. Upon completion in 2011, the joint campus, led by tri-Service 
leadership, will centralize all Army, Navy and Air Force basic and 
specialty enlisted medical training at Fort Sam Houston, Texas. At 
Wright-Patterson AFB, Ohio, the 711th Human Performance Wing has been 
activated and will serve as a cutting-edge joint center of excellence 
for human performance and aerospace medicine.
    These are but some of the ways and places we are working toward 
joint solutions that enhance mission support and benefit the quality of 
medical care for our warfighters and their families.
   bright future and good time to be in the air force medical service
    Air Force medics make a difference in the lives of Airmen, 
Soldiers, Sailors, Marines, family members, coalition partners and 
civilians. They take pride in every patient encounter and earn our 
Nation's trust--everyday!
    As we look to the way ahead, I see a great future for the AFMS, 
built on a solid foundation of top-notch people, outstanding training 
programs and strong partnerships. It is indeed an exciting, challenging 
and rewarding time to be in Air Force medicine! I couldn't be more 
proud.
    We join our Sister Services in thanking you for your enduring 
support.

               FEDERAL HEALTH CARE CENTER AT GREAT LAKES

    Chairman Inouye. I'd like to begin questioning now. Admiral 
Robinson, on October 1 of this year the Great Lakes Naval 
Health Center and the North Chicago Veterans Center will be 
merging. It's not the first DOD-VA activity, but it is without 
question the largest. I'm certain you have, as we have learned, 
legislative and other problems, problems with labor unions, 
problems on the commingling of funds and such.
    Can you tell this subcommittee what is being done at this 
moment?
    Admiral Robinson. The Department of the Navy, working in 
conjunction with the Department of Veterans Affairs, are coming 
together to establish the Federal Health Care Center (FHCC) at 
Great Lakes. We are working to make sure we have a seamless 
healthcare operation in north Chicago that will take care of 
the healthcare needs of the uniformed servicemembers in the 
Great Lakes area, as well as the beneficiaries of the VA 
system.
    There are a number of significant obstacles that I think 
will be overcome, but that is not to say they are not there. 
The first and most notable among them is the IM/IT system. That 
revolves around using VISTA and using ALTA, which system is the 
best. They are incompatible in the sense that we can't use both 
of them together. They do different things for both systems. 
Yet, we need to have one IT system that we can utilize in the 
facility.
    There have been a number of work-arounds. This is not an 
insoluble issue, but it is a major issue that we have to get 
resolution with, and in fact Navy medicine is pledged, along 
with VA, to make sure that we can come to some understanding of 
how we can use the best parts from both systems so that we 
don't destroy either VISTA or ALTA, but at the same time we can 
have one system at the VA.
    There are also issues around recruitment and employee 
relationships at Great Lakes. There are also issues that from 
my perspective as Surgeon General are very large issues in 
terms of credentialing, particularly of our ancillary 
healthcare providers. The VA and how they credential is 
different than what we do in DOD because very few VA providers, 
perhaps none, but very few VA providers are operationally 
oriented or deploy. But I have to make sure my providers 
maintain their operational medical skills so that when I tap 
them to deploy to an operational area they are full up. So I 
have to make sure that we have the credentialing issues that 
are taken care of and that we are going to solve problems that 
I may have in the Navy.
    Then there are the funding streams for both DOD and DVA, 
how those funds matriculate through our services, and the 
oversight of those funds. All of those issues, and this is just 
a very small example, have to be dealt with and we have to 
maintain the equities and missions of both DVA and DOD.
    Again, these are a few examples of the issues that are 
involved. Mr. Chairman, I think that we are going to solve all 
of these issues, but I will also say, with openness, that these 
are very difficult issues, and we're working them hard. So 
there are not easy solutions, but I do think that we can get to 
a place where we can have an excellent healthcare facility at 
FHCC.
    Chairman Inouye. So you're telling us that on October 1 all 
of the issues will not be fully addressed?
    Admiral Robinson. All the issues are not going to be fully 
addressed on October 1. But I think that if we take an 
iterative approach to the issues of how we serve our 
beneficiary population, how we serve our patients, can the 
doors open and can we, in fact, be an effective healthcare 
institution for DVA and DOD patients, I think the answer is 
yes.
    I do not think that all of the issues that I have talked 
about will be fully resolved, and in fact I think that that is 
absolutely essential in order to get to the quality care and 
the quality of service that we in DOD and DVA have to have in 
order to take care of patients.
    Chairman Inouye. There is a problem that is not in your 
jurisdiction, but as a result of these joint facilities we have 
a Veterans Committee, we have an Armed Services Committee, and 
so the matter of who has control is becoming a bit sensitive 
now. But that's not your problem.
    Admiral Robinson. Yes, sir.

                         CENTER FOR EXCELLENCE

    Chairman Inouye. Can I ask a question of General 
Schoomaker. Everywhere you turn there seems to be a center for 
excellence. We have been creating one for traumatic brain 
injury. I support that. We have one for amputees, for hearing 
and vision. Do you believe that by creating centers we give the 
impression that only these centers are the ones that we are 
concerned with and other matters are not of interest to us?
    General Schoomaker. Well, sir, I think I understand your 
question and I understand the concern. I think the efforts of 
those that have chartered those centers, as well as the 
execution of the centers, the leadership of the centers, are 
working very hard not to focus so much on brick and mortar 
solutions, but to act as clearinghouses. I think increasingly, 
with the generosity of the American public and the innovation 
that occurs within the academic community, with other Federal 
research and treatment entities like the National Institutes of 
Health, we are seeing--and the use, that's already been alluded 
to by Admiral Robinson, the use of information technology--we 
have an opportunity for these centers really to be the nexus of 
knowledge networks and to harvest best ideas, to find potential 
solutions, while also monitoring where problems are arising, 
and to move funding, to move energy, to move focus to those 
physical brick and mortar sites where that can be done.
    I think this is--certainly the effort that's underway in 
the Defense Center of Excellence for Traumatic Brain Injury and 
Post-Traumatic Stress Disorder and Psychological Health, I 
don't think anyone--certainly I do not conceive of this new 
center of excellence as being the sole brick and mortar site 
and only repository of good research and clinical activity. But 
certainly it is in a position to reach out to anyone who can 
offer solutions to the problems that are arising.

                 SERVICEMEMBER WELLNESS/FAMILY ADVOCACY

    Chairman Inouye. Admiral and General Roudebush, as you've 
indicated, there's been a rise in suicides, substance abuse, 
spousal abuse, children abuse. Are we making a joint effort of 
all services, or just each service on its own?
    General Roudebush. Well, sir, in terms of approaching what 
are very complex problems that cross a variety of areas when 
you're caring for the active duty soldiers, sailors, marines, 
and caring for their family members, we do approach that in a 
service-specific way which attends to the culture that those 
families both exist within and operate within, whether it's an 
Army post or a Navy station or an Air Force base.
    So we each have an approach that I think is adapted to the 
operational perspective of how we operate, but also attends to 
that culture. But we also work across services in terms of 
sharing both successes and issues, sharing programs, sharing 
insight into what we're doing, and operate I think effectively 
across those areas.
    Now, I will tell you that as we are able to reduce stigma, 
as we are able to increase visibility of issues, we are seeing 
more. Perhaps we're seeing more because there are more, and we 
need to be very attentive to that. But I think we're also 
seeing more because we are able to see more, and give us the 
opportunity to engage, hopefully intervene, to assure that 
proper care is provided at a time when it can make a 
difference, and do it either within the service construct or 
within the joint construct, because we certainly care for Navy 
and Army families in our Air Force facilities, and likewise our 
Air Force families are very well cared for in Army and Navy 
facilities.
    So it's incumbent upon us to work jointly, but we also need 
to work separately to assure that we are getting at the issues 
within our operational platforms.
    Chairman Inouye. Thank you very much.
    Senator Cochran.
    Senator Cochran. Mr. Chairman, thank you.

                          MEDICAL EVACUATIONS

    Admiral Robinson, more marines will be deployed to 
Afghanistan in coming months, and I've been informed that the 
standard time required for medical evacuations in Afghanistan 
are considerably different from those in Iraq. Would you 
comment on the adequacy of the resources that will be available 
and the response time for medical evacuations as more marines 
and corpsmen are involved in that theater of operation?
    Admiral Robinson. Yes, sir, Mr. Vice Chairman. The 
Afghanistan area of operation is substantially different than 
the area of operation in Iraq, both from a terrain and an 
infrastructure point of view. Afghanistan has desert terrain, 
which can reach upwards of 140 degrees Fahrenheit, all the way 
to mountains, which are very, very cold, very sub-zero weather. 
Additionally, infrastructure in terms of roads are almost 
completely lacking in Afghanistan, as opposed to other areas, 
which makes the necessity for how we operate there from a 
medical point of view a lot different in terms of mobility and 
in terms of air evacuation.
    The golden hour which I as a surgeon and as a former chief 
of surgery at Portsmouth Naval Hospital, having trained many 
general surgeons in trauma, is an age-old edict that we've used 
in surgery since it was first developed at the University of 
Maryland Shock Trauma. It's based upon the work from the 
Vietnam war and also the fact that if we can utilize air 
evacuation of critically injured personnel and get them to 
immediate definitive medical facilities we can save lives, and 
in fact that is absolutely true.
    One of the things that we in Navy, Army, and Air Force 
medicine also utilize is the effective resuscitative capability 
that the Army medic, the Navy corpsman, and the Air Force medic 
utilize on the ground at the time of injury, such that we can 
start definitive care. We can start adequate resuscitation of 
injured personnel, stabilize them, control their airway, until 
adequate evacuation capability is there.
    So the 60 minutes and the air evacuation, which is more 
difficult in Afghanistan, is not something that is necessarily 
going to reduce either the capability or the success of trauma 
surgery or trauma capability that we've had in the past. I only 
emphasize that from a medical and a surgical point of view 
because very often the golden hour appears to be truly a 60-
minute evolution. It actually includes the ability to stop 
bleeding, to make sure that we have ABC, airway breathing, and 
circulation reestablished, to make sure that we have 
resuscitation reestablished, to make sure that we've done those 
definitive measures for the injured personnel who are going to 
in fact survive such that we can get them to definitive care. 
And in fact, if we get them there 2 or 3 hours after injury, 
that is usually adequate as long as resuscitation has occurred.
    So the long answer to the short answer: We, Navy medicine, 
Air Force and Army medicine, will be capable of making sure 
that we give the same care to our trauma victims in 
Afghanistan.
    Senator Cochran. That's very impressive and I think 
deserves commendation for the excellent leadership you're 
providing in this area.

           SUFFICIENT SUPPLIES AND PERSONNEL FOR AFGHANISTAN

    General Schoomaker, with the increase in personnel deployed 
to Afghanistan, do you believe that you will have sufficient 
medical personnel and medical supplies to support this troop 
increase?
    General Schoomaker. Sir, I think medical supplies is 
probably the easier of the two to answer. I don't envision any 
rate-limiting element of medical supplies or equipment there. 
We have I think evolved the medical logistics capability of the 
entire CENTCOM area of operation dramatically over the last 6, 
7 years, focusing on the so-called theater level medical 
material centers, one of which is in Europe, one of which is in 
Qatar, and we have distribution sites within Afghanistan.
    So I don't have concerns so much about that. Medical 
personnel I think is a challenge to us. This is one of those 
areas, quite frankly, that the coordination among the three 
services is most important. The Army right now is very heavily 
engaged both in Afghanistan and in Iraq in providing medical 
support. As we draw down troop levels in Iraq, we're going to 
continue to have fairly robust medical support because, as we 
all know, you have to support the areas in which troops are 
operating in.
    So we're going to continue to see Army medics and, for that 
matter, Navy and Air Force as well, maintained in Iraq. So 
we're cooperating I think with the CENTCOM planners and with 
the joint medical planners within Afghanistan to provide the 
resources that we can and the Navy and the Air Force, I think 
as you heard earlier, the air base at Bagram now, and that 
level three or role three facility now is largely Air Force, 
after having been started by the Army and transitioned to the 
Air Force. The Navy is going to play a more important role in 
the south.
    So yes, we're stretched. But we're working as closely as we 
can with our joint partners to cover those areas of 
responsibility.

                     TROOP INCREASE IN AFGHANISTAN

    Senator Cochran. Will the increase in deployment affect 
rotation schedules and deployments of surgeons, as well as 
medical specialists? What is your expectation?
    General Schoomaker. Well, sir, everybody plays a role in 
this in Army medicine. It's not recognized by many people, but 
some of our most heavily deployed specialties are not surgeons 
at all; they're pediatricians, who serve as general field 
surgeons, physicians assistants. Our psychologists, 
psychiatrists, our mental health workers, are very heavily 
engaged.
    Do I think it's going to change the rotation length? No, 
sir, it's not going to change the rotation length. In fact, 
we're working to come closer to what our colleagues in the Air 
Force and the Navy have, which are shorter rotations, even if 
they're more frequent. We know from talking with our families 
and talking with our specialists that not only can they 
maintain the broad range of skills that they require in their 
specialties if they're deployed for a shorter period of time, 
even if that turns into more frequent deployments, but the 
families are much more tolerant of shorter rotations, 
especially 6 month or so rotations.
    So we're working very hard to do that and getting support 
from the line for that.
    Senator Cochran. Thank you very much.
    General Roudebush, what role will the Air Force have in 
supporting the troop increase in Afghanistan?
    General Roudebush. Sir, the Air Force is in Afghanistan, as 
General Schoomaker pointed out. We have the Air Force theater 
hospital at Bagram, which is jointly manned with the Army, but, 
as General Schoomaker pointed out, primarily Air Force, as well 
as a number of other smaller facilities that are either Air 
Force or jointly manned. We will certainly sustain those and 
over time being increasing Air Force medical laydown to support 
what you initially pointed out with Admiral Robinson in terms 
of working the medevac support time, which I believe you know, 
but I will note, our line leadership has really leaned into 
supporting that with additional rotor capability. The Air Force 
is providing additional helicopter assets and other assets to 
assure that we can be as timely as we need to be, and I think 
Admiral Robinson laid that out very well.
    So we will be certainly supporting the increased troop 
laydown. However, I think there's two other points that I would 
note. The Air Force and Navy and Army are also deeply involved 
in rebuilding the nation. We have embedded training teams 
working with the Afghan military and police to rebuild their 
medical infrastructure, to mentor the Afghanis, so that they 
can be ultimately self-sufficient; provincial reconstruction 
teams doing a great deal of work to bring that nation forward 
to the point where it can in fact operate on its own 
recognizance.
    The second point I would make is that we have significant 
support from our North Atlantic Treaty Organization (NATO) 
allies on the ground in Afghanistan from a medical perspective, 
which we also integrate and leverage to assure that we have not 
only a joint approach to this, but we also have a coalition 
approach. So as we look at the overall military laydown in 
Afghanistan, there are a variety of perspectives that play into 
this that I think will assure that our forces are best 
positioned to do the mission that they are being sent there to 
do.
    Senator Cochran. Thank you, Mr. Chairman.
    Chairman Inouye. Thank you.
    Senator Bennett.
    Senator Bennett. Thank you very much, Mr. Chairman.
    Gentlemen, let me thank you for your service and your 
expertise. I come to this subcommittee new, so I don't have as 
intelligent or well-informed questions, but the only way I'm 
going to learn is to ask some stupid ones. So bear with me.

                        MEDICAL HEALTH SCREENING

    General Schoomaker, you talked about general wellness, that 
is physical, psychological, spiritual, et cetera, et cetera. I 
think that ties into this whole question of mental health. The 
discussion about suicides and child abuse and other things has 
been an interesting one to listen to. In this process of trying 
to make sure that the individuals who serve in the armed forces 
are well-rounded and balanced in every area, is there any 
prescreening of people who might be susceptible, more 
susceptible to some kind of mental trauma and preparation prior 
to their going into deployment, so that they might, if 
something happens to them, have some previous training or 
preparation or expectation that could help them after the fact 
deal with the problem more than if it just hit them for the 
first time?
    General Schoomaker. Yes, sir. I think let me talk first 
about the screening because I think that's fairly--that I can 
deal with fairly quickly. That is that, aside from the usual 
accession screening, to include medical and psychological 
screening that occurs on any inductee, we don't have any 
specific screens that are used or selections that are used, 
because, quite frankly, I don't know that we have any 
determinants right now for success or failure in terms of the 
whole fitness of an individual. We use physical fitness 
monitors and assessments of general health, but other than that 
none.
    I think one of the promises of the research that is now 
being conducted in traumatic brain injury, and especially in 
psychological health potentially, is finding early markers, if 
you will, and determinants of psychological injury. There are 
emerging theories and I think there's some empiric evidence to 
support that post-traumatic stress reaction, for example, which 
occurs in a very large number of people subjected to trauma, 
whether that's in combat or the trauma of natural disaster or 
rape or violent crime or family violence, motor vehicle 
accidents, might be the persistence of a dysfunctional flight 
or fight reaction, and that there may be markers that we can 
discover and alert people very early to that emergence.
    In the meantime, what we're doing in the Army is, through 
the use of a set of tools, a suite of training tools called 
Battlemind training, developed by the Walter Reed Army 
Institute of Research, we are building resilience in deploying 
soldiers before they deploy, during the deployment, and then 
upon redeployment. This suite of tools, Battlemind, which has 
become sort of our branded name for that, is one of the 
cornerstones of resiliency training. It's been one of the only 
instruments that we're aware of that has actually been shown to 
reduce during deployment the incidence of new post-traumatic 
stress problems.
    The chief of staff's initiative in comprehensive soldier 
fitness is that attempt writ large. The idea here is that we 
have spent a lot of our time as a corporation, as an 
institution, looking only at the negative events--suicides, 
family violence, driving while intoxicated or drug-associated 
crimes or misconduct, and emergence of post-traumatic stress 
reactions and post-traumatic stress disorder if not addressed 
early enough and reversed. What the Army is trying to do is to 
find those determinants of resilience and growth and post-
traumatic growth, rather than to turn adversity into a trauma 
and into an irreversible psychological injury, is to build the 
capacity of individuals through a multidisciplinary approach 
which works on the positive.
    So we're working with some of the leaders in positive 
psychology and other tools to promote that aspect, rather than 
only measure in terms of what negative events occur. In so 
doing we hope to move the whole population of soldiers and 
families away from the threshold where they become 
dysfunctional.
    Senator Bennett. Thank you. That's really helpful.
    Now, I was interested in the comment that you get 
significant increases, to use the business language, 
significant increases in productivity out of the troops if you 
alter the length of their deployment. I'm guessing here, but 
are there any studies going toward the question of frequency of 
patrols, for example, during the deployment, where you send 
marines into a nasty neighborhood in Fallujah day after day 
after day, as opposed to every other day or every third day or 
something of that kind?
    Is there any research in this regard or any attempt to find 
research in this regard that might have the same impact that 
you have found with respect to the overall length of 
deployment, 6 months gives you better soldiers even if there 
are more deployments than if you put them there, say, for 18 
months and kind of leave them alone. Is there any further 
research in the area I've talked about, about their exposure to 
traumatic situations on deployment?

                      IMPACT OF DEPLOYMENT LENGTH

    General Schoomaker. Well, sir, first of all, you may have 
inferred something that I did not intend to imply, that is that 
productivity of a soldier in general is somehow linked to the 
length of deployment. The chairman I think or the vice chairman 
earlier asked about the tolerance of recurrent deployments of 
medical specialists or surgical specialists as a function of 
the length of the deployment. My comment there is that we 
observe that the skills of, for example, a general surgeon 
begin to deteriorate after a certain amount of time in theater 
because they're not exploring and not using the full spectrum 
of what a general surgeon would use.
    Senator Bennett. I did misunderstand you, then. I got the 
impression that there were data that suggested the front line 
troops would benefit from more frequent, but shorter, 
deployments. You're saying that that's not the case, and I 
misunderstood you.
    General Schoomaker. Yes, sir. I think we have ample 
evidence through a series of annual iterative surveys called 
the mental health advisory teams, MHAT. We're in our sixth 
iteration of this, the sixth year. That team is right now in 
Iraq gathering data. We do have ample evidence that the length 
of deployment is associated with increased problems of the 
development of post-traumatic stress and other problems of 
soldiers in theater.
    So I think you got that exactly right, sir. As we were in 
that period of the surge when we had 15 month long deployments, 
there was no question that the longer that deployment went the 
more problems soldiers had.
    We do find, as I mentioned earlier, that if those soldiers 
pre-deployment and during deployment are exposed to Battlemind 
training and sort of re-inoculation with this, it reduces the 
incidence of that. So as I said before, it has been shown to be 
effective.
    But as far as, so to speak, the productivity of the soldier 
or the effectiveness of a soldier, I would not ask you to infer 
from what I've been describing here that a soldier's 
effectiveness is improved by shortening the length of 
deployment. In fact, operational commanders would probably take 
me--take exception with some of that as a grand statement.
    Senator Bennett. Thank you. I appreciate that clarification 
because as I've studied the Vietnam war one of the things that 
was said was that you just got your unit cohesion going and 
then you'd pull them out and put in a bunch of green troops in, 
and that was one of the problems. So I'm glad to get that 
resolved.
    Thank you, Mr. Chairman.
    Chairman Inouye. Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman.
    Thank you all for your testimony today.

                         DISABILITY EVALUATIONS

    General Schoomaker, let me start with you. How are things 
going with the DOD and the Department of Veterans Affairs 
expansion of the pilot programs to expedite the processing of 
injured troops through the disability evaluation system?
    General Schoomaker. Ma'am, I think that's going very well. 
As you know, or at least I've gone on record to say that the 
pilot, although a very, very good effort and one that we 
support very, very vigorously--in fact, once the pilot was 
established in those few sites like Walter Reed, I've done 
everything in my power to implement it as widely as we can. 
Once we learned that we can simplify bureaucratic morass and we 
can make it more user-friendly for families and soldiers, I 
think we ought to be doing it as quickly as we can.
    But I've also said that I'm concerned that it doesn't get 
at one of the most important and most disaffecting parts of our 
system of physical disability and evaluation, which is the dual 
adjudication of disability, one by the Department of Defense 
for the unfitting condition, for which the soldier, sailor, 
airman, marine, coast guardsman is awarded a specific 
disability rating linked to benefits, not the least of which is 
benefits for TRICARE for him or herself and their families; and 
then the Veterans Administration adjudicates a second, 
comprehensive level of disability based upon the whole person.
    Senator Murray. I thought we were all going to go to the 
same system.
    General Schoomaker. Ma'am, until we change the law, my 
understanding is that we cannot get away from the dual 
adjudication of disability for anyone in uniform. We still have 
the single unfitting condition for the service member and the 
whole person concept for the VA. What we need in my 
understanding is legislative relief to be able to bring those 
two together.
    But every other aspect of this highly bureaucratized system 
I think we're working very hard with the VA in doing, and we're 
encouraging that and supporting that in every way we can.
    Senator Murray. Admiral?
    Admiral Robinson. I think that General Schoomaker has 
summed up well what the issues are. I think that the Federal 
Health Care Center in Chicago actually underscores some of the 
difficulties of the DVA and DOD system in terms of trying to--
your question is specifically with the disability evaluation 
system. But we have two chains of command that work vastly 
different, with different sets of rules and regulations, and 
trying to bring them together has been the real challenge.
    Additionally, the same issues that affect the FHCC, the 
Federal Health Care Center in Chicago, regarding IM/IT--that 
is, VISTA and ALTA--are the same sorts of things that affect 
the merger of the disability evaluation system. How does that 
relate? If we have one system, we're going to have to have one 
medical IT way of dealing with those beneficiaries and whatever 
their medical needs may be.
    That's a very small example, but those come together. In 
terms of my eyes-on Surgeon General of the Navy at the 
Department of Defense for the oversight committees that very 
often General Roudebush and General Schoomaker attend with me, 
both DOD and DVA and all of the reps in between and the Marine 
Corps, and all the other people involved have been working 
tirelessly to make this work, looking first at our patients and 
their needs and not at bureaucratic or other issues.
    I will say that across the board we have done that. We're 
looking at patients and what they need, not at the 
institutional obstacles. I only bring the institutional 
obstacles up because at the end of the day they exist and they 
make a difference.
    Senator Murray. General Roudebush.
    General Roudebush. Yes, ma'am, I think you raise a very 
interesting question. I'd like to offer perhaps an observation 
on your question, but also give it perhaps a little different 
perspective.
    The Department of Defense and the Department of Veterans 
Affairs have different missions. Where we come together, the 
interface really most directly is as we transition an 
individual from Department of Defense--Army, Navy, Marine 
Corps, Air Force--to the Department of Veterans Affairs. We do 
need to assure that that transition is seamless.
    Now, DOD, in my instance the Air Force, needs to determine 
fitness for duty in terms, is that individual fit to serve in 
the mission for which they're trained. The VA takes a rather 
broader look at how that individual is going to function back 
in the private sector. So these are two rather different 
determinations, and I think to the extent that we simplify the 
transition to assure that these great men and women are cared 
for, only have to fill out paperwork once, have a smooth move 
from DOD activities to VA, to include benefits, all benefits, 
is very important.
    Our pilot projects I think are helping in that regard. For 
us, we're going to be expanding to a variety of locations, very 
small, Vance in Oklahoma for example, to very large or larger, 
Elmendorf in Alaska. I think that will continue to be 
instructive.
    The metrics show that we are, in fact, reducing the time, 
but not to the time that we would consider to be appropriate. 
But as we bring these two great institutions, DOD and VA, 
together, we also have other experiences. DOD joint ventures, 
for example. We've got a great example at Keesler, where we use 
centers of excellence, what the VA brings very well within 
their operation, what the Air Force brings in our operation, 
and we leverage each other's capabilities, maintaining mission 
focus for the Air Force, for the VA, but really leveraging each 
other's capabilities.
    So I think those kinds of opportunities and experiences are 
important, and also help instruct such things or inform such 
processes as how to best transition these men and women from 
DOD to VA. So I think we're making progress. We are not where 
you want us to be. We are not where we want to be. But I think 
we are making progress in really identifying the issues that 
need to be attended to as we work this.
    Senator Murray. No one said it was going to be easy.
    General Schoomaker. No, ma'am.
    Senator Murray. But we're working, and we need to get 
there. Okay.
    General Schoomaker. Thank you.
    Senator Murray. Can you provide me with an update on the 
implementation of the comprehensive TBI registry that we 
started, I guess it was 1 year or so ago, including a single 
point of responsibility to track incidence and recovery, 
General Schoomaker?
    General Schoomaker. I will take that for the record, ma'am.
    Senator Murray. Could you?
    General Schoomaker. Yes, ma'am.
    [The information follows:]
                              TBI Registry
    Traumatic brain injury incidence and recovery is tracked through 
various complementary mechanisms at the VA and the Department of 
Defense (DOD). The National Defense Authorization Act for Fiscal Year 
2008 states that the Secretary of Veterans Affairs shall establish a 
registry to be known as the ``Traumatic Brain Injury (TBI) Veterans 
Health Registry.'' The Act further specified that the Secretary of the 
VA collaborate with facilities that conduct research on rehabilitation 
for individuals with TBI, facilities that receive grants for such 
research from the National Institute on Disability and Rehabilitation 
Research (NIDRR), and the Defense and Veterans Brain Injury Center 
(DVBIC) of the DOD and other relevant programs of the Federal 
Government. The VA, NIDRR, and DOD have collaborated in this initiative 
with the VA as lead. The summary below is based upon those 
collaborations. Further details can be provided by the VA.
TBI operational Surveillance: TBI Veterans Health Registry
    The VA has developed a mechanism to collect and consolidate all 
relevant medical data relating to the health status of an individual 
who served as a member of the Armed Forces in OIF or OEF and who 
exhibits symptoms associated with TBI, and who applies for care and 
services furnished by the VA; or files a claim for compensation on the 
basis of any disability associated with such service. Relevant data 
will be merged, and de-identified. The VA will then enlist NIDRR to 
assist with analysis of the data and timely production of reports.
    Status: All components of this program have been designed and will 
be initiated very shortly.
Research Database: TBI Veterans Health Registry with Additional 
        Information
    As per the NDAA for fiscal year 2008, additional information the 
Secretary considered relevant and appropriate with respect to 
individuals will be included in the Registry if the individual grants 
permission to include such information, or is deceased at the time the 
individual is listed in the Registry. The additional information to be 
collected for patients providing informed consent in any of the VA 
PolyTrauma Centers includes a structured TBI Registry with additional 
data elements developed in coordination with the agencies listed in the 
NDAA for fiscal year 2008. These collaborations permit comparisons of 
Registry information with data collected on civilian TBI patients and 
DOD patients and returning service members. The VA TBI Registry has 
substantial overlapping data elements with the civilian Model Systems' 
TBI Registry and the existing DOD TBI Registry, which will facilitate 
future comparative studies.
    Status: This program, involving additional information for patients 
providing informed consent, has been submitted as a protocol to the 
Institutional Review Boards at the PolyTrauma Centers.
National Archive Database
    In addition to the secure database developed as a collaboration 
between VA and NIDRR, additional databases may facilitate the sharing 
of selected elements of the TBI Veterans Health Registry with 
Additional Information with data collected within the DOD and across 
other civilian agencies and centers. The pooling of shared, common data 
elements will facilitate understanding of the course, diagnosis, and 
correlates of TBI in returning service members. The National Data 
Archive, a recent collaboration between NIH and DVBIC will provide for 
secure upload and storage of all original and processed images, 
associated clinical and genomics data for TBI, Post Traumatic Stress 
Disorder (PTSD) patients, and other relevant patient populations.
    Sharing of phenotypic, imaging, and genomic data from a central 
secure repository will include the ability for researchers to validate 
research results, pool standardized information to improve statistical 
significance, use data collected by others to explore new hypotheses 
all in effort to improve PH and TBI treatments, use sophisticated 
analysis tools to gain a better understanding of risk factors and 
mitigating factors in PH and TBI.

    General Schoomaker. That is being--the focus in Army 
medicine is to direct all of our energies and our talents 
toward the Defense Center of Excellence for Traumatic Brain 
Injury and Psychological Health under Brigadier General Loree 
Sutton.
    Senator Murray. Could you get back to me on that? It was 
one of our huge questions 1 year ago; making sure that people 
were registered and we were tracking them. So if you could 
please get back to me on that.
    General Schoomaker. Yes, ma'am.

                    RESERVE HEALTHCARE REQUIREMENTS

    Senator Murray. Let me ask all of you: The Reserves and 
particularly the National Guard have some unique concerns when 
they're deployed. We continue to hear from our folks out in our 
States about this, and obviously as we transition from Iraq to 
Afghanistan they're going to continue to be used. So my 
question for each of you is: Have you budgeted properly to 
accommodate for the Reserve components as they are going to 
need DOD healthcare into the future? General Roudebush, we'll 
start with you.
    General Roudebush. Ma'am, in the Air Force and I believe in 
the other services, we have separate funding streams. The Guard 
comes from the States, the Reserve comes from the Reserve 
dollars, and DOD comes from the defense health programs. Now, 
to the extent that we merge our interests and our activities we 
do cross-flow that very, very carefully.
    For us, for example, we assure that our Guard members and 
our Reserve members and our active duty members are tracked for 
completion of the post deployment health assessment and the 
post deployment health re-assessment (PDHA-PDHRA), and, in 
fact, our Guard and Reserve members are kept on active duty 
status, man-day status, until issues are resolved. So they 
retain full benefits as we work them through.
    But they do come from different streams of money. However, 
the oversight and the application of that is very coordinated 
and very integrated for the Air Force.
    Senator Murray. Admiral.
    Admiral Robinson. Your question is do we have adequate 
funds for the Reserve forces, and the answer is yes. Our 
Reserve forces have adequate funds. We have methods of making 
sure that our Reserve forces, once they come on active duty, 
are cared for just as any other active component member would 
be. As that Reserve component member goes off of active duty, 
the service member and his or her dependents are covered by 
TRICARE for approximately a 180-day period.
    If there is some limiting mental or physical disease or 
condition that would make it better for them to stay on active 
duty, they will remain on active duty. As they transition to 
the Navy mobilization platforms, NMPS, to the Reserve 
component, to the NOSCS, which are the local Reserve units back 
in their home towns or their home cities, they will go back 
into how we fund them from the Reserve component perspective.
    But the key is that we have a number of medical, mental 
health, and other areas that we track our Reserve forces, that 
we integrate our Reserve forces, and that we care for our 
Reserve forces, and we are funded adequately to do that.
    Senator Murray. General.
    General Schoomaker. My comments would echo my colleague's 
here, that we're well funded. They are separate lines for the 
Army National Guard, Reserve, and Army Reserve, and the active 
component. As the Admiral just commented, we're working very 
hard to ensure that any mobilized reservists or National 
Guardsmen while on active duty is kept healthy; if they incur 
an injury, a combat wound or an illness, that it';s fully 
treated and they're restored to health, including dental 
health. We made a major effort to restore dental health and 
hygiene before mobilized reservists and National Guardsmen are 
put back out into civilian life.
    Our warrior transition units are roughly 8,000 in total 
right now across 36 units and nine States, are made up of both 
active--of all three elements, all three components, to include 
National Guard and Reserve. They have full access to those 
warrior transition units. In fact, about one-third of our 
warrior transition units warriors in transition are soldiers 
who are returning from deployments or mobilizations who 
identified a problem that they have, and they're brought in and 
they're retained on active duty until we can take care of the 
problem.
    Senator Murray. Thank you.
    I appreciate a lot of the conversation that's already gone 
on regarding the increase in suicides and mental health. We 
have to stay focused on that, and I appreciate all of your 
earlier comments, so I won't ask you about that.

DEPARTMENT OF DEFENSE FISCAL YEAR 2008 REPORT ON SEXUAL ASSAULT IN THE 
                                MILITARY

    But I did want to ask you about another issue, because 
yesterday DOD made public the fiscal year 2008 report on sexual 
assault in the military, and it showed an 8 percent increase of 
reports of sexual assaults. Now, some are arguing that that 
increase illustrates the fact that victims are now more likely 
to report those crimes, but I find the trend very disturbing 
because these crimes are happening at all.
    I was part of the Women's Military History Month. A week 
ago I participated in the Army's panel on sexual harassment, 
assault prevention and response program, and clearly we all 
share the goal of eliminating sexual assaults in the military. 
But until that goal is achieved, I am very interested to hear 
from all of you about how the medical community is supporting 
the efforts to care for these victims' physical and 
psychological wounds in general.

                  SEXUAL ASSAULT AND RESPONSE PROGRAM

    General Schoomaker, I want to start with you.
    General Schoomaker. Yes, ma'am. First of all, I would say 
that the Army leadership and the Army as a whole shares your 
outrage with sexual assault and any increase in the incidence 
of these crimes. The Army has taken the approach that this is 
an assault, not just on the individual woman, but on the ethos 
of soldiers, of the warrior ethos, that this is not to be 
tolerated, and is taking a very active proactive role in 
education and prevention, which is on the shoulders of 
commanders.
    The medical side of this is that we are the response. We 
provide the examination. We help the woman through the stages 
of forensic evaluation. We have in all of our facilities, to 
include, as General Horoho can tell you, in our visit there 
last week her review of what's taking place in the deployed 
setting in Iraq.
    We have sexual assault response coordinators in each of 
these facilities, either working with the assets we have in 
uniform in the uniformed facility, or in a case when I was the 
installation commander at Fort Dietrich, Maryland, we leveraged 
expertise of the community of Frederick, Maryland, to assist us 
through Frederick Memorial Hospital.
    So we do the counseling, we do the examination. We help the 
woman. We go--we help her through the process that she has to 
go through in order to gather the necessary information about 
the assault and to investigate the crime. But we also do the 
follow-on counseling and help coordinate all those services 
that are necessary for her.
    Senator Murray. Admiral.
    Admiral Robinson. Senator Murray, the Navy has the Sexual 
Assault Victims Intervention Program (SAVI), which was 
established in 1994. From that program has come an effort to 
not only educate people as to what is a sexual assault and to 
bring it to a level of visibility so that we are talking about 
it in our commands and it becomes a leadership issue on a daily 
basis, but we've also grown from that to develop a lot of the 
sexual assault response and prevention programs (SARP) that 
you've seen and participated in some of the workings with DOD.
    From the medical point of view specifically, we help in the 
training of SAVI. The SAVI Program is also interesting because 
it takes the victim and puts the victim at the center of the 
activity. In other words, it makes sure that the victim 
understands, is affirmed, and actually has the counseling that 
he or she may need is a critical element in how we run the 
program.
    The second one is to make sure that we then train the 
forensic experts that need to come along and do the 
investigations, which is what General Schoomaker was referring 
to, which is critically important. I would suggest that if 
those folks are not trained in the military treatment facility 
that we utilize our civilian forensic police and forensic 
facilities to make sure that that's done properly.
    Then the third point is the education and the prevention, 
which is something that needs to be done at the beginning of 
training in the military. This is for men and women, and it 
goes through some of the very didactic, but very necessary 
thoughts regarding training, regarding definitions: What is a 
sexual assault? What does consent mean? What does ``yes'' mean? 
What does ``no'' mean? All of these types of things which men 
and women have to listen to.
    Then the last part is to make sure that after we've done 
that, that we have a program that's sensitive to the needs of 
those people who fall victim the sexual assault. That includes 
psychological and the mental health issues. Additionally, we 
need to make sure that their families are cared for. Very often 
men and women are married or they have other family issues, and 
we have to make sure that that's cared for.
    We in the Navy have taken this full-bore and are very 
sensitive to what you've talked about. We have been working 
this very hard for a long time.
    Senator Murray. I appreciate that answer. Thank you.
    Admiral Robinson. Thank you.
    Senator Murray. General.
    General Roudebush. Ma'am, I think your approach is the one 
that I would echo. We know there are increased numbers. Now, 
whether it's increased reporting or increased incidence, we can 
certainly discuss. The fact that there is one is too many.

                             SEXUAL ASSAULT

    Senator Murray. That's correct.
    General Roudebush. So beginning with that as the going-in 
position is precisely where the Air Force leadership is 
attacking this issue. It's a matter of respect. It's a matter 
of respecting each other. It's a matter of honoring each 
other's integrity and their person and treating each other as 
we would want to be treated.
    It's an operational issue. It has direct mission impact. 
It's a cultural issue. It's a family issue, because we strive 
individually, we execute as a team, but we take care of each 
other as a family. So this is a family issue.
    We come at it in a very structured way. We learned 
important lessons as we assessed the issues at our Air Force 
Academy, which we have implemented across the board in terms of 
a sexual assault program that works to prevent sexual assault, 
but if it occurs we respond in a very sensitive and coordinated 
way, to include restricted reporting if the individual prefers, 
to perhaps help them come forward and get the help that they 
will need.
    We have a sexual assault response coordinator at every 
installation wired into the wing leadership. Medical is a key 
part of it. As General Schoomaker pointed out, we have 
important responsibilities and we are postured and do execute 
those responsibilities. But really, it's a matter of taking 
care of each other, respecting each other, and that's precisely 
where our program is going in terms of training, education, and 
sensitization, and establishing the fact that it will not be 
tolerated any way, any shape, any form, anywhere, any time. 
It's a matter of respect.
    Senator Murray. Well, I appreciate your comprehensive 
answers, all three of you, and I hope that's echoed throughout 
the forces. I think that the worst thing we can do is to not 
talk about it. This is an issue I'm going to continue to 
follow. I encourage all of you as well, to make sure that those 
policies are implemented, so that no one fears coming forward; 
that we start at the very beginning, so that it's not 
tolerated; and then if it does occur, that people get services 
and support and it doesn't become a crime that no one talks 
about.
    So I appreciate all of your answers on that.
    Thank you, Mr. Chairman.
    Chairman Inouye. Thank you very much.
    I have many questions I'd like to submit to you, but one 
final one if I may. When I was wounded in World War II, from 
the battlefield to the hospital it took me 9 hours to be 
evacuated, most of the evacuation carried out by stretcher 
bearers. Today if I were wounded with the same injury in 
Baghdad, I suppose I'd be in a hospital within 30 minutes 
because of helicopters and such.
    As a result, a lot of things have happened. For example, in 
my regiment I don't believe we have one double amputee 
survivor. Today most double amputees survive. And you have many 
brain injuries and such, which in World War II very few ever 
survived.
    But equally as important, I spent 22 months in a hospital. 
Today if I were at Walter Reed I'd be out in 6 months on the 
street. But when I left Percy Jones in Michigan I knew a little 
about carpentry, electrical work, plumbing. I knew how to play 
basketball and swim. I knew how to drive. I knew how to go to a 
restaurant and order food, dine, dance. I knew how to defend 
myself. I knew what sex was all about.

                   COMPREHENSIVE TRANSITION PLANNING

    My question is, do you believe that the men and women who 
are being wounded in this war leave the service as I did, 
reassured, confident that I can tackle the world?
    General Schoomaker. Sir, if I might start the answer from 
the standpoint of the Army, I think your eloquent description 
of what you went through and your sharing that with me 
personally and with my staff in the office visits with you I 
think really captures the essence of what we're attempting in 
this comprehensive transition planning. What we observed--and 
quite frankly, Senator Murray's question about the physical 
disability evaluation system is really incomplete without 
addressing one aspect of this system.
    We have a system that, its name alone telegraphs what it's 
about, ``physical disability.'' It's a system that is rooted in 
the industrial age. It's 50 years old. It's highly bureaucratic 
and it's contentious and adversarial. We're trying to change 
the culture of disability and permanent dependency toward one 
of growth, of rehabilitation, of your experience, without 
leaving any soldier, family without the necessary safety nets 
and transition support that they may require in the case of a 
very severe injury or illness.
    So candidly, we've turned away from--the chief of staff of 
the Army engaged another former wounded soldier, General 
retired Fred Franks, a veteran of Vietnam, where he lost part 
of a leg, and went on to retire as a four-star general, as the 
commander of the 7th Corps in Desert Storm. General Franks has 
looked at the physical disability evaluation system and has 
concluded some of the same things that, much of what I've said 
here today, which is that we need to move the culture away from 
one that's focused on disability and permanent dependency 
toward one that is aspirational, that's positive, that builds 
back a capability and potential in every individual soldier, 
sailor, airman, marine, coast guardsman, and their family.
    We draw upon the experiences of soldiers such as yours. 
Today I will tell you that with your injury you very likely 
would remain in our hospitals the same length of time that you 
were there before, only because it may take that long to fully 
recover from the wounds that you had and to be fully 
rehabilitated to do what you needed to do, to include remaining 
on active duty.
    We've turned away from looking at time as a goal or an 
outcome measure for this system of transition. We look at--
we're beginning to look at and assess the goodness of the 
outcome for the individual soldier and family based upon what 
their comprehensive transition planning is. So have we reached 
that point? At this point I would have to say no, sir, we have 
not. Does every soldier who's wounded grievously or is injured 
or ill to the degree that you suffered or others have have the 
confidence and realize the full potential? At this point I'd 
have to say no. But we won't be successful in this program of 
transitioning until we have all of our soldiers aspiring to 
what you've achieved.
    Admiral Robinson. Mr. Chairman, I think your question and 
your comments are very profound, and it makes me think of a 
movie in 1947 or 1948, ``The Best Years of Our Lives,'' in 
which a sailor is depicted, Homer, a double amputee coming out 
of the war, and spending approximately 24 to 30 months in a VA 
hospital. I think he learned all of the things that you 
learned. I don't think that they ever stated it as you did 
here, but he learned so much.
    But one of the things that was lacking in that movie and in 
that whole scenario was the family, because he was scared to 
death as to how he was going to be received by his mother, his 
father, his sister, and his girlfriend next door.
    The difference now is that we've brought families into the 
whole rehabilitation issue. The second part is that the length 
of time--I absolutely agree with General Schoomaker--it's not 
the time element, although it can be, but the length of time 
that one takes is not commensurate with the length of time that 
they stay in hospital. It's the length of time that they have 
in that rehabilitative process with their families and in that 
re-engagement in the community and to be a full-up member 
economically, socially, spiritually in each community 
everywhere.
    The Marine Corps and the Navy take a much different view 
than the Army, and we think that we need to get them out of 
that care facility environment and into that rehabilitative 
environment that's more community-based and that is run by the 
line element and their leaders, that in fact have those men and 
women take care of those men and women, and place them back 
into those original slots that they have come from if possible, 
or back into their communities, so that they can learn many of 
the things that you learned at the VA hospital in Michigan.
    So I think that what I see as different is that we're no 
longer hiding people away or putting you in a position where 
you are, I won't say warehoused, but you are at least put away, 
and then you reemerge into your communities and into societies 
wondering if in fact you are going to be fully received back 
into those areas. We've merged those systems now. When you're 
wounded, not only are you off the battlefield quicker, not only 
are you back to a definitive care facility faster because of 
the great work that we do across Army, Navy, Air Force 
medicine, but we also make sure that as you get into the 
definitive care facilities we bring your families and we 
include them from day one in that care. That also extends as we 
transition to the VA to make sure that your family and you also 
have an opportunity to do that.
    So it's a completely different model, but I think it is 
trying to in fact do the same things, and that is to make sure 
that when you go out you are prepared to re-integrate into your 
communities and become productive citizens and reestablish 
yourself for the future.
    One last comment. The only thing that you point out and 
underline dramatically is this: wounds of war which are 
incurred during battle in a time sphere become the 
responsibility of the military health system and Department of 
Veterans Affairs for the lifetime of the member and that 
member's family. That means that the wounds of war of 2006, 
2007, and 2008 will be the responsibility of all of us sitting 
here through the out-years in 2040 and 2050. So we have to 
prepare for that and we have to take care of those individuals.

                          DOD/VA COORDINATION

    Chairman Inouye. Thank you.
    General Roudebush. Sir, you frame both a compelling 
argument and a compelling challenge. To the extent that we are 
meeting that today, I offer two quick observations. One, we do 
not even begin the disability evaluation process until we 
believe the individual has recuperated and recovered to the 
full extent, and there is time involved in that and we are 
willing to invest that time.
    As part of that time involved, the wounds that we're seeing 
are not singular in many cases; they are multiple. An amputee 
probably has some aspects of traumatic brain injury, some 
aspects perhaps of post traumatic stress disorder or PTSD. So 
we have to approach each individual holistically and work those 
issues through.
    Now, as we do that, my two observations: One, we have been 
I believe wonderfully assisted by our centers of excellence. 
Walter Reed has done a magnificent job of really centering the 
care of amputees and the Fisher Foundation in building the 
Center for the Intrepid in San Antonio really begins to get at 
a number of those issues you talked about: How do you function 
within a living environment, an apartment, a house? How do you 
ambulate? How do you interact?
    They have done I think wonderful service to our men and 
women in assisting with that. And our centers of excellence at 
Bethesda in terms of head injuries. As we work through this, it 
really is a joint and collaborative issue.
    But I would leave you with one observation. My wife's 
uncle, a delightful gentleman who now resides in Phoenix, was 
injured when a German 88 blew up in his bridging squad bridging 
a river in World War II. He was never the same after that 
injury in terms of his physical capabilities and had 
significant issues through life.
    But he has been a tremendous force in our family, just as 
you have been a tremendous force in our Nation, perhaps based 
on some of those experiences and perhaps based on perspectives 
coming from a position that is different than others who might 
be walking down the street.
    So I think we need to listen very carefully. We need to 
honor, we need to respect, and we need to support. I think 
Admiral Robinson has it just right. This is our challenge, but 
this is our duty.
    Thank you, sir.
    Chairman Inouye. Gentlemen, I thank you.
    Do you have any questions, Senator?
    Senator Cochran. Mr. Chairman, I have no questions. This 
has been an excellent hearing. I thank you.
    Chairman Inouye. I thank you very much, gentlemen.
    Now the second panel, the important one.
    I'd like to welcome back: Rear Admiral Christine Bruzek-
Kohler, Director of the Navy Nurse Corps, also Major General 
Patricia Horoho, Chief of the Army Nurse Corps, and Major 
General Kimberly Siniscalchi, Chief of the Air Force Nurse 
Corps.
    There are many things I'd like to say at this point, but 
it's been my pleasure to work with all of you for many years. 
I'd like to extend my congratulations to Admiral Bruzek-Kohler, 
who has been selected to serve as the first Nurse Corps officer 
ever to be in command of Navy Medicine West and Navy Medical 
Center--San Diego, along with her continued role as Corps Chief 
of the Navy Nurse Corps. I look forward to listening to your 
testimony.
    So may I call upon the Admiral first.
STATEMENT OF REAR ADMIRAL CHRISTINE M. BRUZEK-KOHLER, 
            DIRECTOR, NAVY NURSE CORPS, UNITED STATES 
            NAVY
    Admiral Bruzek-Kohler. Good morning, Chairman Inouye, Vice 
Chairman Cochran, and distinguished members of the 
subcommittee. As the 21st Director of the Navy Nurse Corps, I 
am honored to offer my testimony to you and your esteemed 
colleagues. My written statement has been submitted for the 
record and today I would like to highlight some of the 
remarkable work being accomplished by Navy nurses.
    The role of Navy nursing is unquestioned in today's Navy. 
We are at the forefront of all operations, and are accepted as 
mission essential within Navy medicine in support of the Navy 
and Marine Corps. Under my leadership, we have developed a 
model of professional military nursing, the essence of nursing 
relevance and practice in the Nurse Corps today. Built upon a 
solid foundation of clinical skills, Navy nursing encompasses 
clinical specialization via advanced education and 
certification, operational readiness, and leadership 
development.
    When combined, these yield clinical nursing leaders and 
future executives for Navy medicine who are business-savvy, 
operationally experienced, and clinically adept. These nurses 
can and will impressively lead our people and organization into 
the future.
    As Navy nurses, we are renowned for our steadfast 
commitment to our patients, and respected for our impressive 
ability to collaborate with a host of other healthcare 
disciplines. We are integral in the provision of superb care to 
America's fighting forces, their families, and the retired 
community.
    While we are a corps of many specialties, I have identified 
eight which are the critical wartime mission essential 
specialties: medical/surgical, psychiatric/mental health, 
critical care, perioperative, emergency/trauma, maternal-child, 
certified registered nurse anesthetists, and nurse 
practitioners. Of all of these, medical surgical nursing is the 
bedrock of our practice. For this reason, it is my expectation 
that all nurses in the Navy Nurse Corps maintain their clinical 
relevance in medical surgical nursing, particularly if they 
function in purely administrative roles.
    Our total Navy nursing workforce is composed of over 5,500 
active, Reserve, and Federal civilian nurses. Our active 
component manning is at 96 percent. For the third consecutive 
year, I am proud to share with you that the Navy Nurse Corps 
has met its active duty direct accession goal and, as we heard 
from my Surgeon General, for the first time in over 5 years 
Navy Nurse Corps gains have outpaced our losses.
    In speaking with Nurse Corps officers, I have found that 
their engagement in local recruiting initiatives from 
elementary schools to colleges, opportunities to provide 
nursing support via disaster relief and humanitarian assistance 
missions, and pursuit of advanced education via our Duty Under 
Instruction Program have all contributed to their decision to 
stay Navy.
    While recruiting to the active component remains robust, 
manning in the Reserves is of concern to me and my Reserve 
component deputy director, Rear Admiral Cynthia Dullea, who is 
here with us today. Despite meeting 107 percent of the 
recruiting goal in 2008, deficits from shortfalls in the 3 
previous years have led to challenges in filling junior officer 
billets. To that end, Reserve component recruiting initiatives 
will be targeted toward these vacancies.
    Last year we saw the release of a new retention initiative, 
the registered nurse incentive specialty pay (RNISP), uniquely 
designed to incentivize military nurses to remain at the 
bedside providing direct patient care. We targeted RNISP 
eligibility toward our critical wartime undermanned specialties 
with inventories of less than 90 percent.
    This year we were able to expand the RNISP to include 
psychiatric/mental health nurses and nurse practitioners, 
women's health nurse practitioners, and certified nurse 
midwives. In the future I look forward to being able to offer 
an incentive such as this to all of my nurses practicing within 
their specialties.
    In addition, targeted recruiting efforts for both active 
and Reserve assets will be focused not only on the acquisition 
of medical/surgical nurses, but also on fortifying high 
operational tempo communities of critical care and 
perioperative nurses and family nurse practitioners.
    Recognizing the efforts of those who diligently serve our 
beneficiaries when Navy nurses deploy, we have recently 
implemented two innovative programs to expand the professional 
development of our valued Federal civilian registered nurses. 
One of these programs offers training in perioperative nursing, 
augmenting a high-deploying critical nursing specialty and 
providing service continuity to patients at our military 
treatment facilities.
    The graduate program for Federal civilian registered nurses 
provides funding for competitively selected candidates to 
pursue their master of science degree in nursing, adding to our 
pool of clinical nurse specialists who help mentor and train 
our junior nurses and hospital corpsmen.
    I remain an ardent supporter of the Tri-Service Nursing 
Research Program (TSNRP), and am duly committed to its 
sustainment. Navy nurses throughout our military treatment 
facilities are engaged in research endeavors that promote not 
only the health and wellness of our servicemembers, but that of 
their families as well.
    Nurses have always been recognized for their expertise in 
disease prevention, health promotion, and patient education. 
The melding of Navy nurses' clinical proficiency in the 
aforementioned areas, and their keen operational focus, ensures 
success in Navy deployments and encounters in rural isolated 
villages with impoverished communities.
    My nurses are agile, adaptable, capable, and ready to 
deploy. The Navy's newest nurses graduating from the Officer 
Development School in Newport, Rhode Island, eagerly inquire 
how soon they might deploy after reporting to their very first 
command. All of my nurses from ensign to captain, because of 
their clinical relevance, have the potential opportunity to 
deploy. Today's deployment environments involve locations in 
harm's way and include practice settings that require the 
application of clinical expertise in a myriad of areas.
    Line-type commanders recognize our nurses' value 
immediately and champion their assumption of key operational 
leadership roles previously held by other professional corps 
and services. Recently returned from deployment as the officer 
in charge of the combined joint task force cooperative medical 
assistance team in Afghanistan, a Navy pediatric nurse 
practitioner offered and I quote ``I would be willing to 
redeploy to an operational setting and endure separation from 
my family and even sacrifice my safety because of the 
overwhelming sense of fulfillment that I received in helping 
empower the women of Afghanistan. Even the smallest changes 
that we made to increase their education, economic stability, 
and improve their health will ultimately make a profound 
difference in their lives and that of their children.''
    A Navy nurse deployed as an individual augmentee assumed 
the role of team leader for an embedded training team in Kabul. 
She served as a mentor to a senior nursing leader of the Afghan 
National Army and was instrumental in the development of a 
variety of educational programs for over 80 military nurses and 
140 health aides. She shared that she and her team empowered 
these nurses to become not only teachers, but leaders, and in 
doing such they became role models to others within their 
organization.
    The maturity, sense of personal fulfillment and confidence 
of having done something that their peers have not done is 
readily identifiable among my nurses returning from these 
unique deployments. From the way they act, talk, and perhaps 
even the swagger in their walk, one can tell that they have 
returned with experiences foreign to many, accomplished goals 
unrealized in the past, and matured in a way years could never 
have provided. Indeed, they are forever changed.
    However, in order to remain resilient we are committed to 
ensuring they have access to all resources via our Care of the 
Caregiver Program and can continue to live in a healthy manner 
as members of our corps.
    Last year we celebrated the 100th anniversary of the Navy 
Nurse Corps. Within the next century we have identified what we 
must do to continue to prepare our nurses to deploy in any 
environment to care for America's heroes. We are not the same 
Nurse Corps of our ancestry. We are moving into assignments and 
uncharted roles that were never held by Navy nurses before.
    For example, within this coming year a Navy nurse will 
become the first nurse assigned to headquarters, Marine Corps. 
Are the marines in for a surprise.
    We are models of interoperability as we function seamlessly 
in missions beside our sister services on land, sea, and air. 
Our skillful integration and translation between services is 
perhaps best exemplified in this last vignette. At the 
conclusion of one of my nurses' briefs in Afghanistan during a 
transfer of authority between incoming and outgoing personnel, 
a colleague turned to her and said: ``While you might not have 
learned a lot of Dari while you were here, you can sure speak 
Army well. Hoo-ah.''

                           PREPARED STATEMENT

    I appreciate the opportunity to share some of these 
accomplishments of my wonderful nurses and I look forward to 
continuing our work together as I lead Navy nursing. Thank you.
    Chairman Inouye. Thank you very much, Admiral.
    [The statement follows:]

     Prepared Statement of Rear Admiral Christine M. Bruzek-Kohler

                            OPENING REMARKS

    Good Morning, Chairman Inouye, Senator Cochran and distinguished 
members of the subcommittee, I am Rear Admiral Christine Bruzek-Kohler, 
the 21st Director of the Navy Nurse Corps. Nursing relevance and 
practice is the Navy Nurse Corps of today. Navy nurses are inculcated 
into our organization based on the development of a solid clinical 
skills foundation. It is my expectation that all nurses in the Navy 
Nurse Corps maintain clinical relevance from the day they are 
commissioned until the day they retire.
    Today I will highlight the accomplishments of a total Navy Nurse 
Corps force composed of over 5,500 active, reserve and federal civilian 
nurses who play an invaluable role in Navy Medicine as clinicians, 
mentors, teachers, and leaders. We are renowned for our steadfast 
commitment to our patients and respected for our impressive ability to 
collaborate with other healthcare disciplines in the provision of 
superb care to America's fighting forces, their families and the 
retired community.

         CLINICAL EXCELLENCE/READINESS AND CLINICAL PROFICIENCY

    My goal is to establish a culture of clinical excellence for all 
nurses in all missions and support a consistent, interoperable standard 
of nursing practice throughout Navy Medicine, one that easily 
transitions to interoperability as we work more and more 
collaboratively with our sister services. We assessed the current state 
of clinical proficiency in various nursing specialties and developed 
and delivered standardized nursing core competencies. These 
competencies transition to all nursing practices throughout Navy 
Medicine ensuring clinical proficiency. Competencies in the nursing 
fields of medical/surgical, emergency/trauma, psychiatric/mental health 
and critical care have been deployed throughout Navy Medicine for 
almost a year. We are currently developing competencies in the 
following practice areas: neonatal intensive care, maternal infant, 
pediatrics, perioperative, multi-service ward, operational nursing, 
case management, and immunizations.

                                TRAINING

    Today's Navy nurses face unprecedented challenges in caring for 
America's returning wounded warriors. They are confronted with injury 
and wound complexities that they have never seen or treated before. 
From the moment the service members reach our medical facilities until 
the day they are discharged home with their families, Navy nurses have 
served as a galvanizing force among a cadre of healthcare professionals 
in helping the wounded, ill and injured successfully transition to a 
life post combat.
    Navy nursing is spearheading the development and implementation of 
the Combat Wound Initiative, composed of two programs: Complex Wound 
and Limb Salvage Clinic (CWLSC); and, Integrated Wound Care Programs at 
Walter Reed Army Medical Center (WRAMC) and National Naval Medical 
Center (NNMC). Over the past year, there were approximately 2,000 
patient encounters between the two programs. The CWLSC is an advanced, 
multi-disciplinary wound care center which uses state-of-the-art 
assessment, testing, and evidence-based treatment for the care of 
complex wounds in the combat wounded and DOD beneficiary. The CWLSC, a 
portion of the Combat Wound Initiative, integrates targeted clinical 
and translational research incorporating advanced technology and 
treatment, informatics, and tissue banking.
    At NNMC, a Navy nurse serves as the Medical Evacuation (MEDEVAC) 
team leader and expertly orchestrates staffing and equipment decisions 
which were essential to the safe transportation of over 220 patients on 
100 inbound MEDEVAC missions from Andrews Air Force Base to NNMC over 
the course of the past year.
    Our nurse at Fleet Forces Command facilitates a quarterly Tidewater 
Medical Coordination Council consisting of Type Commander (TYCOM) 
Medical Leadership and the local Military Treatment Facility's (MTF) 
executive officer, clinic directors, officers-in-charge, and 
Operational Forces Medical Liaison Services. The purpose of these 
meetings is to bring both sides together to ensure fleet Sailors are 
receiving the care they need in a timely manner and to address any 
concerns from the MTF perspective.
    Navy nursing leaders partnered with the Navy Chaplain Corps to 
develop and implement the Combat and Operational Stress Control 
Training for Caregivers course to provide state of the art knowledge to 
a full range of caregivers in the recognition of deployment related 
reactions, planning of effective interventions, enhancing caregiver 
collaboration, and facilitating the use of mental health services for 
individual service members and military families. Phase one of this 
training included over 1,500 participants. This year's training is 
designed specifically to address the deployment experiences of families 
and is being offered to over 3,000 caregivers at 19 sites worldwide.

  JOINT TRAINING AND MUTUAL SUPPORT WITH OTHER UNIFORMED SERVICES AND 
                               COUNTRIES

    In highlighting perhaps some of the most publicly recognized joint 
initiatives in which Navy nurses have participated, one must include: 
the Federal Health-Care Center in North Chicago, the merger of two 
highly acclaimed Army and Navy medical centers into the Walter Reed 
National Military Medical Center in the national capital area, and 
missions aboard the USNS MERCY (T-AH 19) and USS KEARSARGE (LHD 3) and 
BOXER (LHD 4).
    Navy nurses from the Naval Health Clinic Great Lakes diligently 
work on both local and national level committees with their colleagues 
from the North Chicago VA Medical Center (NCVAMC) in preparation for 
the merger of the two facilities to become the first Federal Health-
Care Center in 2010.
    Collaborating with medical department members from all three armed 
services and other partners, the Navy nurses at Joint Task Force 
National Capital Region Medical (JTF CAPMED) are actively developing 
the master transition plan to close Walter Reed Army Medical Center, 
develop the first integrated regional military medical command and 
expand the National Naval Medical Center into the ``world-class'' 
Walter Reed National Military Medical Center.
    The nurses at NNMC and WRAMC held two nursing integration kick-off 
meetings in 2008 to network with their counterparts and strategize 
plans of actions for the new Walter Reed National Military Medical 
Center-Bethesda (WRNMMC). These meetings were well attended and the 
nurses are committed to ensuring the success of this venture.
    USNS MERCY (T-AH 19) departed San Diego, California in May 2008 
with a 1,000-person joint, multi-national, Military Sealift Command 
Civilian Mariner, U.S. Public Health Service and non-governmental 
organization (NGO) team to conduct Pacific Partnership 2008 (PP08). The 
core nursing team consisted of 40 Navy and five Air Force Nurse Corps 
Officers. Additional nursing augmentation was provided by 84 colleagues 
from the Navy Reserves. Supplemental support was available via military 
nurses from partner nations Australia, Canada, Indonesia, New Zealand, 
and the Republic of the Philippines, as well as NGO nurses from 
International Relief Teams, Project HOPE and Operation Smile.
    USNS MERCY's Casualty Receiving (CASREC) nursing team processed 
over 1,900 patients, of which more than 1,500 were admitted. A total of 
1,369 shipboard surgeries were performed, with Navy nurses involved in 
every phase of the operative process. During Pacific Partnership 08 
(PP08), the ship's reduced operating status (ROS) perioperative nurse 
was selected as Medical Advance Team Leader in Chuuk, Federated States 
of Micronesia (FSM). In this role, he identified prime locations and 
established logistical support for medical clinics ashore, facilitating 
the treatment of 12,000 patients in 8 days. In addition, he worked with 
local and U.S. public health and government officials to contain a 
deadly outbreak of multi-drug resistant tuberculosis. He coordinated 
efforts between the FSM President's Office, Chuuk Governor's Office, 
U.S. Ambassador, and Centers for Disease Control, ensuring that 100 
percent of suspected cases were contacted, screened and prescribed 
appropriate treatment.
    Navy nurses also served aboard both USS KEARSARGE (LHD 3) and USS 
BOXER (LHD 4) as they delivered relief services and provided medical 
care to over 71,000 patients from eight Latin American and Caribbean 
nations during Operation Continuing Promise.
 collaboration with civilian medical institutions/communities/outreach
    We will soon mark the 1 year anniversary of the merger of the Navy 
Nurse Corps Anesthesia Program with the Uniformed Services University 
(USU) Graduate School of Nursing anesthesia program. The inaugural 
class of this federal nurse anesthesia program will graduate in 2010.
    At the Expeditionary Medical Facility, Camp Lemonier, Djibouti 
City, Djibouti, Africa, our nurses are members of a small surgical team 
who provide teaching assistance in areas such as laparoscopic surgery, 
regional anesthesia, and sterilization at Africa Peltier General 
Hospital, Djibouti via a request the hospital made to the U.S. Embassy 
and the United States Agency for International Development. While the 
surgeons focus on teaching laparoscopic techniques, the nurses foster 
collegial relationships and offer classes on improved sterilization 
techniques, laparoscopic equipment care and use, epidural catheter 
placement for surgery and pain control, and caudal anesthesia in 
pediatrics.
    In collaboration with a Chief Naval Operations (CNO) working group, 
Bureau of Navy Medicine and Surgery (BUMED) and Navy Medicine East 
(NME), a plan has been approved to redesign a building into a 28 bed 
long term care facility to house aging Special Category Residents 
(formerly Cuban Exiles) who receive assisted living or total nursing 
care on the wards of the Naval Hospital Guantanamo Bay, Cuba. At times, 
these patients can absorb 50 percent of the naval hospital bed 
capacity. Navy nurses are working with civilian facilities in the 
Portsmouth, VA area to obtain requisite training as they move forward 
with this one of a kind Navy facility. Staffing will consist of a 
combination of military, civilian and foreign national home health 
aides.
    Senior nursing leaders from Naval Hospital Camp Lejeune join their 
civilian peers from Onslow County, North Carolina in monthly meetings 
as partners in the East Carolina Center for Nursing Leadership Robert 
Wood Johnson Grant for ``Partners for Rural Nursing.'' The grant's 
objective is to mobilize rural nurse leaders' ability to partner, 
evaluate, and develop interventions to solve local nursing workforce 
issues and create healthier communities in eastern North Carolina. The 
long-term goal of this project is the creation of a permanent county 
nurse association that will recruit more nurses to the county and 
increase the overall educational level of the nurses and educators.

                    DEPLOYMENTS/OPERATIONAL MISSIONS

    Coinciding with the advancement of their professional practice is 
the simultaneous development of our nurses as naval officers who are 
operationally ready to meet any call to deploy in any mission at a 
moment's notice. As such, the Navy Nurse Corps continues to be a 
mission critical asset in supporting Navy Medicine deployments.
    From January 2008 to January 2009, 441 Navy nurses have deployed--
Active (257) and Reserve (184). They served admirably in operational 
roles in Kuwait, Iraq, Djibouti, Afghanistan, Bahrain, Qatar, 
Indonesia, Thailand, Southeast Asia, Pakistan, Guantanamo Bay, Cuba, 
Germany, and aboard both hospital ships, USNS MERCY and USNS COMFORT, 
and on grey-hulls such as USS KEARSARGE and USS BOXER. They are part of 
Provincial Reconstruction Teams (PRTs), Expeditionary Medical 
Facilities (EMFs) and Flight Surgery Teams. They participate in the Sea 
Trial of the Expeditionary Resuscitative Surgery System (ERSS) and 
perform patient movement via Enroute Care at or near combat operations.
    Nurses in our Reserve Component (RC) have made significant 
contributions to operational missions over the past year with Medical 
Readiness Training Exercises (MEDRETE) in Peru, Suriname, Honduras, and 
Trinidad and Tobago. Additionally, there are currently 101 RC nurses 
mobilized to Landsthul Regional Medical Center, Germany.
    In Afghanistan, Navy Nurse Corps officers have assumed the role of 
Officer in Charge (OIC) of the Combined Joint Task Force-101/82 joint 
Cooperative Medical Assistance (CMA) team. Previously held by Army 
Medical Officers, this position was most recently held by a senior Navy 
Nurse Corps officer who was also a pediatric nurse practitioner. The 
mission of the Cooperative Medical Assistance (CMA) team is to plan, 
coordinate and execute medical and veterinarian humanitarian civil-
military operations across the combined joint operations area of 
Afghanistan. Under Navy Nurse Corps leadership, the CMA team has 
mentored and taught over 250 Afghanistan physicians, midwives, and 
nurses in the past year. Additionally, the CMA team provided direct 
medical and veterinarian care in over 200 rural villages in hostile 
areas along the Pakistan border and in Southern Afghanistan. In an 
effort to fight the overwhelming infant and childhood mortality rates 
in Afghanistan, the first Navy Nurse OIC of the CMA team authored a 
U.S. CENTCOM's Humanitarian Assistance, Disaster Recovery and Mine 
Resistance grant to fund three projects in Regional Command--East, 
Afghanistan. Currently in the execution phase, this $50,000 grant will 
provide medical intellectual capacity building to Afghan healthcare 
providers in some of the most remote, hostile and rural areas of 
Afghanistan; directly impacting the lives of Afghan infants and 
children.
    We continue to monitor our deploying specialties within the Navy 
Nurse Corps. While earlier deployments were more aligned with our 
critical wartime specialties of certified registered nurse 
anesthetists, advanced practice nurses, psychiatric/mental health, 
medical/surgical, critical care, perioperative and emergency/trauma 
nurses; we have noted the communities of pediatrics and women's health 
are also being engaged for roles on Provincial Reconstruction Team and 
Humanitarian Assistance missions.

                         CARE OF THE CAREGIVER

    Navy Medicine leaders have recognized that operational and 
occupational demands impact the quality of patient care and caregiver 
quality of life. Consequences of untreated cumulative stress can result 
in medical errors, physical illness, decreased job satisfaction, and 
emotional difficulties. The Navy Medicine Caregiver Occupational Stress 
Control (OSC) Program, sometimes called Care for the Caregiver, has 
three fundamental principles; early recognition, peer intervention, and 
connection with services as needed. There are many strategies and 
resources that are being developed to assist Navy Medicine caregivers 
with the operational, occupational, and compassion demands of the care 
we provide to Sailors, Marines, and their families. One of the main 
strategies for addressing the psychological health needs of our 
caregivers is to develop occupational stress training and intervention 
teams for our major treatment centers.

        THE WARFIGHTER, THEIR FAMILIES AND THE CONTINUUM OF CARE

    Navy nursing encompasses the care of warriors and their families in 
countless interactions in locations at home and abroad.

                             THE WARFIGHTER

    A Nurse Corps officer at Naval Medical Clinic Patuxent River plays 
an invaluable role in their local ongoing Individual Augmentee (IA) 
pre-deployment program by ensuring that all medical records are pre-
screened as soon as the active duty member receives IA orders. This 
early screening affords sufficient time to explore potential deployment 
medical disqualifiers and provides the squadron's time to identify an 
alternate in the event the augmentee is deemed non-deployable.
    The Department head of the Occupational Health Clinic at Naval 
Hospital Camp Lejeune, a civilian nurse, along with the local military 
audiologist, identified that a significant number of 17-27 year old 
active duty members were being fitted bilaterally for hearing aids 
after returning from war. This led to the inception of a new initiative 
called ``Warriors Silent Wound'' hearing conservation program 
addressing readiness, education and hearing protection for the Camp 
Lejuene based Marines.
    The Medical Rehabilitation Platoon (MRP) Case Manager position at 
Camp Geiger, Branch Medical Clinic, Naval Hospital Camp Lejeune is held 
by a Nurse Corps officer who coordinates the care for over 80 Marines, 
ensuring that every patient in MRP receives accurate and timely 
healthcare reducing the time spent in MRP and increasing the amount of 
Marines returning to training and eventually to the Fleet Marine Force.
    A Navy Nurse Corps officer currently runs a Warrior Return Unit at 
Expeditionary Medical Facility Kuwait for injured/ill warfighters. 
Located on Camp Arifjan and initiated in 2005, its mission is to 
maximize the quality of life for coalition forces during the period of 
convalescence, expediting return to duty or transfer to definitive 
care. The Warrior Return Unit (WRU or ``Roo'') is a three-building 
complex, 136 bed capacity, dedicated solely for the purpose of 
providing a place for service members to live, relax, and heal from 
their illnesses, injuries, or surgical procedures and, ideally, return 
to duty. The WRU also provides an entertainment lounge, DSN lines for 
business or morale calls, gaming stations, and internet access, as well 
as 24 hour staffing, with a nurse on site and dedicated transportation 
to and from the hospital. Approximately 80 percent of all wounded 
warriors do indeed return to duty from the WRU and almost three-
quarters of them return directly back to Iraq. Those who cannot return 
to duty are medically evacuated to Landsthul Regional Medical Center or 
back to Military Treatment Facilities in the continental United States 
(INCONUS).
    At NNMC, the Casualty Affairs Office consists of a Navy nurse and a 
Hospital Corpsman. They meet with every combat casualty and their 
family in order to insure all of their needs are met; allowing them to 
focus solely on the healing process. The Casualty Affair Office employs 
the ethos ``their feet never hit the ground''; referring to the fact 
that no request goes unnoticed for the 110 patients and families they 
have met in the past year.

   GROWING MENTAL HEALTH REQUIREMENTS/PSYCHIATRIC AND MENTAL HEALTH 
                                NURSING

    The Navy Nurse Corps has met the Surgeon General's guidance for 
psychiatric/mental health nurse practitioners (PMHNPs). We have 
programmed 18 PMHNPs through the Future Years Defense Plan (FYDP) to 
meet currently projected growth of the Marine Corps, Blue in Support of 
Green (BISOG) and the development of the Operational Stress Control and 
Readiness (OSCAR) teams.
    Our psychiatric nursing leaders are critical members of the 
multidisciplinary team writing the maritime doctrine for combat and 
operational stress control for the U.S. Marine Corps and U.S. Navy. A 
Nurse Corps officer has been appointed as the first Coordinator for the 
Line owned and led Navy Operational Stress Control (OSC) program. 
Secretary of the Navy and the Chief of Naval Operations have directed a 
Navy stress control program to specifically (1) define doctrine and 
organization; (2) address mental health stigma; (3) define curricula, 
develop training and exercise requirements for pre-deployment and post-
deployment of all personnel; and (4) build resilient Sailors and 
families. Operational Stress Control is leader-focused actions and 
responsibilities to promote resilience and psychological health in 
Sailors, commands, and families exposed to the stress of routine or 
wartime military operations in all environments, whether at sea, in the 
air, or on the ground, and in both operational and supporting roles. 
The goals of OSC are to create an environment where Sailors, commands, 
and families can thrive in the midst of stressful operations.
    EMF Kuwait mental health nurses are providing outreach training for 
more than 200 personnel at various units on anger/stress management and 
improving communication skills. One Navy mental health nurse 
practitioner from EMF Kuwait forward deployed for a 3 week period into 
Iraq, backfilling a transitioning Army psychiatrist billet providing 
mental health services throughout Iraq.
    A newly hired civilian mental health nurse practitioner at Naval 
Medical Clinic Quantico's Deployment Health Center assumes the 
continuation of care for patients who require more than eight 
encounters at the center, providing continuity of care and bolstering 
patient/provider rapport.
    The newly opened Post Deployment Health Center in Groton, CT, part 
of the DOD initiative to respond to mental health needs of returning 
veterans, provides individual and group counseling services to active-
duty members from all branches of the military from throughout the 
Northeast. Prior to the opening of this clinic, patients would have had 
to travel as far as Bethesda, MD for this same type of care milieu.
    The first active duty PMHNP assigned to the Deployment Health 
Center at Naval Hospital Twentynine Palms, closely follows 80 of the 
clinic's 225 active cases.
    She provides initial psychological evaluations, medication 
screenings, and shares valuable information with colleagues, general 
medical providers, and commands on recommendations about service 
members' fitness for deployments. She also serves as the clinic 
spokesperson and is closely involved with the family advocacy program 
and substance abuse counseling center, ensuring that information is 
provided to dependents as well as the active duty member. This PMHNP 
candidly offers that this has been her ``most fulfilling job in the 
Navy''.

                               THE FAMILY

    Last year, several Outside Continental United States (OCONUS) and 
geographically remote Continental United States (CONUS) military 
treatment facilities (MTFs) received fourteen junior Nurse Corps 
officers who attended our new 4 week Perinatal Pipeline training 
program at Naval Medical Center San Diego, Naval Medical Center 
Portsmouth, and National Naval Medical Center. The program was designed 
to train medical-surgical nurses who expect to work in labor and 
delivery or the newborn nursery at OCONUS or geographically isolated 
facilities. This program has increased the nurses' knowledge, 
confidence, and subsequently the quality of care and patient safety for 
these commands. Along this same theme, Naval Hospital Okinawa hosted 
the Western Pacific Perinatal Orientation Education Program/Neonatal 
Orientation Education Program (PEOP/NEOP) training for 40 staff from 
Okinawa, Yokosuka and Guam; yielding over $160,000 in training cost 
savings to the aforementioned facilities.
    At Naval Medical Center Portsmouth, a pediatric nurse practitioner 
with a passion for early detection and prevention of child abuse 
identified an opportunity to improve communication between her facility 
and outside protective services. With the help of the hospital's web 
designer, and 2 years of diligent dedication, she created an online 
algorithm and reporting system nicknamed C.A.N.A.R.E.E.S., which stands 
for Consolidated Abuse, Neglect, Assault, Reporting Electronic Entry 
System. This program, presently piloted in the facility's Emergency 
Department, links to the Composite Health Care System and provides 
consolidation of all demographic data and patient encounter information 
into required report formats. This new reporting mechanism alleviates 
illegible handwriting and streamlines reporting agency notifications. 
It also serves as a data repository that may be used in quality 
assurance and statistical analysis to target training or educational 
offerings as indicated by set thresholds.

                   THE WOUNDED WARRIOR CARE CONTINUUM

    Wounded Warrior Case Management is quite different now than it was 
2 years ago. Many of the more severely injured are cared for at one of 
Navy's large medical centers or at one of four VA Polytrauma centers 
closest to the service members' homes.
    The Wounded Warrior Berthing, also known as the ``Patriot Inn,'' at 
Naval Medical Center Portsmouth continues to provide temporary lodging, 
monitoring, and close proximity to necessary recovery resources for 
active duty ambulatory patients in varying stages of their health 
continuum.
    At Naval Hospital Camp Pendleton, active duty Nurse Corps officers 
work directly with the Wounded Warrior Battalion to manage the wounded 
warrior cases, providing a comprehensive plan of care throughout the 
healthcare system. The patients assigned to this battalion are 
primarily ambulatory patients who are receiving continuing care for 
orthopedic or mental health issues.
    The Naval Medical Center San Diego's (NMCSD) Comprehensive Combat 
and Complex Casualty Care (C\5\) Program (recipient of the 2008 
Military Health System Healing Environment Award) recently expanded its 
Primary Care division to include two government service nurse 
practitioners (one former Army veteran), one physician assistant, two 
civilian health technicians (one former Independent Duty Corpsman) and 
two Hospital Corpsmen. This group provides continuity in medical 
management of these service members; ensuring primary health care needs 
are addressed during their rehabilitation. Recently, the C\5\ lead 
nurse case manager received the prestigious San Diego Regional Chamber 
of Commerce Military Honoree Award for 2008.
    NMCSD is also home to an Army Warrior Transition Unit (WTU), the 
only one of its kind in a non-Army treatment facility. This staff is 
comprised of a provider, nurse case managers, licensed clinical social 
worker and administrative support staff who oversee the medical and 
non-medical case management of soldiers transferred here for 
rehabilitation services.

                           GRADUATE EDUCATION

    Continuation of a Navy nurse's professional development via 
advanced educational preparation, specialization, and pursuit of 
national certification is necessary to better serve our beneficiary 
population, as well as strengthen their respective communities of 
practice and prepare the officer for promotion. Our training plan this 
year included the opportunity for 70 officers to seek advanced degrees. 
We focused on fortifying our critical wartime inventories of certified 
registered nurse anesthetist, psychiatric/mental health clinical nurse 
specialist and nurse practitioner, and critical care and medical/
surgical nursing.

                            NURSING RESEARCH

    I remain an ardent supporter of the Tri-Service Nursing Research 
Program (TSNRP) and am duly committed to its sustainment. Navy nurses 
assigned throughout our MTFs are engaged in research endeavors that 
promote not only the health and wellness of our warriors, but that of 
their families too. My senior nurse executives have identified creative 
ways to pique junior officer's interest in research activities.
    At Naval Hospital Oak Harbor, a Navy nurse has a research study 
entitled, ``Breastfeeding Rates among Active Duty Military Women across 
the First Year Postpartum'' with Independence University. A novice 
researcher, she is being mentored in her first endeavor by the Senior 
Nurse Executive at her command and a nurse researcher assigned to Naval 
Medical Center San Diego.
    The Senior Nurse Executive at NMCSD has implemented the Senior 
Nurse Executive Nursing Fellowship Awards. This competitive award 
recognizes two junior nurses/Clinical Nurse Specialist (CNS)/Nurse 
Researcher team dyads and provides them the resources and man-hours to 
conduct a year long research proposal. Both junior nurse/CNS dyads 
attend research methods or evidence based nursing courses to assist 
them in the development and implementation of their studies. The 
results have been quite impressive.
    One dyad completed a pilot study to determine whether an 
educational intervention could be designed to reduce Compassion Fatigue 
in the healthcare providers caring for C\5\ (Comprehensive Combat and 
Complex Casualty Care) patients. The findings demonstrated that the 
study participants' scores in compassion satisfaction increased and 
burnout scores decreased after viewing the Compassion Fatigue 
intervention. The dyad presented a poster at the Karen Rieder Federal 
Nursing Poster Presentation titled Compassion Fatigue in C\5\ Staff 
Caring for Wounded Warriors. A study-designed educational intervention 
was developed from this study and was implemented to 43 staff caring 
for Wounded Warriors, awarding 172 contact hours.
    The second dyad was awarded the Research Award for Best Evidence 
Based Practice from the Zeta Mu Chapter of the Sigma Theta Tau 
organization. The proposed project was titled ``Implementation of An 
Open Crib Phototherapy Policy: Adaptation of an Evidence Based 
Guideline Project''. The dyad's work has resulted in the local 
implementation of the guideline to include standardizing physician 
order sets and staff education. One member of the dyad has been invited 
as a presenter to the annual National Association of Neonatal Nurses 
(NANN) Research Summit.

                        EDUCATIONAL PARTNERSHIPS

    Navy nurses, at our hospitals in the United States and abroad, 
passionately support the professional development of America's future 
nursing workforce by serving as preceptors and mentors for a myriad of 
colleges and universities.
    Because of the vast array of clinical specialties available at our 
medical centers at Bethesda, Portsmouth and San Diego, they have 
multiple Memoranda of Understandings (MOUs) with surrounding colleges 
and universities to provide clinical rotations for nurses in various 
programs from licensed practical/vocational nursing, baccalaureate, and 
graduate degrees which include nurse practitioner and certified nurse 
anesthetist tracks.
    Not to be outdone, nurses at our smaller facilities such as Naval 
Hospital Twentynine Palms, Beaufort, Bremerton, Charleston, Cherry 
Point, and Guam coordinate training opportunities with local hospitals 
in resuscitative medicine, medical/surgical and obstetrical nursing and 
serves as clinical rotation sites for local colleges.
    During Pacific Partnership 2008, Navy nurses from USNS Mercy (T-AH 
19) served as subject matter experts to nurses in five host nation 
hospitals on topics such as basic and advanced life support, critical 
care and pediatric nursing, isolation techniques, and blood transfusion 
therapy. In total, at least 200 hours of classroom instruction were 
presented to over 1,000 students.
    Navy nurses deployed to the Expeditionary Medical Facility, Camp 
Lemonier, Djibouti City, Djibouti, collaborated with the Djibouti 
School of Nursing to review nursing fundamentals and discuss nursing 
issues important to Djibouti nurses as part of an English language 
skills enhancement class.

                          NURSING PUBLICATIONS

    Navy nurses are accomplished authors whose works encompass all 
specialty areas of nursing and have appeared in nationally recognized 
publications as follows: Advances in Neonatal Care, AORN Journal, 
Critical Care Nursing Clinics of North America, Journal of Advanced 
Nursing, Journal of Forensic Nursing, Journal of Pediatric Healthcare, 
Journal of Psychosocial Nursing, Journal of Trauma Nursing, Nursing 
Administration Quarterly, Military Medicine and Viewpoint.

                        PRODUCTIVITY INITIATIVES

    At Naval Hospital Lemoore, Nurse Corps officers in the Primary Care 
Clinics spearhead various clinical functions such as telephone triage, 
dysuria protocol, and newborn infant well-baby visits saving 
approximately 80 appointments per month for higher level providers and 
yielding improved access to care for patients.
    A Navy nurse midwife who serves as both the Director of Health 
Services and the Department Head of Obstetrics and Gynecology at Naval 
Hospital Charleston was also the second highest provider in patient 
care encounters compared to peers who practice at the same facility.
    A women's health nurse practitioner at Naval Hospital Beaufort is 
solely responsible for the women's health visits of 4,000 female 
recruits. Other nurse-run clinics at this facility medically in-
processed 22,234 Marine recruits and administered over 154,000 
immunizations.

                FORCE SHAPING/RECRUITMENT AND RETENTION

Recruitment
    Today's Navy Nurse Corps (AC) is 95.7 percent manned with 2,780 
nurses serving around the globe. We expect to make Navy Nursing's 
recruiting goal for 2009 within the next few months and this will be 
the third year in a row that we have achieved this important milestone. 
Our recruiting efforts this year have outpaced those of 1 year ago. Our 
nurses' diligent work and engagement with local recruiting initiatives 
have certainly contributed to these positive results.
    The top three programs that we should credit to this accomplishment 
include the increases in Nurse Accession Bonus (NAB) now at $20,000 for 
a 3 year commitment and $30,000 for a 4 year commitment; the Health 
Professions Loan Repayment Program (HPLRP) amounts up to $40,000 for a 
2 year consecutive obligated service and the Nurse Candidate Program 
(NCP), offered only at non-Reserve Officer Training Corps (ROTC) 
Colleges and Universities, which is tailored for students who need 
financial assistance while in school. NCP students receive a $10,000 
sign on bonus and $1,000 monthly stipend. Other factors contributing to 
our recruiting success include the location of our duty stations and 
the opportunity to participate in humanitarian missions.
    Last year we created a Recruiting and Retention cell at the Bureau 
of Medicine and Surgery (BUMED) with a representative identified from 
each professional corps. These officers serve as liaisons between Navy 
Recruiting Command (NRC), Naval Recruiting Districts (NRD), Recruiters 
and the MTFs and travel to and or provide corps/demographic specific 
personnel to attend local/national nursing conferences, or collegiate 
recruiting events. In collaboration with the Office of Diversity, our 
Nurse Corps recruitment liaison officer coordinates with MTFs to have 
ethnically diverse Navy personnel attend national conferences and 
recruiting events targeting ethnic minorities. This has allowed us to 
broaden our reach and recruit at national nursing conferences that we 
never before attended.
    The Nurse Corps Recruitment liaison officer works with a speaker's 
bureau comprised of junior and mid-grade Nurse Corps officers 
throughout the country who reach out to students at colleges, high 
schools, middle and elementary schools. We recognize that the youth of 
America are contemplating career choices at a much younger age than 
ever before. Over the course of the past year, we have tailored more of 
our recruiting initiatives to engage this younger population. Our 
nurses realize that each time they speak of the Navy Nurse Corps they 
serve as an ambassador for our corps and the nursing profession too.
    Since returning from Pacific Partnership 08, USNS MERCY (T-AH 19) 
has collaborated with the Navy Recruiting Region WEST Medical Programs 
Officer to host two recruiting tours. In total, 40 potential Navy 
Medicine candidates visited the ship. Both the USNS MERCY and USNS 
COMFORT are invaluable tools in the Nurse Corps recruiting arsenal. 
Shipboard tours are frequently requested by faculty and students alike.
    Naval Hospital Camp Lejeune, in conjunction with Navy Recruiting 
District Raleigh, NC, has initiated a joint effort to recruit Nurse 
Corps officers from the Eastern North Carolina area. In supporting the 
Nurse Corps recruiting and retention initiatives, Naval Hospital Camp 
Lejeune has created the Nurse Recruiting and Retention team. The team, 
co-chaired by two senior Nurse Corps officers works closely with the 
medical department recruiter to coordinate visits to area universities 
to speak with students regarding benefits of joining the Navy Nurse 
Corps. The team members also provide real life testimony to the 
students and provide insight into the personal experiences of team 
members. The team also serves as points of contact for interested 
students and is available to entertain questions or concerns via email 
or telephone. This mentoring provides yet another example of why the 
Navy Nurse Corps is so attractive to the students. The team encourages 
and sponsors visits to the Naval Hospital and gives them the 
opportunity to see Navy nurses, civilian nurses and hospital corpsmen 
working together to provide world class care. The team also supports 
the Recruiting District by coordinating and conducting the personal 
interviews required as a portion of the Nurse Corps application 
process. Since its inception in September 2008, this effort has led to 
25 potential Navy Nurse Corps officers accessioned into the recruiting 
pipeline for NRD Raleigh, North Carolina.
    A senior Nurse Corps officer at Fleet Forces Command serves as a 
liaison between the fleet shore-based Sailors and the MTF. She and 
other officers around the world have become mentors to the Medical 
Enlisted Commissioning Program (MECP) applicants. The MECP program is a 
robust enlisted commissioning track that selects and educates 55 
Sailors and Marines to become Navy nurses each year.
    Last year the Navy Nurse Corps reserve component (RC) met 107 
percent of their recruiting goal. Over 56 percent of the goal was 
comprised of NAVETS (nurses coming to the RC from active duty) and the 
remainder were direct accessions to the Navy Reserve. Success in 
recruiting NAVETS is related to the initiation of an affiliation bonus 
of $10,000 and the policy that guarantees NAVETS coming into the RC 
will be granted a 2 year deferral from deployment. Recruiting 
initiatives targeting direct accessions offer entry grade credit for 
advanced education and work experience among the critical wartime 
specialties of psychiatric/mental health, emergency room, and 
perioperative nursing. The RC recruiting shortfall in fiscal year 2005, 
2006, and 2007, coupled with the national nursing shortage and 
increased competition with both the civilian and federal employment 
healthcare sectors, had a detrimental impact on filling RC Nurse Corps 
billets with junior officers.
    Today, the Reserve Component is 1,189 nurses strong and manned at 
89.1 percent. The last 4 years of missed reserve nurse recruiting goal 
has impacted critical wartime specialties in nurse anesthesia (59 
percent), perioperative (73 percent), and critical care nursing (80 
percent) and subsequently contributed to their 145 unfilled billets.
Retention
    Recruiting is just one-half of the story for Navy nursing. 
Retention tells the other important half. Last year was the first time 
in the past 5 years that the Navy Nurse Corps' losses nearly matched 
our gains. In talking to Nurse Corps officers around the globe, I have 
found that we are implementing creative mentoring and leadership 
programs designed to get the information to the officers before they 
make a career decision to leave the Navy.
    Naval Hospital Bremerton's senior Nurse Corps officers conduct 
quarterly Career Development Boards for officers at various decision 
points in their career (first tour, promotion eligible, considering 
Duty under Instruction, considering release from active duty). Nurse 
Corps officers also participate with medical programs recruiters in 
Seattle and Denver to provide tours, interview candidates, answer 
questions, join them for local college career days and attend 
conferences.
    Naval Medical Center San Diego established a Nursing Retention and 
Recruitment Committee. There was an exceptional response to the request 
for volunteers. Members of the committee include a wide cross-section 
of nurses throughout the command, to include active duty (all ranks), 
government service, contract, reservists and recruiters. The committee 
meets monthly and reports to the Senior Nurse Executive.
    The Registered Nurse Incentive Special Pay (RNISP) program was a 
new retention initiative begun in February 2008 and included critical 
care and perioperative nursing, pediatric nurse practitioners, and 
family nurse practitioners. We have noted improvements in overall 
manning percentages for the aforementioned nursing communities. The 
RNISP program is designed to encourage military nurses to continue 
their education, acquire national specialty certification and remain at 
the bedside providing direct care to wounded Sailors, Marines, 
Soldiers, Airmen and Coastguardsmen. This year the RNISP program was 
expanded to include four additional communities: psychiatric/mental 
health nurses, psychiatric/mental health nurse practitioners, women's 
health nurse practitioners, and certified nurse midwives. Certified 
Registered Nurse Anesthetists (CRNAs) have been long standing 
recipients of the ISP, and they are currently manned at 99 percent.
    Continuing deployment cycles and Individual Augmentee roles 
continue to pose a challenge to retaining nurses in our service, yet 
our fiscal year 2008 Nurse Corps continuation rate after 5 years is 68 
percent, up slightly from last year. We continue to work issues to 
retain mid-grade officers at the 4 to 9 year point of commissioned 
service.
    The Operational Stress Control program has an indirect impact on 
the shape of the force, military retention, and Navy nurses. By 
developing and providing education and training opportunities 
throughout the career of the nurse, ``from Accessions through Flag 
Officer'', OSC will build resilience and increase effective responses 
to stress and stress-related injuries and illnesses. The art of nursing 
service members and their families through illness to wellness is 
frequently stressful. Strengthening the resilience of Navy nurses will 
assure they are better equipped to meet the day-to-day challenges of 
both naval service and their profession.
    Our total Navy nursing workforce, active and reserve components 
plus federal civilian registered nurses, is over 5,500 strong. 
Recognizing the invaluable contribution that our civilian nursing 
workforce provides in regards to continuity of care and access to 
services for our patients, especially during our deployments, we have 
established two new education programs exclusively for them.
    The Perioperative Nurse Training Program is a competitive program 
in which federal civilian registered nurses may apply to attend the 
fully funded 12 week Navy perioperative nurse training program. Upon 
completion of the training, the federal civilian nurse incurs a 1 year 
continued service agreement and works in the perioperative setting.
    The Graduate Program for Federal Civilian Registered Nurses 
provides funding for competitively selected federal civilian registered 
nurses to pursue their Master of Science in Nursing. Selected 
candidates agree to work a compressed work schedule during the time 
they are in graduate school and incur a 2 year continued service 
agreement. Our hope is that these new programs will not only serve to 
retain our current civilian nurses but also entice new nurses to 
consider entry into federal service with Navy Medicine.

                             COMMUNICATION

    The overarching goal for communications is to optimize the 
dissemination of official information that is easily accessible, 
current, and understood. This has been accomplished via monthly ``Nurse 
Corps Live'' video tele-conferences on a variety of topics relevant to 
our nursing communities, electronic publication of ``Nurse Corps News'' 
newsletter and the Nurse Corps webpage.

                               MENTORSHIP

    The development of our career planning guide will serve as a 
mentoring tool for all nurses. Core nursing mentors will be identified 
at each command to facilitate mentorship to officers, enlisted members, 
civilians and students alike.
    Naval Hospital Bremerton received the University of Washington 
School of Nursing's Preceptor of the Year Award for 2008 in recognition 
of the 14 years that the hospital's clinicians, administration and 
staff have provided exceptional learning opportunities for all nurse 
practitioner and certified nurse midwife students.
    The Director for Nursing Services at Naval Hospital Oak Harbor is 
working with local Career Counselors to schedule ``board interviews'' 
for Naval Air Station Whidbey Island sailors interested in pursuing 
careers in Navy nursing via one of our commissioning pipeline programs.
    The ``Nurse Corps Roundtable'' is a forum used by nurses from Naval 
Health Clinic, Great Lakes with local Navy Reserve Officer Training 
Corps nursing students, to facilitate their understanding of ``life as 
a Navy nurse.'' Topics include deployment opportunities, duty stations 
and assignments, and the unique camaraderie that military nurses enjoy.
    The division officer of the inpatient mental health unit at Naval 
Hospital Camp Lejeune has sparked the interest in mental health nursing 
in five junior nurses. He established a new mental health nurse 
teaching program, developed 15 individual lectures and provided 
individual mentoring over a 9 month period to five new military nurses 
who will be given an opportunity to gain the mental health subspecialty 
code. He is helping to change the stigma of mental health nursing to 
positively reflect a fulfilling and respected form of nursing practice 
to our young staff.

                               LEADERSHIP

    It is the amalgamation of our officers' clinical skills foundation, 
education, specialization and operational experiences that develop the 
highest caliber leaders for Navy Medicine today and in the future.
    CDR Michele Kane's work on ``Genotoxic and Cytotoxic Carcinogenesis 
Effects of Embedded Weapons Grade Fragments of Tungsten Alloy 
Shrapnel'' was recognized with awards for best in research by the 
Association of Military Surgeons of the United States, the Uniformed 
Services University for Health Sciences top award for Research 
Excellence from the Graduate School of Nursing, and the prestigious 
Uniformed Service University Board of Regents Scholastic Award for 
Research (an award normally reserved for medical students).
    The Bureau of Medicine and Surgery (BUMED) has partnered with the 
Chief of Naval Personnel (CNP, N1) to temporarily assign a Nurse Corps 
officer to establish the position of Navy Operational Stress Control 
Coordinator (OSC). CAPT Lori Laraway is responsible for OSC program 
development and execution across the entire Navy Enterprise and chair's 
the OSC Governance Board. Networking, reducing duplication of effort 
and formulating effective lines of communication have resulted in a 
Navy-wide program that addresses the needs of line leaders, Sailors and 
families.
    Previous team leaders for all Embedded Training Teams (ETT) have 
been Medical Service Corps Captains, until CDR Judith Bellas was 
selected as team Lead for Kabul ETT. CDR Bellas was recently recognized 
for her contributions during this year long deployment with the Bronze 
Star Medal. LCDR Keith B. Hoekman, a nurse practitioner, was awarded 
the Bronze Star Medal while deployed as the Medical Officer for the 
Provincial Reconstruction Team (PRT) in Ghazni Province, Afghanistan. 
Additionally, he received a Certificate of Recognition from the 
Ministry of Health, Kabul, Afghanistan for his community outreach 
initiatives on Women's Health that ultimately reached 30,000 villagers.
    LT Tony Wade from Naval Hospital Camp Pendleton recently received a 
Navy Commendation Medal with ``Combat V'' as he was directly 
responsible for saving Marine lives under austere and dangerous 
conditions in Afghan in support of the 2/7 Marines. When his trauma bay 
was hit by a mortar round and the surgeon was incapacitated, LT Wade 
and two corpsmen continued the trauma treatment for a Marine who had 
sustained life threatening injuries, their efforts directly resulted in 
saving his life.

                            CLOSING REMARKS

    Chairman Inouye, Senator Cochran, distinguished members of the 
committee, thank you again for providing me this opportunity to share 
with you the remarkable accomplishments of Navy nurses as we partner 
with our colleagues in meeting Navy Medicine's mission. I look forward 
to continuing our work together over the course of the next year.

    Chairman Inouye. General Horoho.

STATEMENT OF MAJOR GENERAL PATRICIA D. HOROHO, CHIEF, 
            ARMY NURSE CORPS, UNITED STATES ARMY
    General Horoho. Chairman Inouye, Vice Chairman Cochran, and 
distinguished members of the subcommittee: It's an honor and 
truly a privilege to be able to speak before you today on 
behalf of over 40,000 officers, enlisted and civilians of the 
Army Nurse Corps. It has been your continued unwavering support 
that has enabled Army nurses as part of the larger Army medical 
department team to provide the highest quality of care to all 
those that are entrusted to our care.
    Army nurses are a corps of seasoned combat veterans that 
are highly trained, highly skilled and highly committed. We 
deploy an average of 400 to 500 Army nurses a year, so we've 
moved well beyond lessons learned to lessons applied.
    For example, Army nurses in Iraq, in the Iraq theater, who 
fly medevac with critically wounded patients have developed a 
set of tactics, techniques, and protocols over the last 7 years 
that we've codified into an intra-theater flight nursing 
program, a program we'll sustain for the future. Our flight 
nurses have decreased the incidence of hypothermia for the 
patients that fly in the back of these medevacs from 20 percent 
to less than 5 percent.
    On my recent trip to Iraq I was absolutely humbled to see 
the level of care that is provided to not only our 
servicemembers, but to coalition forces, contractors, and the 
detainee populations that we serve. I was told how at the Ibn 
Sina Hospital that's in Baghdad Army nurses moved patients into 
the hallways away from the glass windows when the hospital was 
under mortar fire and covered them with their own bodies so 
that they were protected. These patients were wounded Iraqis.
    Army nurses are partnering with Iraqi nurse leaders to help 
them begin to rebuild their profession of nursing. The nurses 
of the 345th Reserve Component Combat Support Hospital 
established training programs on the fundamentals of emergency 
nursing and subsequently are providing medical diplomacy at the 
most crucial interface, between two nursing cultures.
    During this year of the noncommissioned officer, I want to 
share a story with you about a particular NCO that established 
an automatic external defibrillator (AED) program for the 
entire Iraq theater. This NCO recognized the need to have 
emergency cardiac care equipment in theater that provides our 
soldiers with the same standard that we offer in the United 
States. He created the theater-wide policy that mandated easy 
accessibility to AEDs. This NCO had an opportunity to put into 
action his own policy when he encountered a sergeant major that 
was in cardiac arrest. He quickly responded with the AED and 
saved the sergeant major's life.
    I'd like to introduce to you Sergeant Major Brewer, who's 
in the audience today. He is my sergeant major--could you 
please stand. He is my Corps sergeant major and is returning 
from his second deployment in Iraq. We could not be more proud 
to have him as part of our team.
    Furthermore, I would like to highlight the nurse case 
management program at Camp Cropper and Camp Bucca detainee 
camps in Iraq, built and managed by our NCO licensed practical 
nurse Army nursing team members. To date the program has 
provided specialized medicine care for over 1,000 Iraq 
detainees requiring case management care for diabetes, 
hypertension, and medical management. I am proud of the Army 
nursing team as they shape the face of deployed nursing.
    We are sustaining best practice strategies to provide 
standardized nursing care from the combat zone to an Army 
medical treatment facility, through the warrior transition 
unit, all the way into our VA hospitals.
    The Army Nurse Corps is undergoing the most massive 
transformation that I've seen in my 25 years on active duty. 
We're using the first-ever Army Nurse Corps campaign plan to 
operationalize a Nurse Corps that consistently achieves 
performance excellence, fosters innovation, builds knowledge 
and capabilities, and ensures organizational credibility and 
sustainability. We are piloting an in-patient and an ambulatory 
nursing care delivery system that uses best practices and 
evidence-based data to optimize patient outcomes.
    These pilots are already showing improvements in staff 
satisfaction and interdisciplinary communication. We're also 
incorporating data from the military nursing outcomes database 
study, as well as evidence-based research from the Tri-Service 
Nursing Research Program, funded studies of which we are 
extremely grateful for your support into our practice, to 
reduce the incidence of care indicators like patient falls and 
medication errors.
    We are standardizing nursing care delivery systems to 
decrease patient variance and improve patient outcomes. For 
example, nurses at Walter Reed Army Medical Center collaborated 
with our VA nurse colleagues to develop the first-ever 
evidence-based nursing transfer note that is electronically 
exported to a web-based portal, allowing staff to 
bidirectionally exchange critical patient information in real 
time. This effort significantly optimized Army and VA nurses' 
ability to tell the patient's story via the electronic medical 
record.
    We are harnessing the power, the pride and the passion of 
Army nurses to transform into a corps that by 2012 is leading a 
culture of performance innovation and improvement across the 
entire continuum of care. This is unequaled in the delivery of 
nursing excellence. We will use the vision to embrace the past, 
engage the present, and envision the future.

                           PREPARED STATEMENT

    On behalf of the entire Army Nurse Corps team serving 
worldwide, I'd like to thank each of you for your unwavering 
support, and I look forward to continuing to work with you. 
Thank you.
    Chairman Inouye. Thank you very much, General.
    [The statement follows:]

         Prepared Statement of Major General Patricia D. Horoho

    Mr. Chairman and distinguished members of the committee, it is an 
honor and great privilege to speak before you today on behalf of the 
nearly 10,000 officers, enlisted, and civilians of the Army Nurse 
Corps. It has been your continued unwavering support that has enabled 
Army Nurses, as part of the larger Army Medical Department (AMEDD) 
team, to provide the highest quality care for our service members, 
families and all those entrusted to our care.
    As I assumed the responsibility of this great Corps, I realized 
that 4 years as Corps Chief is not much time. Although we cannot 
eliminate or predict the uncertainty of the future, we are developing a 
framework to harness every opportunity and manage ambiguity. To this 
end we have embarked on a campaign plan that will transform the Army 
Nurse Corps over the next 4 years and prioritize a 15 year blueprint 
for a vibrant, relevant, and flexible Army Nurse Corps.
    The Army Nurse Corps Campaign Plan, which was developed at the 
first ever Army Nurse Corps Strategic Planning Conference in October, 
is built around four strategic objectives: Leader Development and 
Sustainment, Warrior Nursing Care Delivery, Evidence-Based Management 
and Clinical Practice, and Optimization of Human Capital. It reflects 
our mission and is aligned with the Department of Defense's, Army's and 
Army Medical Department's goals and objectives. At the heart of the 
Campaign Plan is what I call, ``the triad of nursing.'' This triad 
consists of the active and reserve component officers, Non-commissioned 
Officers (NCOs), and civilians that make up our great Corps and are 
vital for ensuring that those who wear and have worn the cloth of our 
Nation and the families that support them, receive timely, 
compassionate and high quality care.
    Execution of the Campaign Plan will be driven by courage to do the 
right thing, ingenuity to meet the rapidly evolving battle and medical 
demands of the 21st century, and constant compassion for those we serve 
and those with whom we serve.

                   LEADER DEVELOPMENT AND SUSTAINMENT

    The success and sustainability of our campaign plan rests squarely 
on the shoulders of Army nurse leaders. Accordingly, my first priority 
is to develop full-spectrum Army nurse leaders through a leader 
succession plan.
    We are creating the next generation of inspiring leaders who are 
agile in responding to the Army's evolving needs and who have the 
capabilities and capacities that are required for current and future 
missions. These leaders will be adaptive to any conditions-based 
mission, able to provide a persuasive voice at key echelons of 
influence in the AMEDD, and provide innovative doctrine to blueprint 
the future of the Army Nurse Corps.
    Over half of our Corps has deployed in support of Operation Iraqi 
Freedom (OIF) and Operation Enduring Freedom (OEF). We are leveraging 
the experience of these returning Army nurse combat veterans to 
incorporate and codify their lessons learned into our leader training 
programs and nurse care delivery systems.
    Army nurse leaders adapted readily to the intra-theater flight 
nursing mission in Iraq. Their lessons learned on over 300 missions 
transporting approximately 500 critically injured patients have been 
codified into a flight nursing program that includes standardized 
clinical practice guidelines and patient outcome metrics. On-board 
flight nurses decreased the incidence of patient hypothermia during 
transports from 20 percent to less than 5 percent. One of our Army 
nurses transported a Soldier who sustained severe burns over 70 percent 
of his body from a forward surgical team to the 86th Combat Support 
Hospital (CSH). Last month we heard from the Soldier's wife and three 
children that he is undergoing full rehabilitation and has made a 
remarkable recovery. Thanks to our adaptive Army nurse leaders, we are 
working to develop the role of the intra-theater flight nurse and 
codify it with the additional skill identifier of N5.
    Army Nurse Leaders are currently commanding two Combat Stress 
Control (CSC) units in Baghdad and Mosul. In Mosul, the 528th Medical 
Detachment (Combat Stress Control) is commanded by MAJ Chris Weidlich, 
a psychiatric nurse practitioner, leading a 46-member team with an area 
support mission to mentally sustain coalition forces at nine Forward 
Operating Bases (FOBs) and surrounding areas within the Multi-National 
Division North (MND-N). Since their deployment from Fort Bragg, North 
Carolina in March 2008, MAJ Weidlich and his team have led the way in 
improving far forward mental health assessment and treatment, 
evaluating approximately 10,000 Soldiers to date. Additionally, they 
are bringing far forward the latest on mental health resiliency 
training and assessment of mild Traumatic Brain Injury to over 50 Joint 
Security Stations (JSS), Military Transition Teams (MiTTs) and Combat 
Outposts (COP); all while maintaining a 99.4 percent return to duty 
rate.
    Army Nurse Corps leaders are also furthering medical diplomacy aims 
by continuing to expand Iraqi nurse training partnerships. Nurses with 
the 345th CSH are helping to re-build Iraq's medical infrastructure by 
instituting a train-the-trainer emergency nursing program. The first 
iteration of the ``Emergency Nursing Train-the-Trainer Program'' 
concluded its first ``Partnership in Patient Care,'' program with 
thirteen Iraqi nursing students--four females and nine males. This 6-
week course is building sustainability into the Iraqi nurse education 
program. In the future, these nurses will teach other Iraqi nurses of 
Salah ad Din Province thereby expanding the expertise of the Iraqi 
nursing professionals.
    345th CSH nurses worked with the local Provisional Reconstruction 
Team (PRT) to develop, build, and furnish the Iraqi Nursing Skills 
Learning Lab in the International Business Iraqi Zone (IBIZ). This 
skills learning lab is known as the ``Salah Ad Din Victory Health Care 
Training Center'' and provides classroom space and a separate skills 
training lab for the Iraqi nursing program and other Iraqi healthcare 
programs. The training center also facilitates a safe training and 
collaboration site for both Iraqi medical and nursing professionals and 
allows our combat support hospital nurses to share knowledge as 
consultants. This sharing provides the Iraqis with the most up to date 
nursing education processes that are positively impacting the state of 
healthcare in Iraq.
    While the experiences of deployment produce exceptional nurse 
leaders, I am concerned about the resiliency and ability of our 
returning nurses to reintegrate with their families and return to 
hospital positions where they continue to provide care to wounded 
warriors--in some cases, the same warriors they helped to resuscitate 
in theater. Their compassion fatigue is evident when I talk with them, 
many of whom are on their third and fourth deployments. We are 
developing retention strategies that allow these caregivers to ``take a 
knee'' so they can re-charge their mental, physical, and emotional 
energies in order to re-engage as Army Nurses.
    With respect to leadership training, we currently have 255 new Army 
Nurse Officers at nine of our Regional Medical Centers receiving 
individual training and mentoring that emphasizes development and 
acquisition of clinical deployment skill sets and competencies to 
bridge the gap between academic preparation and the clinical practice 
environment. We are leveraging courses such as the Emergency Pediatric 
Nurse Course and the Trauma Nurse Competency Course (TNCC) to ensure 
every one of our nurse officers has the right capabilities to deploy in 
support of any condition-based mission.
    Trauma nursing is our core competency. Subsequently we are focusing 
on emergency and critical care skills required in a disaster or 
deployed setting to increase the quality of care we provide. To 
accomplish this, I have directed a top-to-bottom review of all Army 
Nurse Leader development training programs. This strategic objective 
emphasizes development of clinical, leader, and deployment skill sets 
and competencies for Army Nurse Corps personnel as they progress in 
rank and clinical experience.
    Last, we are looking at redesigning the entire leadership 
lifecycle, from staff nurse through Deputy Commander for Nursing. Our 
goal is to create a robust program that ensures nurses have the 
required skill sets and experiences at each step in their careers. This 
means ensuring that there are appropriate training opportunities phased 
throughout the lifecycle and a clearly defined job description and 
associated competencies for each role. In addition, we are looking at a 
set of potential structural changes to the lifecycle aimed at 
increasing flexibility and creating new career pathways for our diverse 
set of nurses.
Warrior Nursing Care Delivery
    My second strategic objective is to get back to the basics of 
delivering high-touch, supported by high tech, nursing care. We are 
designing nursing care delivery systems that wrap nursing capability 
around The Surgeon General's goals and mission. I'd like to talk about 
five special initiatives we are pursuing in support of providing model 
nursing care.
    In our first initiative, we completed a comprehensive evaluation of 
best practice civilian and federal nurse care delivery systems in order 
to distill elements into standardized Army Nurse in-patient and 
ambulatory care delivery systems. For example, nurses at Walter Reed 
Army Medical Center (WRAMC) are using several patient discharge 
management tools that are decreasing length of stay, re-admission 
rates, and improving patient satisfaction. Nurses at Tripler Army 
Medical Center (TAMC) implemented Relationship Based Care (RBC), a 
nursing care delivery model, in 2007. This model emphasizes patient and 
family centered care, a primary-within-team nursing model, as well as 
well-defined scopes of practice for all nurses. Since implementation of 
RBC, nursing at TAMC has experienced an increase in both nursing and 
patient satisfaction, as well as a decrease in civilian nursing staff 
turnover.
    We incorporated several of these perspectives into the professional 
nursing pilot at Blanchfield Army Community Hospital at Fort Campbell, 
Kentucky. This pilot combines and capitalizes on care delivery 
advancements made at individual military treatment facilities (MTFs) 
and has three aims: develop nursing practice standards across all MTFs, 
improve patient satisfaction and outcomes, and increase staff 
satisfaction and retention. These aims will be reached through 
combining increased nurse autonomy and skill building with structured 
interdisciplinary communication and patient-centered and evidence-based 
care. The pilot is still underway, but after only a few weeks there has 
been a marked improvement in how the nursing staff communicates with 
their patients and physicians, as well as how they feel their input is 
valued by hospital leadership. We are implementing results of the pilot 
across all of Blanchfield's wards, and ultimately to all MTFs, to 
decrease practice variance and improve inpatient nursing care delivery.
    Our second initiative focused on ambulatory nurse role redefinition 
and developing appropriate, functional nurse staffing models. The Army 
Nurse Corps ambulatory workgroup developed a primary care staffing 
model that changes the role of the Registered Nurse (RN) from a 
reactive, episodic-focused role to a proactive, population-focused 
role. In September 2008 we initiated a year-long pilot study at 
Moncrief Army Hospital focusing on nurse role redefinition, staffing 
mix, and professional nursing care. We were able to develop a model by 
which patients with unmet medical requirements were targeted by a 
specific nurse assigned to their case (``My Nurse''), who would then 
work with the provider to review the patient appointment list prior to 
appointments and identify tests, labs, x-rays, etc. that a patient may 
need ahead of time. This not only provides a new role for the clinic 
nurses, but also expedites the ambulatory care process for both the 
patient and medical team. Outcome measures for the pilot include 
improving patient and staff satisfaction, decreased urgent care and 
emergency rooms visits, improved compliance with Health Effectiveness 
Data and Information Set (HEDISR), Clinical Practice Guidelines (CPGs) 
and other health metrics, increased percentage of time seeing their 
assigned provider and increasing access to care. Initial feedback from 
patients is that they love the personal attention they receive from 
``My Nurse'' and appreciate having someone they can call with questions 
or having someone call them to remind them of appointments or follow-up 
with them with educational materials, etc. The role of ``My Nurse'' is 
a paradigm shift in outpatient nursing and will require education and 
training of all outpatient nurses if identified as a best practice.
    Our next initiative is focused on the case management role, both in 
theatre and stateside. Nurse Case Managers (NCM) remain an integral 
member of the triad of care in Warrior Transition Units since their 
inception in April 2007. In addition to ensuring high patient 
satisfaction with care, NCMs have continued to facilitate other patient 
care improvements. In October 2008 the Warrior Care Transition Office, 
in coordination with the AMEDD Center and School conducted the first 
resident Warrior Transition Unit Cadre Orientation Course. The course 
is 2 weeks in duration with a 3 day track focused specifically on case 
management standards and skills. To date, the course has been conducted 
three times, with over 100 NCMs completing the training. NCMs continue 
to assist in decreasing the average length of stay for Warriors in 
Transition.
    In the Iraqi Theater of Operations, we established a NCM role aimed 
at caring for patients who have chronic, complex care requirements. The 
theater NCM's role includes monitoring average length of stay according 
to diagnosis, as well as by classification of personnel, such as United 
States, detainee, contractor, Iraqi Army, Iraqi Police, and civilian. 
In addition, the NCM helps facilitate the discharge plan with the 
physician and the inter-disciplinary team. COL Ron Keene was 
instrumental in establishing the first Nurse Case Management Program 
for detainees in a wartime theater with huge patient successes in the 
management of hypertension, wound care, and even chronic diabetic care 
management. The dedication of the Army Nurses and physicians focusing 
on the total care of our chronically ill detainees can be demonstrated 
by the decrease in admissions for the management of chronic illness by 
38 percent. This success has actually enabled reductions in bed 
requirements at the 115th CSH. Close management of chronically ill 
detainees follows strict adherence to the DOD/VA Clinical Practice 
Guidelines (CPG's) which are incorporated in daily detainee healthcare 
practices. With education and routine contacts, a growing percentage of 
the detainees have come into greater compliance and medication levels 
are either reduced or ultimately removed. Detainees are offered 
customer satisfaction surveys in Arabic and have reflected above 
average satisfaction with their care--results that rival the best 
customer satisfaction scores in our premiere Army hospitals. 
Additionally, Army NCMs insure that Iraqi Imams visit our patients 
weekly to provide religious support and guidance as a part of their 
health recovery.
    Another Warrior Care initiative focuses on developing a practice 
model that incorporates the use of our outstanding enlisted corps. At 
the Bucca detainee hospital, one of the senior NCO Licensed Practical 
Nurses (LPN's) oversees the 68W (medic) primary care screening of over 
14,000 detainees. The LPN ensures that each 68W has completed the 
Algorithm Directed Troop Medical Care (ADTMC) screening classes and 
demonstrates a sound understanding of the screening process, 
documentation and medication administration within the guidelines of 
the ADTMC scope of practice.
    The NCO LPN's are also integral to the new Iraqi nurse partnership. 
For the first time, an Operating Room and Intensive Care Unit team 
(includes one NCO/LPN) from one of our small hospitals at Al Kut will 
be going to one of the local hospitals to help train the Iraqi staff in 
operating room and post operative care procedures. The RN and LPN team 
provided hands on demonstrations to the Iraqi nurses helping them 
improve their clinical practice skills. At the Jamenson Combat Medical 
Training Center (JCMTC) in Iraqi, 1SG Eric Woodrum volunteered to work 
in the Air Force hospital Emergency Room to observe Point of Injury 
care. Those lessons learned were taken back and used at the Jamenson 
schoolhouse to improve Combat Lifesaver training and patient outcomes.
    Last, we are working with other Federal Nursing Service Chiefs to 
align initiatives and develop compatible practice models. For example, 
through strong Congressional support, the Army Nurse Corps, along with 
the Federal Nursing Services Chiefs, started the Psychiatric Nurse 
Practitioner program at the Uniformed Services University (USU). This 
program, while providing traditional curriculum, adds clinical training 
addressing some of the military unique behavioral health challenges and 
leadership building. The program will pay dividends in the future as we 
address the behavioral health challenges faced by our Service Members 
in theaters of operation and after they return home.
    We are also furthering cooperation through the Tri-Service Nursing 
Research Program (TSNRP) to improve trauma and deployment competencies 
for nurses in all military services. One example of that cooperation is 
the publication of the evidence-based ``Battlefield and Disaster 
Nursing Pocket Guide''. This guide provides a portable, up-to-date, 
evidence-based source of information for nurses on the battlefield and 
those responding to disaster or humanitarian situations. TSNRP has 
provided 7,500 copies of this handbook to both deployed and non-
deployed nurses throughout the services. We are also leveraging TSNRP 
funded research to improve Warrior care delivery. For example: Pain and 
Sleep Disturbance in Soldiers with Extremity Trauma; Impact of Body 
Armor on Physical Work Performance; A Comparison of PTSD and Mild TBI 
in Burned Military Service Members, and Sleep Disturbances in U.S. Army 
Soldiers after Deployment to Afghanistan and Iraq.
Evidence-based Management and Clinical Practice
    Evidence-based management aims to merge best practices in both 
clinical care and business practice to produce outstanding outcomes. 
These goals are supported by blending data measurement and analysis and 
system redesign into the daily performances of all our nurses.
    In support of our aims, we are working to train the next generation 
of nurse researchers by leveraging TSNRP and Army Nurse Corps 
researchers both stateside and in deployed environments. Developing the 
expertise of military nursing researchers is paramount to TSNRP's 
mission, as evidenced through its courses in grant writing, publishing, 
and advanced research methods. In addition, it is one of the only 
research programs to require its investigators to attend a post-award 
workshop where they are given information pertaining to the regulations 
of managing a grant. TSNRP provides a very high level of oversight of 
its awardees, ensuring the research is conducted with the highest 
rigor. We in the Army Nurse Corps appreciate their dedication to 
developing nurse researchers of the highest caliber.
    Besides training top-notch researchers, we are working to focus our 
research on improved systems and clinical outcomes, preferably with 
real-world recommendations that can be easily applied at the patient's 
bedside. One such research project was the Military Nursing Outcomes 
Database (MilNOD). Facilitated and implemented as an Army Nurse Corps 
initiative, MilNOD is the most comprehensive and historical effort of 
its kind in the United States. Analysis of data from 115,000 nurse 
shifts established significant associations between nurse staffing and 
patient outcomes, such as the occurrence of falls and medication 
administration errors as well as nurse needle stick injuries. 
Participating MilNOD MTFs decreased patient fall rates by 69 percent, 
medication administration errors rates by 50 percent and hospital 
acquired pressure ulcer prevalence by 62 percent, all of which were 
statistically significant reductions. Participating MTFs also 
experienced considerable cost avoidance (falls--$900,000/year; 
medication errors--$230,000/year; pressure ulcers--$450,000/year). As 
one of the most seminal studies linking nurse care practices with 
patient outcomes, the study results will be published in an upcoming 
edition of The New England Journal of Medicine.
    Army nursing has made a special effort to support research at all 
levels, as young researchers of today will become leaders in their 
fields in years to come. To that end, the nurses of Tripler Army 
Medical Center (TAMC) started a funded Evidence Based Practice (EBP) 
research project in 2007 that is now a part of their nursing practice 
culture. This fiscal year, nurses throughout the facility initiated 
seven new Evidence Based Practice Projects (EBPP). These studies ranged 
from improving infection control in ICU settings, to patient 
satisfaction for pregnant patients on bedrest, to improving 
communication between nurses on different hospital units. The range of 
topics studied demonstrates an impressive effort to improve systems 
while bringing research back to the bedside. I thank our officers, 
ranging from Lieutenants to Lieutenant Colonels, for their dedication 
to improving nursing care at every level.
    As we move forward with this strategic objective, we are making a 
special effort to use the power of technology to develop and 
disseminate best practices throughout the Corps. Integrating technology 
into best practices has started with ensuring patient safety through 
proper patient handoffs. Research has demonstrated that smooth, 
seamless patient handoffs are vital to safe patient care. Nurses at 
WRAMC in collaboration with the Department of Veterans Affairs (VA) 
Poly-Trauma Centers have developed a researched based nurse's note that 
is sent directly to the VA electronic medical record. This nurse-driven 
project resulted in increased nursing knowledge of patient conditions 
which enabled the receiving facility to put in place safety mechanisms 
to improve patient care and diminish risk of patient injury or poor 
outcomes. This project is one of the first times we have been able to 
transmit patient data directly from one electronic medical record into 
another agency's electronic record.
    Without dissemination of our collective knowledge, our advances 
would mean little to the Corps at large. Thus, we have developed a new 
ANC interactive website that allows for real time exchange of ideas and 
best practices, and improves communication across the Corps. We are 
also making a special effort to link research cells at different MTFs 
to promote Corps-wide collaboration.
Optimization of Human Capital
    My final objective, Optimization of Human Capital, is the strategic 
and coherent approach to the management of our organization's most-
valued assets, our people, who individually and collectively contribute 
to the achievement of the ANC objectives. Investing in human capital 
requires special attention to the recruitment and retention of our 
civilian and active duty nurses, while trying to influence the 
profession of nursing through academic partnerships.
    Recognizing that the majority of our organization is our civilian 
workforce, we are continuing to break down the barriers in recruiting 
and retaining stellar civilian healthcare professionals. We are 
committed to streamlining and reducing the gates in the personnel 
hiring process by setting accountability timelines compared to local 
averages. To maintain an influence on civilian nursing recruitment and 
retention, we have placed an ANC Officer in the Civilian Personnel 
Office in order to partner and facilitate progress on these issues.
    We have also started focusing on retention efforts for our civilian 
workforce. We have been very successful with our civilian nurse loan 
repayment program which was initially implemented 2 years ago. For 
fiscal year 2009, 169 of 186 applicants participated in the nurse loan 
repayment program. As a result of this program, we will be required to 
expend fewer resources to recruit and train new nurses. In addition, we 
have consulted with VA nursing to leverage their concept of clinical 
ladders for our civilian workforce. We are evaluating how best to use 
this program to promote clinical leadership opportunities for civilians 
and establish glide paths for their success in order to retain them on 
our team.
    Turning our focus toward active duty and reserve officers, the Army 
Nurse Corps has been very successful in recruiting this past year. For 
the first time in 7 years, United States Army Recruiting Command 
exceeded mission for both the active and reserve components. Regular 
Army Nurse Recruiters produced 297 nurse recruits against a mission of 
205 and the Army Reserve Recruiters produced 528 nurse recruits against 
a mission of 362. In addition, the Reserve Officer Training Corps 
(ROTC) experienced great success this past year and expects the same 
for the next 2 years. In fiscal year 2008 ROTC was responsible for 
producing 173 Army Nurses against a mission of 225. This was the 
highest number of accessions in 10 years. In fiscal year 2009, ROTC 
predicts a production of 221 Army Nurses against a mission of 225. And 
in fiscal year 2010, ROTC is projected to exceed their mission of 225 
by over 20 nurses (for a total number of 249).
    One of our most crucial retention tools is developing a track that 
will take our ANC officers through a lifecycle that focuses on clinical 
competencies even at the senior level. We are also evaluating our 
current force structure to ensure we have the right mix of skills and 
rank, and that we are assigning based upon capabilities. In addition, 
one of our most successful programs for retention has been the 
implementation of Incentive Specialty Pay (ISP) and Critical Skills 
Retention Bonus (CSRB). To date, 962 (44 percent) Army Nurse Corps 
officers have taken either the ISP or CSRB.
    Looking forward to the recruitment and retention of all our 
nurses--civilian, active, and reserve--we decided to optimize one of 
our most important retention strategies: responsive listening to our 
nurses. Accordingly, I directed dissemination of a Corps-wide 
organizational survey that asked our nurses what's on their minds. As a 
result, more than 2,000 Army Nurses identified areas for improvement in 
Corps performance. A key opportunity area identified is to increase 
junior officer involvement in setting the Nurse Corps' strategic 
agenda. In response, we incorporated the voices of Army Nursing's 
future leaders at our annual ``CJ Reddy Junior Leadership Conference'', 
held this past October in Washington, DC. This Conference brings 
together the most promising junior officers in the Corps for an 
intensive session built around learning, skill building, and 
networking. When asked what motivates them each day as a member of the 
Nurse Corps, these officers answered with five consistent themes: (1) 
the mission of serving their country and caring for Soldiers; (2) the 
diversity of opportunities the Corps provides; (3) the Corps' 
camaraderie and sense of family; (4) the available leadership training; 
and (5) the abundant rewards and benefits. We believe these five 
attributes create an unparalleled environment to practice nursing and, 
under my Human Capital imperative, plan to reinforce each of them to 
become an even stronger recruiting power.
    Last, we feel that to truly optimize our human capital strategy, we 
must pursue academic partnerships. The professional staff at several 
MTF's have worked diligently to support the clinical experiences of 
advanced practice nursing students. In addition, in cooperation with 
all the Federal Corps Chiefs, we are supporting Uniformed Services 
University in their active engagement of academic partnerships with 
nursing leadership organizations and schools of nursing to maintain an 
active and influential role in the future of nursing in America. 
Additionally, we are leveraging our retired AN officers, who are 
professors at a variety of civilian institutions, to serve as nursing 
role models, mentors, subject matter experts and ambassadors for the 
ANC.

                               CONCLUSION

    Since becoming Corps Chief last July, I see clearly how to harness 
the power, passion, and pride of the Army nurses to develop the Army 
Nurse Corps priorities in support of the national health agenda and our 
Nation at war. Over the next 2 years we will execute the Army Nurse 
Corps campaign plan and use it to codify best practices for 
sustainability. The third year we will begin campaign planning again to 
ensure we remain relevant and well-postured as a force multiplier for 
military medicine.
    I envision an Army Nurse Corps in 2012 that serves as a model for 
the Nation, leading a culture of performance improvement across the 
entire continuum of care that is without peer in the delivery of 
nursing care excellence--where we measure our successes in the 
improvement of healthcare outcomes for patients and families, retention 
and satisfaction of our staff, and improved stewardship of our precious 
resources.
    I am establishing a culture that evaluates every aspect of 
traditional practice to ensure that we achieve the desired improvements 
in our patient's emotional, physical and spiritual well-being. The Army 
Nurse Corps will be known for the ingenuity and innovation applied to 
the most challenging opportunities, so characteristic of Army Nurses 
for the past 233 years. Constant compassion will continue to fuel us, 
driven by the courage to always do the right thing.
    I would like to leave you with a story about one of our nurse 
heroes. In 2007 we tragically lost a Command Sergeant Major to an 
apparent heart attack at Camp Victory, Iraq. This incident sparked an 
NCO to develop and implement a theater-wide Automated External 
Defibrillator (AED) program. The magnitude of this program was so 
important that GEN Petraus endorsed the NCO's plan. Just several weeks 
after the NCO initiated this program, he was confronted with a Soldier 
who was in cardiac arrest. He used an AED to resuscitate the Soldier, 
who was treated and sent home to his family. The NCO I've been 
discussing is SGM Richard Brewer, the LPN I brought into my Corps Chief 
office to enable my concept of the Army Nurse Triad that includes our 
LPN colleagues.
    I am so proud of our Corps and look forward to speaking with you 
next year about the progress we've made on our campaign plan. I'll 
close with our new motto that is the way ahead for the Army Nurse 
Corps: ``Embrace the Past''--leverage our lessons learned; ``Engage the 
Present''--achieve performance excellence; and ``Envision the 
Future''--ensure organizational credibility and sustainability. Thank 
you.

    Chairman Inouye. Now General Siniscalchi.

STATEMENT OF MAJOR GENERAL KIMBERLY A. SINISCALCHI, 
            ASSISTANT AIR FORCE SURGEON GENERAL FOR 
            NURSING SERVICES, UNITED STATES AIR FORCE
    General Siniscalchi. Mr. Chairman, Mr. Vice Chairman, and 
distinguished members of the subcommittee: It is an honor to 
come before you today to represent the United States Air Force 
Nurse Corps. I am proud to serve alongside Brigadier General 
Catherine Lutz, Air National Guard; Colonel Ann Manley, Air 
Force Reserves, and Chief Master Sergeant Joseph Potts, 
Aerospace Medical Service Career Field Manager. Together we 
represent a robust total nursing force supporting our Air Force 
chief of staff's top priorities.
    I would like to thank you for your continued support of our 
Air Force Nurse Corps. Thank you for providing the funding for 
our accession bonuses, health professions loan repayment and 
scholarship programs, and our first-ever incentive special pay 
program. We anticipate the incentive special pay program will 
positively impact our retention.
    Last year 55 percent of our nurses who separated had less 
than 20 years of military service and 61 percent of those were 
our young lieutenants and captains. We are diligently working 
with our Air Force personnelist and our Surgeon General to 
address and correct this issue. Although the incentive special 
pay will help retain our nurses, retention may further extend 
timing and reduce promotion opportunity until we correct our 
grade structure.
    Our enlisted medical technicians, in partnering with A1, 
secured funds for their critically manned specialties. Our 
independent duty medical technicians are heavily tasked with 
deployments and manned at only 72 percent. I along with Chief 
Potts am eager to see this initiative's impact.
    Through your sustained support of our Tri-Service Nursing 
Research Program, we recently published the ``Battlefield and 
Disaster Nursing Pocket Guide''. This guide is utilized 
throughout our deployed locations.
    We continue to conduct state-of-the-art research and 
validate evidence-based practice. Colonel Margaret McNeil, a 
Ph.D. Air Force nurse, is in Iraq as a member of the newly 
deployed combat casualty care research team, exploring 
advancements in medical therapies for our wounded warriors.
    The key to successful peacetime and wartime nursing 
operations is a robust nursing force, a force with the right 
numbers, right experience, and the right skills. Recruiting 
experienced nurses continues to be a significant challenge. 
Although we reached 93 percent of our accession goal, 56 
percent were novice nurses, validating the importance of our 
nurse transition program. I am pleased to inform you that our 
first civilian program at the University Hospital in Cincinnati 
graduated their first class on December 12.
    Our enlisted nurse commissioning program grows Air Force 
nurses from our highly skilled enlisted force. We had our first 
two graduates this year and we'll have 19 next year.
    Air Force nursing is an essential operational capability. 
In 2008 our total nursing force represented 34 percent of all 
deployments within our medical service. Our medics deployed to 
44 locations in 16 countries. Our total nursing force is well-
trained, highly skilled and committed to saving lives. We are 
called to a mission of caring for America's sons and daughters, 
and here are a few examples.
    Captain James Stewart, a nurse anesthetist, deployed to 
Joint Base Bilad, received a message from his friend and co-
worker Captain Dave Johnson informing him that his son, Army 
Staff Sergeant Curtis Johnson, had been wounded and was en 
route to Bilad. Captain Stewart met Curtis on arrival and 
recalls: ``He arrived stable, so we placed a call to his dad so 
they could talk before we started surgery. Curtis's spirits 
were high and I was amazed at how well he was taking the loss 
of both his lower legs.'' Following surgery, Curtis was 
aeromedically evacuated to Brooke Army Medical Center and is 
now undergoing rehabilitation at the Center for the Intrepid.
    The commemorative Air Force recognized Captain Bryce 
Vandersway with the Dolly Vincent Flight Nurse Award for 
aeromedical evacuation support to 651 sick and injured 
warriors, including two K9 military working dogs injured by 
improvised explosive devices (IEDs).
    As the trauma nurse coordinator at Joint Base Bilad, 
Captain Darcy Mortimer recalls her most precious memory: ``We 
simultaneously received five casualties from an IED blast. When 
the emergency department settled down, the hospital held a 
ceremony for the soldier we could not save. Two of his wounded 
comrades requested that their litters be placed so they could 
salute their fallen comrade and friend.''
    In the midst of death and heartache, there are stories of 
hope and joy. This past October, our staff delivered the first 
Afghan baby born at Craig Joint Theater Hospital, Bagram. The 
mother sustained massive injuries as a result of an explosion, 
but with the help of the Air Force medical team she delivered a 
healthy baby girl. According to Technical Sergeant Jeremiah 
Diaz: ``We had 15 minutes to come up with something. We used a 
warming blanket and made a little tent with coat hangers and an 
egg crate mattress. The newborn's presence was a ray of 
light.''
    Mr. Chairman and distinguished members of the subcommittee, 
thank you for allowing me to share today just a few of the many 
achievements of Air Force nursing. As our Air Force Medical 
Service celebrates its 60th anniversary, we recognize and we 
stand on the shoulders of giants. I commit to you we will 
continue to meet every challenge with professionalism, pride, 
and patriotism that have served as the foundation for our 
success. Our warriors and their families deserve the best 
possible care we can provide.
    It is the nurse's touch, compassion, and care that often 
wills a patient to recovery or softens the transition from life 
to death. There has never been a better time to be a member of 
this great Air Force nursing team.

                           PREPARED STATEMENT

    So on behalf of the men and women of nursing services, 
thank you for your tremendous advocacy and continued support.
    [The statement follows:]

      Prepared Statement of Major General Kimberly A. Siniscalchi

    Mister Chairman and distinguished members of the Committee, it is 
an honor and pleasure to come before you to represent Air Force Nursing 
Services and our Total Nursing Force (TNF). The TNF encompasses officer 
and enlisted nursing personnel of the Active Duty, Air National Guard 
(ANG), and Air Force Reserve Command (AFRC) components. The past year 
has brought many leadership changes to our TNF, and I look forward to 
serving alongside my senior advisors, Brigadier General Catherine Lutz 
of the ANG and Colonel Anne Manly of the AFRC. We are glad to have 
Colonel Manly back after her recent deployment to Joint Base Balad, 
Iraq where she served as Chief Nurse of the 332nd Expeditionary Medical 
Group, and saw first-hand the incredible work our nurses and 
technicians perform daily. Together we will continue to strengthen our 
TNF by supporting our nursing service personnel as they continue to 
meet ever-increasing commitments, deployments, and challenges with 
professionalism and distinction; and supporting the Chief of Staff of 
the Air Force's (CSAF) top priorities to (1) Reinvigorate the Air Force 
Nuclear Enterprise, (2) Partner with the Joint and Coalition Team to 
Win Today's Fight, (3) Develop and Care for Airmen and their Families, 
(4) Modernize our Aging Air and Space Inventories, Organizations and 
Training, and (5) Acquisition Excellence.

                        ORGANIZATIONAL STRUCTURE

    On September 29, 2008, the Air Force Medical Service (AFMS) 
achieved the CSAF's directive to transform and consolidate headquarters 
management functions by establishing the Air Force Medical Operations 
Agency (AFMOA) in San Antonio, Texas. This single support agency was 
established through an Air Force Smart Operations 21 initiative, and is 
led by a cadre of experts from across the Air Force Medical Service. 
They provide premier support and guidance to nine Major Commands 
(MAJCOM), 75 Military Treatment Facilities (MTF), and 39,000 medics to 
reduce levels of oversight at the MAJCOM levels. Brigadier General Mark 
A. Ediger assumed command of AFMOA on September 29, 2008.
    This past summer, the AFMOA Surgeon General Nursing (SGN) 
directorate, led by Colonel Leslie Claravall, in conjunction with the 
MAJCOM SGNs, successfully transitioned the clinical oversight as well 
as education and training functions from United States Air Force Europe 
Command and Air Mobility Command. In May, June, and July of this year, 
the AFMOA SGN will take on the clinical oversight of Air Education and 
Training Command, Air Force Material Command and Air Force Special 
Operations Command respectively. In 2010, the remaining MAJCOM SGN 
functions will transition to AFMOA. As a result, areas such as 
education and training, provision of nursing care, inpatient and 
outpatient, and nursing service resourcing will be centrally located. 
In short, AFMOA is progressing to a centralized reach-back Field 
Operating Agency.

                     BUILDING ENDURING COMPETENCIES

    The Air Force Nursing Service Education and Training programs are 
inherent to, and the foundation of the successful development of our 
core competencies. The Nurse Transition Program (NTP) is experience by 
providing hands-on patient care while working side-by-side with nurse 
preceptors. The program focuses on maximizing skills utilizing real-
world patients and minimizing the use of simulation labs. In 2008 we 
had 10 NTP sites with 212 seats available to novice nurses entering the 
Nurse Corps with less than 6 months nursing experience. Last year Major 
General Rank reported the possibility of partnering with University 
Hospital in Cincinnati, Ohio for our NTP. I am pleased to inform you 
that our inaugural class of ten students graduated from our first 
civilian NTP Center of Excellence (CoE) at University Hospital on 
December 12, 2008. I had the privilege to attend and participate in the 
ribbon-cutting this past October and I am proud of the phenomenal work 
course supervisors, Major Chris Berberick and Captain Josh Lindquist, 
have accomplished. Due to the medical center's trauma census, students 
were able to acquire 95 percent of the required clinical skills from 
real-world patients after only 5 weeks into the 11 week course. As a 
result, we will decrease our Cincinnati course to 9 weeks to 
accommodate more classes. We have already expanded our total seats 
available to 241, and will soon add another civilian partner CoE as we 
open our eleventh site this July with the Scottsdale Healthcare System, 
in Scottsdale, Arizona. This facility has earned Magnet Status 
recognition from the American Nurses' Credentialing Center. Magnet 
status facilities are measured by excellent patient outcomes, high 
levels of job satisfaction, and low staff turnover. Additionally, they 
have a proven record of involving nurses in data collection and 
research-based nursing practice. We look forward to a long and 
productive partnership with the Scottsdale Healthcare System.
    Our enlisted medical technicians, led by Chief Master Sergeant 
Joseph Potts, are critical to the overall success of our TNF. Our need 
for highly skilled clinicians continues to rise and we are committed to 
training and developing enlisted clinical leaders. We continue to 
enhance our enlisted clinicians through our Critical Care Technician 
(CCT) Course, based out of Eastern New Mexico University. This program 
targets medical technicians working in intensive care units (ICU) that 
have low patient acuity levels, or medical technicians who have 
previously earned the Critical Care Technician identifier, but no 
longer work in that clinical setting. We offer twelve classes per year 
and have doubled the number of rotating training sites from two to four 
of our larger MTF/Medical Centers. Through this course, we have enabled 
115 Airmen to refresh and sharpen their critical care competencies, 
thus improving quality of care both at home station and abroad.
    July 10, 2008 marked another step toward what's being called the 
largest consolidation of training in the history of the Department of 
Defense, when the ceremonial groundbreaking service paved the way for 
the construction of the Medical Education and Training Campus (METC). 
Currently projected for completion in 2011, METC will serve as a joint 
campus, co-locating the Army, Navy, and Air Force's five major learning 
institutions currently spread across four states, into one consolidated 
medical training facility at Fort Sam Houston, Texas. The development 
of this tri-service training center will result in standardized 
training for medical enlisted specialties enhancing interoperability 
and joint training by educating Soldiers, Sailors, Marines, and Airmen 
on service-specific capabilities. Chief Master Sergeant Manuel Sarmina, 
chairman of the METC Tri-Service Enlisted Advisory Committee noted, 
``America's best and brightest will begin arriving here to work and to 
train in an environment that will be known and recognized as the 
premier learning center for our enlisted medical force.''
    On another front, over the past year David Grant Medical Center at 
Travis Air Force Base, California has implemented an Optimized Upgrade 
Training program for nurses. Captain Linda Peavely, who spearheaded the 
development of this program explains, ``Our goal was to increase the 
knowledge of nurses on medical-surgical units and progress them from 
the `competent' to `proficient' stage of nursing practice.'' Students 
participate in both didactic and clinical training in the intensive 
care unit. The result has yielded many additional benefits including 
improved wartime readiness skills, increased clinical capability and 
care of higher acuity patients, improved communication among staff, and 
recaptured revenue by decreasing the need to transfer patients. To 
date, David Grant Medical Center has produced 33 graduates, many of 
whom have recently returned from deployment and commented on how much 
more prepared and confident they felt stepping into the wartime 
environment as a direct result of this program. In January, Captain 
Peavely's hard work paid even more dividends when the Air Force 
Personnel Center, Nursing Education Branch, recognized this training 
platform as an official Air Force course, granting 92 hours of 
education credits to each graduating student.
    The Uniformed Services University of the Health Sciences (USUHS) 
Graduate School of Nursing (GSN) is yet another source preparing 
advanced practice nurses and nurse researchers. In 2008, Lieutenant 
Colonel Julie Bosch and Colonel Lela Holden successfully defended their 
dissertations, completing their Doctorate in Nursing degree. Major 
Brenda Morgan and Lieutenant Colonel Karen O'Connell are students 
currently in the USUHS doctoral program. Major Morgan is focusing her 
research on ``Positive Emotion and Resiliency'', while Lieutenant 
Colonel O'Connell is pursuing a study on ``Mild Traumatic Brain 
Injury.''

                         EXPEDITIONARY NURSING

    The cornerstone of our profession is that Air Force Nursing is an 
essential operational capability. Combined with our enlisted medical 
forces, we are a critical component of the total AFMS network 
supporting our warfighters. In 2008, 18 percent (2,802) of our TNF 
deployed to 44 locations in 16 countries. Our medical forces deployed 
in support of Operations ENDURING FREEDOM and IRAQI FREEDOM, as well as 
a myriad of humanitarian missions spanning the globe. I am proud to 
report that our TNF represents 34 percent of all Total Force 
deployments within the AFMS. TNF nurses and medical technicians are 
providing remarkable operational support. We are well-trained, highly-
skilled and are committed to saving lives, educating others, and 
improving quality of life through research. We serve in this capacity 
not out of obligation, for we are an all-volunteer force. We are called 
to a mission of putting others first--of caring for America's sons, 
daughters, brothers, sisters, fathers, and mothers. We are called to a 
mission of forging international partnerships for a common good, and to 
aid war-torn countries in developing medical infrastructures, while 
sharing the message of hope and goodwill. In this regard, I offer you a 
sampling of our nurses' and medical technicians' experiences.
    In September, Lieutenant Colonel Kathryn Weiss, a Certified 
Registered Nurse Anesthetist (CRNA) assigned to a Critical Care Air 
Transport Team (CCATT) deployed to Camp Cunningham in Bagram, 
Afghanistan. CCATTs are a three-person team made up of a physician, 
nurse, and respiratory therapist, specially trained in critical care 
transport. Lieutenant Colonel Weiss recalls flying on an Aeromedical 
Evacuation (AE) mission aboard a C-130 airframe to a Forward Operating 
Base (FOB) that had an unexpected surprise. She stated, ``We'd been 
told we'd be picking up one CCATT patient, but discovered we had two. 
Our unexpected patient was a very young boy who had been shot in the 
head and brought to this desolate outlying FOB by his father.'' The 
surgeon had stabilized him, but he was in dire need of more definitive 
care. Lieutenant Colonel Weiss and crew packaged their patients for 
transport and returned to Bagram. Most recently she reported ``this 
past month has been especially difficult as we responded to two mass 
casualties from improvised explosive device (IED) blasts, flying five 
times in 6 days as patients were stabilized for transport. Two young 
Servicemen suffered burns on up to 75 percent of their body. The 
emotional aspect of caring for these young 20-year olds is unimaginable 
. . . praying for them and their families. We have incredible support 
from our front-end crews . . . they bend over backwards to assure we 
have what we need to care for these young men. The bonds and friendship 
we form here will continue long past this deployment.''
    Major Terry Vida deployed as a Discharge Planner to Task Force Med 
in Afghanistan from Travis Air Force Base, California. Shortly after 
arriving she was instructed to establish relationships with the Afghan 
hospitals to coordinate supportive care of local nationals once 
discharged from U.S. facilities. Due to local security threats, she was 
accompanied by Special Forces. She successfully solidified working 
relationships with four of the local hospitals and in the process, 
noted their most compromised areas included patient safety, infection 
control, and lack of training. As Major Vida stated, ``It is evident 
through observation they need our mentorship. They know about isolation 
in theory, but have no means or resources to apply what they have 
learned.'' She was fortunate enough to make contact with an English-
speaking worker at the local rehabilitation center and ultimately 
coordinated their first patient transfer for supportive orthopedic 
care. However, her most notable memory of the trip to Kabul was finding 
out she and her envoy had narrowly missed a suicide bomber's explosion 
by 10 minutes.
    These are but a few examples of the tremendous work our TNF is 
providing, saving lives, making a difference, and always rising to the 
challenge, whatever it may be.

                               READINESS

    In order to provide our TNF personnel the critical care, trauma, 
and deployment skills necessary, we utilize numerous training 
platforms. The AFMS and Nurse Corps continue to produce hundreds of 
deployment-ready medics through the Centers for Sustainment of Trauma 
and Readiness Skills (C-STARS) located at University Hospital in 
Cincinnati, Ohio, R. Adams Crowley Shock Trauma Center in Baltimore, 
Maryland, and Saint Louis University Hospital in Saint Louis, Missouri. 
Each C-STARS site is known for high-quality/high-volume trauma care, 
cutting-edge research and excellence in education. The C-STARS 
Baltimore focuses on surgical and emergency care, while the Cincinnati 
site is designed specifically for clinical sustainment of CCATTs. The 
C-STARS Saint Louis is a dual Active Duty and ANG platform, with half 
of the faculty and students represented by the ANG. In 2008, 781 
physicians, nurses, and technicians completed this vital operational 
training. When enrolled in this course, almost half of the students are 
hard-tasked to deploy, while the remaining students will deploy some 
time in the next scheduled deployment cycle.
    Another building block in our arsenal of educational programs is 
the Critical Care and Trauma Nursing Fellowships. This fellowship 
program has consistently produced skilled critical care and trauma 
nurses, and has helped us in meeting our requirements in these critical 
specialties. Recruiting fully qualified critical care and trauma nurses 
continues to be a challenge. Nurse Corps officers are competitively 
selected to enter an intense 12-month training program at one of the 
following locations; Wilford Hall Medical Center in San Antonio, Texas, 
St. Louis University Hospital in St. Louis, Missouri, or the National 
Naval Medical Center in Bethesda, Maryland. By the time students reach 
their seventh month in the program, they are clinically and 
didactically prepared to deploy in their specialty. Last year this 
fellowship program produced 23 nurses combined, and currently enrolled 
this academic year are 18 critical care and 5 trauma nurse fellows. 
Additionally, as part of the preparation for this course, the student 
must complete either the Essentials of Critical Care Orientation (ECCO) 
course or the Emergency Nurses Orientation (ENO) course, respective to 
their specific fellowship. Both courses are online, self-paced, and 
focus on the skills and theory required to successfully care for 
critically ill adults. These online courses are available to all Air 
Force critical care and emergency nurses, so they may continue to hone 
their skills while earning up to 68 hours of continuing education 
credits. Over the past year, 117 nurses have enrolled in the ECCO 
course and 63 nurses have enrolled in the ENO course.
    Two additional avenues employed to assist our TNF in remaining 
deployment-ready are clinical rotations established through Training 
Affiliation Agreements (TAA) and the Sustaining Trauma and 
Resuscitation Skills--Program (STARS-P). In 2006 we identified a need 
to ensure nurses who were assigned to outpatient or non-clinical 
settings, were maintaining their operational clinical currency, and 
therefore recommended nurses attain 168-hours of bedside nursing care. 
Over the past 3 years, this initiative opened the door for 57 TAAs, 
further strengthening our partnership with civilian and sister-service 
facilities. Where available, our medical technicians have also 
capitalized on these joint ventures. These relationships and training 
opportunities are critical in producing nurses and technicians prepared 
for diverse patient populations in the deployed environment. For 
example, in August 2008, nursing personnel from the 3rd Medical Group 
(MDG) DOD/Veteran's Administration (VA) Joint Venture Hospital and the 
Alaska Native Medical Center expanded their TAA partnership to include 
rotations in the pediatric intensive care unit. Unfortunately, up to 40 
percent of the patients in military hospitals in both Iraq and 
Afghanistan are local children. As Major Dais Huisentruit, who deployed 
to Balad as the Intensive Care Unit Flight Commander explains, ``we had 
nurses from different ICU backgrounds, but most worked with adults. It 
was amazing to see them work together taking care of these children. At 
one point we had a total of 6 burned kids in the unit at one time, 
ranging in age from 2 to 7 years-old. On another occasion, we even had 
a group of three brothers . . . two of them in the ICU. They all 
survived.'' The skills our TNF has garnered through these TAA is saving 
lives and paying immeasurable dividends.
    The STARS-P is a program whose focus will not be on pre-deployment 
immersion, but ongoing clinical rotations at local civilian treatment 
facilities with Level I, and in some cases Level II trauma programs. 
The AFMS currently has five TAAs for STARS-P training sites in 
cooperation with local MTFs (San Antonio Military Medical Center, 
Texas, Luke AFB, Arizona, Nellis AFB, Nevada, Wright-Patterson AFB, 
Ohio, and Travis AFB California), and is looking to add a sixth site 
connected to Scott AFB, Illinois later this year. Currently projected 
for full implementation in fiscal year 2010, clinical rotations will be 
scheduled for 1 to 2 weeks and may also include technically-advanced 
simulation centers.

                              QUALITY CARE

    After 9/11, medical leaders across the military health services 
enacted a plan to develop and implement a trauma system modeled after 
the successes of civilian systems, but modified to account for the 
realities of combat--this plan matured into what is now known as the 
Joint Theater Trauma System (JTTS). Nursing's role within the JTTS's 
trauma performance improvement program spans the trauma continuum. 
Nurses serve as Trauma Nurse Coordinators (TNC) in combat zone MTFs, 
flight nurses within the Air Force AE system, members of 
multidisciplinary trauma teams at overseas, stateside, and VA 
hospitals. Many of the trauma performance improvement initiatives that 
have occurred since the development of JTTS have been led by nurses 
serving within this system. One vitally important role is that of the 
TNC. The TNC is the critical link in the complex continuum of trauma 
care from point-of-injury to treatment facilities in the Continental 
United States (CONUS). The TNC provides data to affect local and 
system-wide changes, in addition to trauma care expertise. Their role 
is fast-paced and multi-faceted. At the local level, the TNC impacts 
people and processes in several spheres of influence including primary 
trauma care, education, process improvement, and collaboration with 
literally every hospital department and specialty. They review all 
trauma patients' charts, compile and analyze complex data, and channel 
the information into the trauma system to improve combat casualty care.
    Another program that has positively impacted patient outcomes and 
safety is the Rapid Response Team (RRT). This nurse-led program, 
initiated at David Grant Medical Center, was established to provide the 
nursing staff an avenue for early intervention at the first signs of 
negative changes in a patient's condition. When the RRT is called upon, 
an experienced critical care nurse and respiratory technician come to 
the bedside within 5 minutes to assess the patient and provide pre-
emptive care, preventing further deterioration. This pro-active 
approach has resulted in earlier medical interventions, a lessening of 
the severity in patient conditions, improved communication, and 
expected seamless, well-coordinated transfers between units when 
necessary. RRT is an example of an ICU without walls where critical 
care teamwork makes a difference for both our patients and staff.
    Our enlisted forces have also made great achievements this past 
year. In August, Special Experience Indicator (SEI) 456 was approved 
for our enlisted medical technicians who maintain national currency as 
a Paramedic. Our Career Field Manager, Chief Master Sergeant Joseph 
Potts is leading a team of experts in building standardized Air Force 
Paramedic protocols. By establishing this SEI we ensure our medical 
technicians have a nationally defined advanced care capability to meet 
operational needs.
    One more example of our multi-faceted approach to quality care is 
the Center of Excellence for Medical Multimedia (CEMM), 
organizationally aligned at AFMOA. The CEMM's mission is to provide 
patient education material that improves knowledge, patient compliance, 
and patient satisfaction. Diseases or conditions must meet certain 
criteria to be targeted for CEMM program development. Some program 
examples include Women's Health, Traumatic Brain Injury, and Diabetes 
Prevention. As CEMM's Director of Education Services, Captain Laurie 
Migliore's role is diverse as she assists in program design, 
development, and product deployment. The CEMM has distributed 85,000 
programs per year and won over 75 national awards.
    Our profession is not one just of caring, but educating others as 
well. Members of our TNF are filling critical roles in medical Embedded 
Training Teams (ETT) in areas across Afghanistan. The mission of these 
ETTs is to strengthen and improve the Afghan National Army (ANA) 
healthcare system through education and training of Afghan medical 
personnel.
    Lieutenant Colonel Susan Bassett, deployed as a 205th Afghan 
Regional Security Integration Command Mentor, adds, ``We have taught 15 
classes so far, with an average of 25-30 attendees including nurses, 
medics, laboratory technicians, x-ray technicians, and pharmacists. I 
try to use very animated examples and write key words on the dry-erase 
board. They are extremely studious and eager to participate. They ask 
for handouts and complain if they are solely in Dari . . . they want 
them in English and Dari as they are trying to learn to read English. 
After giving them power point slides, several of the more experienced 
Afghan nurses volunteered to teach some of the modules themselves. They 
were proud as peacocks!'' She goes on to share, ``The other day one of 
the nurses told a visiting reporter, in very halted English, `We . . . 
love . . . Mama Bassett!' '' Lieutenant Colonel Bassett has certainly 
made a lifelong difference in the quality of care these Afghan nurses--
provide just one more step in winning their hearts and minds.

                                RESEARCH

    The research initiative known as the Deployed Combat Casualty Care 
Research Team (DCCCRT) consists of six Army and three Air Force members 
with the purpose of facilitating mission-relevant research in the 
Multi-National Corps--Iraq Theater. In September 2008, a Balad research 
team was established which included Colonel Margaret McNeill, an Air 
Force Ph.D.-prepared nurse, a flight surgeon, and a podiatrist. Colonel 
McNeill is the first Air Force nurse researcher to join the DCCCRT. The 
role of the team is to provide guidance and initial review for all 
research conducted in Iraq. The Ph.D.-prepared nurses provide 
leadership on human subject protections and the ethical conduct of 
research. Each team member is involved in collecting data for a variety 
of research protocols focusing on the care of combat casualties. Over 
100 research studies have been conducted or are in planning stages as a 
result of the team's efforts. More than 12,000 subjects have been 
enrolled in studies. Areas of research conducted by the military in 
Iraq that have led to advancement in medical therapies include 
tourniquet application, resuscitation, blood product administration, 
burns, wound care, ventilation management, patient transport, Post 
Traumatic Stress Disorder (PTSD), Traumatic Brain Injury, and 
infectious diseases. Nurse-led studies have investigated pain 
management, carbon monoxide exposure, women's healthcare, sleep 
disturbances in soldiers, and PTSD/burnout and compassion fatigue in 
nursing personnel.

                        RECRUITING AND RETENTION
 
   According to the latest projections from the U.S. Bureau of Labor 
Statistics, more than 1 million new nurses will be needed by 2016. Of 
those, 587,000 are projected to be new nursing positions, making 
nursing the nation's top profession in terms of projected job growth 
(www.bls.gov/opub/mlr/2007/11/art5full.pdf). A separate report, titled 
``The Future of the Nursing Workforce in the United States: Data, 
Trends, and Implications'', found that the shortage of RNs could reach 
as high as 500,000 by 2025 (www.jbpub.com/catalog/9780763756840). It is 
evident Air Force Nursing will need to take advantage of every 
opportunity to recruit and retain nurses.
    In fiscal year 2008, we accessed 302 nurses against our total 
accession goal of 325 (93 percent). The Air Force Recruiting Service 
ultimately delivered 226 nurse accessions, filling 69.5 percent of our 
total accession goal. Our challenge remains with recruiting fully 
qualified and specialty nurses in the areas of mental health, 
anesthesia, medical-surgical, emergency and critical care. While 93 
percent appears positive, only 44 percent of those were considered 
``fully qualified,'' meaning they had a minimum of 6 months previous 
nursing experience. Fifty-six percent of all nurse accessions were 
``novice nurses,'' having less than 6 months nursing experience. The 
shortage of experienced nurses is a direct reflection of our national 
nursing shortage. Additionally, it is difficult to compete with our 
civilian counterparts in recruiting experienced nurses, as they offer 
many lucrative incentives.
    We take advantage of numerous venues to access nurses. In addition 
to our recruiting services, we bring nurses into the Air Force through 
a variety of programs. Utilizing the Air Force Reserve Officers' 
Training Corps, Airmen Education and Commissioning Program, the 
Enlisted Commissioning Program, and the Health Professions Scholarship 
Program, we accessed 70 nurses in 2008.
    In 2007 we launched our Nurse Enlisted Commissioning Program 
(NECP). The goal is to grow Air Force nurses from our highly successful 
enlisted medics. The NECP is an accelerated program for enlisted Airmen 
to complete a full-time Bachelor of Science in Nursing (BSN) at an 
accredited university while on active duty. This program produces 
students completing their BSN and obtaining their nursing license in 24 
months or less through either a 2 or 1 year program, depending on their 
entry level. Airmen who complete this program are then commissioned as 
second lieutenants. Since its inception we have selected 73 students 
from 83 applicants and project a steady state NECP quota of 50 per year 
for the 2 year program beginning fiscal year 2011.
    We strive to sustain and exceed our recruitment goals, but Nurse 
Corps retention remains problematic. In 2008, 55 percent of the nurses 
who separated had less than 20 years of military service. In 2008 
alone, 61 percent of those separating were our young lieutenants and 
captains. The number of lieutenants separating has nearly tripled over 
the past 3 years. We are hopeful the implementation of the Nurse Corps 
Incentive Special Pay (ISP) program will make a positive impact on 
retention; however, we are concerned about the unintended consequences. 
A resulting increase in retention of company grade officers may further 
extend timing and reduce promotion opportunity due to our small number 
of field grade requirements.
    While we currently offer incentive special pay to CRNAs at variable 
rates, we have never had the resources to recognize clinical nurses for 
seeking and earning professional national certification and advanced 
academic degrees in various nursing specialties. With ISP we offer an 
even more appealing pay incentive if a nurse with an identified 
certification, additionally desires and commits to work in an approved 
clinical area and for a specific amount of time. We are pleased to be 
able to acknowledge our highly-skilled professional nurses in the 
clinical arena.
    Our active duty enlisted forces also scored a win this past year 
with their own Selective Re-enlistment Bonus (SRB). Even though their 
overall manning appears to be strong at 94 percent, our Independent 
Duty Medical Technicians (IDMT) are heavily tasked with deployments and 
manned at only 72 percent. This SRB is a first-ever for our IDMTs, and 
I, along with Chief Master Sergeant Potts, am eager to see the impact 
of this initiative.

                               LEADERSHIP

    As a Corps, we place heavy emphasis on purposefully developing 
leaders, clinically and professionally for the AFMS. Our Nurse Corps 
Development Team (DT) convenes three times a year to ensure Nurse Corps 
officers are provided deliberate career progression opportunities. The 
DT competitively selects our squadron commander and chief nurse 
candidates, both of which represent pivotal career leadership 
milestones. Furthermore, the DT identifies through a scored-board 
process, those leaders who would most benefit from developmental 
education in-residence. In 2008, the Nurse Corps garnered 90 annual 
quotas to send our best and brightest captains to Squadron Officer 
School.
    Another recent development on the topic of clinical leadership is 
the creation of master clinician authorizations. This affords an 
opportunity for our most clinically experienced senior nurses with 
advanced academic preparations to remain in patient care settings 
without sacrificing promotion or advancement opportunities. We 
currently have identified 20 master clinician positions scattered among 
our larger MTFs as well as the Uniformed Services University of Health 
Sciences representing the areas of CRNAs, Perioperative Nursing, 
Education and Training, ICU, Family Nurse Practitioner, and Nursing 
Research.
    Nurse leaders are critical in every environment, especially in 
deployed locations. Last year we successfully acquired a deployed 
Colonel Chief Nurse position at Joint Base Balad, Iraq, and we 
anticipate permanently adding another at Bagram's Craig Theater 
Hospital. The corporate experience of seasoned chief nurses in the 
grade of Colonel lends itself to mentoring not only nursing services 
personnel, but officers from across the AFMS.
    Not only do we deploy as chief nurses, but in the role of 
Commanders as well. Colonel Diana Atwell served as the 332nd 
Expeditionary Medical Operations Squadron Commander at Joint Base 
Balad. As commander, she led a squadron of approximately 200 combat 
medics ranging from trauma surgeons to medical technicians, whose 
efforts contributed to an overall survival rate of 98 percent at the 
DOD's largest and busiest level three theater hospital.

                              ANG AND AFRC

    The ANG and AFRC are vitally important contributors to our TNF and 
the backbone of our highly-successful global AE mission. Since 2007, 
all AFRC mobilization requirements have been met solely by volunteers. 
In 2008, 503 AFRC nurses and medics stepped up to meet deployment needs 
at home and abroad, with 133 of those personnel sourced for missions 
related to Hurricanes Gustav and Ike. The ANG also played a key role as 
they deployed 268 medics and AE personnel. They processed and moved 600 
patients prior to and after the hurricanes. In addition to activating 
AE crews, the ANG mobilized AE Liaison teams (AELT), Command and 
Control (C\2\) elements, and Mobile Aeromedical Staging Facilities 
(MASF). The MASF changed location three times ``chasing the storm'' and 
providing evacuation assets to the area in most need. Rounding out TNF 
representation, the 43d Aeromedical Evacuation Squadron (AES) from Pope 
AFB, North Carolina, also played a role in responding to Hurricanes 
Gustav, Hanna, and Ike by deploying MASFs, AELTs, AE crews, and C\2\ 
elements to areas in Louisiana and Texas.
    Our AE system provides the vital link in uninterrupted world class 
medical care from the battlefield to definitive treatment facilities at 
home. We boast a 98 percent survival rate for those that reach a 
theater hospital; the highest survival rate in history. It is a total 
force human weapons system comprised of 32nd AE Squadrons representing 
12 percent Regular Air Force, 60 percent AFRC, and 28 percent ANG. The 
AE deployment requirements in support of Operations Iraqi and Enduring 
Freedom have moved nearly 71,000 patients since October 2001. The 
mission of AE is one close to all our hearts--a mission of carrying the 
most precious cargo of all, our wounded warriors.

                         HUMANITARIAN MISSIONS

    The TNF nurses and aerospace medical technicians represented a 
United States presence in locations crossing the globe including Iraq, 
Afghanistan, Qatar, Kuwait, Europe, Korea, Honduras, Trinidad, El 
Salvador, Guatemala, Morocco, Cambodia, Peru, and Suriname, to name 
only a few.
    Master Sergeant Jeffrey Stubblefield, an IDMT assigned to the 3rd 
MDG in Alaska, had the unique opportunity to deploy to Laos on a 
mission to recover remains of two Raven Intelligence Officers whose 
plane crashed after taking enemy fire during the Vietnam Conflict. As a 
medic assigned to Recovery Team One, he provided medical support to 51 
team members traversing treacherous terrain to reach our fallen 
comrades and enable the repatriation of their remains.
    Major Susan Perry, a CRNA assigned to Wright-Patterson AFB, Ohio, 
was part of JTF-Bravo, a medical element surgical team partnering with 
civilian surgeons in Comayagua, Honduras. Her team was pivotal in 
responding to and saving the lives of 30 civilians injured in a motor 
vehicle collision.
    Captain Troy Mefferd and First Lieutenant Ranjodh Gill deployed 
aboard the U.S. Naval Ship Mercy in support of joint humanitarian 
mission, Pacific Partnership 2008. Through this endeavor, medical care 
was provided to nearly 8,000 patients as well as 1,200 receiving dental 
care through Operation Smile.
    Lieutenant Colonel Tambra Yates, Flight Commander of Women's Health 
Services at Elmendorf AFB, was the first women's health provider to 
accompany a Family Practice Team to three remote Alaskan villages as 
part of Alaska Taakti Top Cover. She treated 32 patients, diagnosing 
three with cancer which required immediate surgery. As a result of her 
many contributions, future Taakti missions will include a Women's 
Health Service Provider as part of the team.
    Seven members of the 43rd AES participated in a historic mission 
which brought home three American contractors who'd been held captive 
for over 5 years by leftist Revolutionary Armed Forces of Colombia 
after their plane crashed in February 2003. The 43rd AES crew, along 
with 17 Airmen from Charleston AFB, South Carolina cared for and 
delivered them safely back to the United States on July 2, 2008. The 
close proximity to July fourth gave an all new meaning to 
``Independence Day'' for these former captives.

                              RECOGNITION

    It was a banner year as Air Force nurses and medical technicians 
were recognized for outstanding performance by a variety of 
professional organizations. Technical Sergeant David M. Denton captured 
the Airlift/Tanker Association's ``General P.K. Carlton Award for 
Valor.'' This annual award is presented to an individual who 
demonstrates courage, strength, determination, fearlessness, and 
bravery during a combat, contingency, or humanitarian mission. 
Technical Sergeant Denton was also named as the AFMS ``Outstanding Non-
Commissioned Officer AE Technician of the Year.''
    Every year the Commemorative Air Force (CAF) recognizes one 
exceptional flight nurse who engaged in live aeromedical evacuation 
missions and contributed significantly to in-flight patient care, by 
awarding them the ``Dolly Vinsant Flight Nurse Award.'' This award pays 
tribute to Lieutenant Wilma ``Dolly'' Vinsant who was killed in action 
over Germany during an AE mission on August 14, 1946. This year the CAF 
recognized Captain Bryce Vanderzwaag of the 86th AES at Ramstein AB, 
Germany. Captain Vanderzwaag provided direct AE support to 651 sick and 
injured patients, including two K-9 military working dogs injured by 
IEDs, during his deployment.
    Lieutenant Colonel Mona P. Ternus, an AFRC nurse, was recognized by 
the Tri-Service Nursing Research Program, Federal Nursing Section, as 
she was awarded the ``Federal Nursing Service Essay Award'' for her 
research and essay entitled, ``Military Women's Perceptions of the 
Effect of Deployment on their Role as Mothers and on Adolescents' 
Health.'' These are but a few examples of the stellar work our nurses 
and medical technicians perform every day.

                             OUR WAY AHEAD

    Nursing is a profession vital to the success of our healthcare 
system. Our top priorities include, first and foremost, delivering the 
highest quality of nursing care while concurrently staging for joint 
operations today and tomorrow. Second, we are striving to develop 
nursing personnel for joint clinical operations and leadership during 
deployment and at home station, while structuring and positioning the 
Total Nursing Force with the right specialty mix to meet requirements. 
Last, but not least, we aim to place priority emphasis on collaborative 
and professional bedside nursing care.
    Mister Chairman and distinguished members of the Committee, it is 
an honor to be here with you today and represent a dedicated, strong 
Total Nursing Force of nearly 18,000 men and women from our Active 
Duty, Air National Guard , Air Force Reserve, civilian, and contract 
forces. Our warriors and their families deserve nothing less than 
skilled and educated nurses and technicians who have mastered the art 
of caring. It is the medic's touch, compassion, and commitment that 
often wills the patients to recovery and diminishes the pain. As our 
Air Force Nurse Corps celebrates its 60th Anniversary, I look forward 
to working with our Sister Services and our Federal Nursing Team, as we 
partner to shape the future of our profession.

    Chairman Inouye. On behalf of the subcommittee, I thank all 
of you, but I have a few questions.
    There's no secret that there's a national nursing shortage. 
But somehow you gals have done a good job. The Air Force has 
met 93 percent of its goal. Army and Navy have exceeded their 
goals. What's the secret?

                    NURSE RECRUITMENT AND RETENTION

    General Horoho. Mr. Chairman, I think the secret is a 
couple things: the support that we've received from Congress 
with the different incentive specialty pay bonuses, that has 
had an overarching success with our nurses choosing to remain 
on active duty. The other is working very collaboratively with 
the Army Medical Recruiting Brigade. We stood up that brigade 
in 2007 that focused on recruiting nurses and the entire Army 
medical team, and so the first time last year since 2001 they 
actually exceeded the mission by 147 percent for recruitment of 
nurses on active duty.
    So having that specialized--there were also bonuses that 
were given to the recruiters to be able to target special 
critical categories. We've also been very, very proactive with 
telling the Army Nurse Corps story and having our nurses 
engaged in helping with the recruiting effort.
    Admiral Bruzek-Kohler. Mr. Chairman, there's no doubt that 
the support we received from you for our accession bonus 
increases and in particular our loan repayment program has made 
a tremendous difference in the numbers of direct accessions, 
particularly in light of the economic situation. For many of 
our new students, they come with extremely high student loans, 
more than I would have anticipated.
    In fact, I remember meeting a lieutenant in Bahrain who had 
not yet heard about the program, a new graduate with over 
$60,000 worth of school loans. So that has made a major, major 
difference in their lives.
    We've expanded our opportunities with our recruiters to use 
our own nurses in geographic areas, particularly nurses who are 
going to many of our professional organizations, both in terms 
of clinical skills, but also in terms of some of our diversity 
issues, and selling our story, telling our story as well. That 
has really made a difference in bringing in some of the 
diversity that we've not been able to get in the past.
    So we will continue to use all of those opportunities to 
bring in our direct accessions. We also have a huge pipeline, 
as we've heard from our sister service in the Air Force, with 
our medical enlisted programs, and using our corpsmen and other 
enlisted rating applicants to come into the Nurse Corps has 
really been our life's blood really for keeping our Corps at a 
level of being able to provide the kinds of care we provide. We 
will continue to support those programs, as well as our ROTC 
programs and our candidate programs.
    So again, we thank you for that support for all of those.
    General Siniscalchi. Senator Inouye, thank you, and I would 
like to reiterate my nursing colleagues' for our Air Force 
accessions. I can attribute our success has been with 
recruiting novice nurses, the nurses who are completing their 
baccalaureate degrees and are coming into the Air Force as 
novice with less than 6 months experience.
    Our loan repayment program, the increase that we received 
has been very successful. We were able to increase our quotas 
from 76 to 102. The increase in our health professions loan 
repayment quotas had a significant impact on our ability to 
recruit more novice nurses. The accession bonus has also been a 
very successful recruiting tool, and we appreciate the 
increased funds that we received in accession bonuses this 
year.
    We are finding that with the $30,000 in accession bonus and 
up to $40,000 in the loan repayment combination it's very 
helpful to those students who have large loan repayments. So I 
would like to thank you again for your support with those 
programs.
    We've taken several initiatives to continue success with 
recruiting. Dr. Cassells and Dr. Hinshaw from USU had organized 
a conference for academic partnerships addressing military 
nursing shortages, and that occurred this past weekend. We had 
the opportunity to meet with nursing deans and faculty across 
the country, and our objective was building collaborative 
relationships among military nursing services with the schools 
of nursing to foster additional educational opportunities and 
begin a campaign to educate the faculty from these schools, so 
as they are mentoring and advising their students they can help 
direct them toward military nursing as a potential career 
option.
    Chairman Inouye. Do you believe that we have enough nurse 
anesthetists, critical care nurses, operating room nurses, 
these specialties?
    Admiral Bruzek-Kohler. Those are our critical areas right 
now that we are looking at in terms of retention as well as 
accessing. We do not have enough. Critical care nurses are 
undermanned at about anywhere from 60 to 70 percent. We think 
anything below 90 percent is critical and we have to pay 
attention to them.
    I will say, our nurse anesthetists actually are very 
healthy. They aren't really one of the groups that we are 
focused on this year. Our perioperative nurses, our operating 
room nurses, our critical care nurses, and our nurse 
practitioners are below that critical 90 percent at this point 
in time.
    So we're doing a couple of things. When we're recruiting, 
we are looking to recruit those specialties, which means we 
will bring in a more seasoned, more experienced clinical nurse 
at a more senior rank. We don't anticipate, nor do we know at 
this point, whether these nurses would want to continue on a 
full naval career or at least be with us during a very critical 
time in our history while this war is still going on.
    For retention, again the loan repayment program has been 
helpful. The RNISP has been absolutely the most positive action 
we could have taken to entice our more senior nurses, 
particularly those who are at the point of either the 10-year 
mark where they either make the decision to leave now or they 
continue on for 20 years, or for some who have come in from the 
enlisted ranks, who at the 10-year officer mark now have 20 
years and can, in fact, retire. Those incentives have actually 
been positive in making the decision for them to stay in the 
Navy.
    Also, the opportunities to deploy have been remarkable 
incentives for our people to stay in the Navy.
    Chairman Inouye. General Horoho.
    General Horoho. Mr. Chairman, both the emergency nurse 
specialty as well as the ICU specialties are two of our highest 
deployers as we support two theaters of operations. So we have 
been working very aggressively to expand our critical skill 
sets by helping them with deployment skills and training. We 
have increased the number of seats to be able to train more.
    We have also started to target the population at the rank 
of major because I'm at 50 percent strength at that middle 
grade leadership, and we're trying to force more clinical 
expertise back at the bedside. So there's a pilot project 
that's ongoing that gives us the authority to be able to 
recruit individuals to come on active duty for a 2-year 
obligation. So what we are doing is working very closely with 
Recruiting Command and Accessions Command to be able to target 
that clinical expertise and bring them on active duty for a 2-
year obligation to help us bridge that critical shortfall that 
we have.

                            NURSE RECRUITING

    Chairman Inouye. General Siniscalchi.
    General Siniscalchi. Sir, direct recruitment of our nurse 
specialties continues to be a challenge. We've come up with 
programs, very successful programs, to help us with retention 
and to help us develop those skill sets that we need ourselves.
    The biggest impact on retention has been the incentive 
specialty pay program. We just started this program in January 
and so far over 76 percent who decided to participate in the 
program accepted the 4-year active duty service commitment. So 
that will have a significant impact on our ability to retain 
those critical areas.
    We've developed fellowships that are year-long in critical 
care, emergency training, and trauma training. That helps us to 
grow nurses in those critical areas.
    We continue to select nurses annually to attend USU for 
advanced academic training in critical areas. We've increased 
our family nurse practitioner quotas from 5 to 20 this year. We 
have an operating room cross-training course at Wilford Hall 
and a neonatal intensive care course at Wilford Hall, which is 
helping us to meet those critical specialties.
    Our future plan for this year is to build a mental health 
nursing course at Travis Air Force Base. We've had difficulty 
recruiting mental health nurses and, as you know, they are very 
critical in the care of our wounded warriors. So we are hoping 
to see this program come to fruition this year.
    We're building master clinician opportunities at the 
colonel ranks so that we can have senior leaders in anesthesia, 
in the operating room, in emergency rooms, and in critical care 
areas that can help grow and mentor those nurses in those 
critical specialties.
    Chairman Inouye. Thank you very much.
    Mr. Vice Chairman.
    Senator Cochran. Mr. Chairman, thank you.
    I'm concerned that the challenges in view of the war and 
the constant separation from families and friends may have a 
very serious consequence in terms of the success of recruiting. 
I was sitting here thinking about what could we do as a 
subcommittee to be helpful to you in increasing the likelihood 
that your goals were met and that retention rates are high in 
what you need.
    Would additional funding of specific programs targeted to 
recruiting and retention be in order, or do you have enough 
money to do what you need to do?
    Admiral Bruzek-Kohler. Well, I'll begin by saying that the 
support that you have given us to this date in time has shown 
dramatic improvements in the numbers of accessions, direct 
accessions, and the retention numbers. They have shown that 
they are successful in enticing people to join the Navy, as 
well as retaining them for a full commitment to a full career 
in the Navy.
    So I thank you for those and certainly we would appreciate 
to be able to continue to offer those incentives both as 
accession bonuses as well as our loan repayment program. As I 
mentioned, they have been an amazing support to our new 
students and our new graduates. While there is competition from 
the civilian sector our retention bonuses give them the 
opportunity to want to continue to serve their country.
    We do exit interviews of all of the nurses that leave the 
service, and I will tell you that deployments are generally not 
the reason why they leave the Navy. Usually it's family issues, 
dual career families and they want to get stable in a 
community. We also find as we are doing recruiting, 
particularly at schools of nursing throughout the country, that 
deployments are not a reason not to join the Navy. In 
particular, with our ability to provide humanitarian assistance 
and that type of service to other countries, that again is very 
enticing to a nurse who really wants to feel like they are 
fulfilling what the purpose of being a nurse is in the first 
place.
    So at this point I would just say thank you for what you've 
done for us up to this juncture and we would certainly be 
thankful for that continued support.
    Senator Cochran. General Horoho.

                            NURSE RETENTION

    General Horoho. Yes, sir. I would echo and say continued 
support of the programs that we do have in place, because when 
we have looked at our nurses 97 percent of those that are 
eligible to take those loan repayment programs or the bonuses 
have accepted them. So I think it does show that they are 
positive incentives to helping individuals remain on active 
duty.
    The other incentive is that there is tremendous pride with 
our nurses that deploy, and most of them that come back have 
echoed that they found great self-worth to be able to know that 
they were helping to enhance the healthcare of those 
servicemembers that are supporting our freedoms, as well as 
helping with the nation building.
    One of the things that has truly impacted I think retention 
is that we have changed our policy for deploying nurses from 12 
months down to a 6-month rotation. That in itself has helped to 
help with the time, to decrease the time away from their family 
members. So when we look at that, it's the financial incentive 
programs as well as those support programs that we have in 
place.
    We did a survey across the entire Army Nurse Corps so that 
I could have a baseline understanding of kind of the health of 
the Corps. Out of that survey we found two areas that we're 
going to focus on. One of them is looking at the redefinition 
of our head nurse role, of wanting to make sure that that role 
is having the ability to impact patient care and is really 
focused on outcome-based as well as leader development.
    So we have got a team that has stood up to look at best 
practices across our entire Army medical department, as well as 
looking at what is being done within our civilian health 
sector. Then we're going to redesign that leader development 
role, and we're also looking at the entire leader development 
training programs that we have in place, because when you look 
at young nurses during the exit survey--and we do exit surveys 
on everybody who's leaving--a majority of it is because of 
family reasons, either starting families or an elderly parent 
and needing to be home.
    So two things that we're doing. We're looking at and 
partnering with the Army to see how is it that we can have a 
program in place to help nurses take a leave and be able to 
still meet their family needs as well as their military 
obligation. Then we're also looking at how do we ensure that 
we've got our nurses best prepared for the deployment. So we're 
redoing--this past year we had 186 lieutenants that were 
assigned to each one of our medical centers for a year-long 
clinical immersed program to help them get their clinical 
skills solidified as well as their critical thinking skills 
prior to deployment.
    So I think those were the major things that came out of the 
organizational survey.
    Senator Cochran. Thank you.
    General Horoho. Thank you.
    Senator Cochran. General Siniscalchi.

                        NURSE ACCESSION BONUSES

    General Siniscalchi. Sir, I would add, in addition to your 
support for our nurse accession bonuses and the health 
professions loan repayment program, it's more than just the 
financial incentives that incentivize our nurses. The 
opportunities for advanced education, the opportunities for 
increased leadership roles and leadership training, has a 
significant impact on retention.
    The support of the health professions scholarship program 
has been critical. That program, the funding for that program, 
has allowed us to take nurses who already have baccalaureate 
degrees and put them in programs, civilian nurses, sponsor 
their education, put them in programs for anesthesia training, 
to become family nurse practitioners, women's health 
practitioners. And that allows them the opportunity to have 
advanced education paid for by us and then come on active duty 
and serve in those critical areas.
    So I would submit that continued support of the health 
professions scholarship program is a big incentive. We do 
continue to look at opportunities to partner with civilian 
programs so our nurses can have increased opportunities for 
advanced education and leadership training.
    Senator Cochran. Thank you very much.
    Chairman Inouye. Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman.
    I apologize for having to step out and miss your testimony. 
But I wanted to personally thank all of you and everyone you 
oversee for the tremendous work that they do. General Horoho, 
it's good to see you here. I appreciate everything you've done 
out at Madigan Army Medical Center and appreciate your 
leadership.
    Time is getting late, so let me just ask one question. I'll 
submit the other ones for your answers later. General Horoho, 
as you know, the Army's deployment schedule and adequate care 
of both soldiers and their families is very important to me. 
We've had the chance to talk about that. I wanted just to ask 
you how you are planning to continue to take care of children 
and families of servicemembers?

                      MADIGAN ARMY MEDICAL CENTER

    General Horoho. Yes, ma'am. First I'd like to thank you for 
your support, because we get tremendous support from you and 
your entire team in Madigan Army Medical Center being able to 
meet its mission.
    Madigan Army Medical Center--the troop strength on Fort 
Lewis has grown over the years, and so our enrolled population 
at Madigan has increased from 84,000 to currently we have 
106,000 enrolled beneficiaries. When you add on the healthcare 
benefits of that reliant population, which are those reserve 
soldiers and National Guard that are able to get extended 
healthcare, that increases it about 33,000. So we have the 
third largest enrolled beneficiary population in the Army, so 
about 133,000.
    Of that, 20,000 of those are women, so it's a growing 
population. The increased strength is 20,000 for women and for 
children.
    So what we've done is we have looked at--we have submitted 
a proposal for funding for a women's health center that will 
allow us to consolidate all of those services together to 
better meet the needs of our women and our children, so it's 
more of a continuum from infants through the adult parent.
    With that, if it's awarded, in 2010 we would look at design 
and construction beginning and having it completed about 2014. 
What that would allow us to do is to be able to maximize the 
efforts. We have a DOD fellowship, the only one in the Army, 
for developmental pedes as well as maternal-fetal medicine. So 
we'd have that capability of having the right case mix to be 
able to help our residents grow and our physicians grow in that 
specialty.
    We also are looking at, if that building is built, then we 
would take that space that is relieved to further expand our 
primary care to be able to meet the increased demand that we 
have from that troop population growth.
    Senator Murray. Well, I really appreciate your strong push 
on that and I want to be supportive in any way I can. It's a 
great way to move forward, I think. Obviously, whatever I can 
do from my end to support that, I will do.
    General Horoho. Thank you.
    Senator Murray. I just want all of you to know I'm worried 
about compassion fatigue with our nurses, and I know that's a 
recruiting issue, and a retention issue. We have to look at 
what we can do, Mr. Chairman, to support them. General, you 
mentioned several good ways to do that, and I want to encourage 
all of us to continue to do that.
    I do have several other questions. I know you've been 
sitting here a long time, so I will submit them for the record. 
But I do really appreciate the work that all of you do. So 
thank you so much.
    General Horoho. Thank you, ma'am.
    Chairman Inouye. The nurses are fortunate to have Senator 
Murray here.
    Senator Murray. We all stick together.
    Chairman Inouye. One of the priority projects I had when I 
first got on this subcommittee was to make certain that nurses 
got full recognition for their service. The one way to do that 
in the service was by rank. At that time, I believe I met one 
nurse who was a colonel. Most of the nurses I knew were 
captains or lieutenants. I'm happy to see two stars all over 
the place.
    But I note that in the Navy you have a rear admiral one 
star, rear admiral upper half two stars. But in the Army and 
Air Force there's no billet for one stars. Why is that?
    General Horoho. I'll go first if you don't mind. Sir, one 
of the things is that we have the Surgeon General's full 
support of leader-developing all of our Army Medical Department 
leaders. Our general officer slots are branch and material. 
What we do is we work very, very hard as a collective force to 
be able to ensure that we have the right leadership skill sets, 
not only the education programs, but the command opportunities, 
as well as the clinical opportunities to lead at that level.
    So we are working very closely to ensure that we have a 
pool of personnel that will be competitive for general officer 
at the one-star rank.

                           COMPETITIVE GRADES

    General Siniscalchi. Sir, having gone from colonel directly 
to two stars, the current construct has worked very well, and 
I've had tremendous support from my senior leaders. Within the 
Air Force, we have a limited number of general officer 
authorizations and we have elected to allow each of our corps 
the opportunity to have a star as their pinnacle rank.
    So if we add a Nurse Corps one star, we will have to offset 
it elsewhere. So our current plan is to continue with the 
current construct and continue to develop our colonel nurses 
and select those nurses who have more time in grade and more 
time in service, so that we're selecting our senior colonels as 
we promote them to the rank of two stars.
    Chairman Inouye. So it would help if we authorize one star 
billets with the money that we can provide here. You won't be 
against that, would you?

                     ADDITIONAL COMMITTEE QUESTIONS

    General Siniscalchi. Sir, I would never turn down stars.
    Chairman Inouye. Well, I thank you ladies very much. I want 
to thank General Schoomaker, Admiral Robinson, General 
Roudebush, General Horoho, Admiral Bruzek-Kohler, and General 
Siniscalchi for your testimony and for your service to our 
Nation.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]

      Questions Submitted to Lieutenant General Eric B. Schoomaker
            Questions Submitted by Chairman Daniel K. Inouye

                          JOINT DOD/VA CLINICS

    Question. General Schoomaker, since there are other joint DOD/VA 
clinics and presumably more to come, are all the Services involved in 
raising, discussing, and resolving the myriad of issues presented by 
these joint facilities or is it done on a facility unique basis?
    Answer. The Health Executive Council and Joint Executive Council 
provide the basis for managing efforts related to joint DOD/VA clinics. 
The recent revival of the VA/DOD Construction Planning Committee will 
facilitate future joint planning efforts. Army facility pre-planning 
efforts take into account existing/proposed Community Based Outpatient 
Clinics (CBOCs) and also consider the possibility of current and future 
Joint Ventures. For example, the U.S. Army Medical Command (MEDCOM) is 
currently working with the local VA medical center and the Veterans 
Integrated Service Network to define the scope for a William Beaumont 
Army Medical Center (WBAMC) hospital replacement at Fort Bliss, Texas. 
WBAMC currently shares services through a Joint Venture agreement with 
the co-located VA medical center. There is potential for additional 
sharing and this is the heart of the ongoing pre-planning effort. 
MEDCOM has also incorporated CBOCs within hospital replacement projects 
such as Bassett Army Community Hospital at Fort Wainwright, Alaska, and 
DeWitt Army Community Hospital at Fort Belvoir, Virginia. The VA and 
Army are also working to locate CBOCs on Army installations such as 
Fort Detrick, Maryland and Fort Meade, Maryland. The VA recently 
renovated space at the former Lyster Army Community Hospital at Fort 
Rucker, Alabama, as it was downsized to an Army Health Clinic. The VA 
was able to vacate a lease for its CBOC in downtown Dothan, Alabama, 
and move closer to its beneficiary population at Fort Rucker.

                         CENTERS FOR EXCELLENCE

    Question. General Schoomaker, there seems to be an insatiable 
appetite for creating Centers of Excellence for everything from sensor 
systems to urban training and now we are creating them for medical 
research. While I fully support the establishment of the Defense Center 
of Excellence for Traumatic Brain Injury and Psychological Health, we 
also created them for amputees, vision, and hearing. All of these areas 
are critical to the health of our service members but we can't create 
centers for every issue facing our service members. Therefore, how do 
we ensure the appropriate level of attention and allocation of 
resources are devoted to the issues we are faced with today and also 
those we might encounter in the future?
    Answer. A Center of Excellence designation serves to establish 
priority; whether directed by Congress or within the Department. It 
results in a specific activity gaining visibility and attention above 
other areas. COE designation to date has come with costs as we grow 
organizational structure to oversee a specific area of interest. There 
is a critical balance that must be kept in check. The Services are 
operating comprehensive healthcare systems. We are caring for Soldiers 
and Families with a very broad spectrum of healthcare needs--nearly the 
entire spectrum of medical practice. We must be careful not to focus 
too much effort in too few areas and cause us to fail to meet the true 
needs of our beneficiaries; the majority of which fall outside the 
sphere of established COEs. Moreover, every one of my Army hospitals is 
a Center of Excellence. We provide exceptionally high quality 
healthcare outcomes. I must be able to appropriately resource every 
hospital and every patient encounter because every patient is 
important. A robust and capable direct care system is essential to the 
Army. I ask for continued support in resourcing our direct care system, 
as a system with global responsibility, and not fragmenting our system 
into a series of new Centers of Excellence.

                     CENTERS FOR VISION AND HEARING

    Question. General Schoomaker, Congress is awaiting the Department's 
detailed plans for establishing the Centers for Vision and Hearing. Can 
you tell me if you and your colleagues are approaching the staffing and 
resourcing of all of these Centers strategically or as independent 
centers?
    Answer. The Service Surgeons General do not have an active role in 
the development of the Department of Defense Centers of Excellence for 
Hearing and Vision. The approach to funding and staffing these Centers 
is being managed by the Office of the Assistant Secretary of Defense 
for Health Affairs.

                TRAUMATIC BRAIN INJURY/MALARIA RESEARCH

    Question. General Schoomaker, what are the specific mechanisms in 
place to ensure coordination at the planning, budgeting, and technical 
levels between the various Federal agencies (including NIH) on areas 
like Traumatic Brain Injury or Malaria research? Are there examples of 
DOD, VA, or NIH dollars being moved or redundant activities being 
terminated as a result of these coordination efforts?
    Answer. The U.S. Army medical research and development community 
coordinates closely with other services and agencies for both the 
President's Budget and the large Congressional Special Interest (CSI) 
funded programs to avoid redundancy. We include representation in our 
planning processes to identify various service or agency research 
portfolio lead, and gap areas across the spectrum of federally funded 
research. Through coordination with the other services and agencies we 
have not needed to terminate programs, but have instead been able to 
maximize our ability to direct research funds toward the gap areas. 
Traumatic Brain Injury (TBI) and Malaria are two of several extensively 
coordinated research areas.
    Planning and programming coordination is taking place through 
involvement of NIH and VA representatives on the expanded Joint 
Technical Coordinating Groups of the Armed Services Biomedical Research 
& Management (ASBREM) Committee, which are planning the investment for 
the future years Defense Health Program Research Development Test and 
Evaluation investment. At the technical levels, DOD, VA, and NIH 
scientists and research program managers actively participated in joint 
planning activities for major TBI and Psychological Health (PH) 
research programs, including the fiscal year 2007 Congressionally 
Directed Medical Research Program TBI/PH program and the fiscal year 
2008 Deployment Related Medical Research Program. These planning 
activities included joint program integration and review panels that 
were responsible for identifying research gaps, developing language for 
program announcements, and reviewing and recommending research 
proposals for funding. In fiscal year 2009, an integration panel with 
DOD, VA, and NIH members identified remaining TBI/PH knowledge gaps and 
developed a program announcement for research that addresses TBI/PH 
topics in response to a fiscal year 2009 CSI for TBI/PH research.
    The DOD is creating a collaborative network in the area of TBI/PH 
research. The DOD has partnered with Federal and non-Federal agencies 
to cosponsor several scientific conferences. The DOD recently partnered 
with NIH, VA, and the National Institute on Disability and 
Rehabilitation Research to sponsor a common data elements workshop, 
which will lead to the ability to compare results and variables across 
studies. The DOD is sponsoring a state-of-the-science meeting in May 
2009 to evaluate non-impact blast-induced mild TBI and identify for 
future research gaps in our current knowledge. Attendees have been 
invited from several Federal agencies (NIH, VA, and Environmental 
Protection Agency) as well as academia and industry. The DOD is 
planning a conference for November 2009 and will partner with several 
agencies to sponsor a TBI/PH research portfolio review to help identify 
gaps and assist with setting funding priorities among the various 
agencies. While new projects that address residual gaps in the science 
may overlap with ongoing research objectives, continuous 
interdepartmental and interagency portfolio analyses ensure that 
resources obligated through DOD funding mechanisms target residual and 
emerging gaps in TBI/PH research.
    The Defense Centers of Excellence (DCoE) for TBI and PH is 
establishing a strategic level TBI/PH research working group to further 
collaboration within the scientific community. This working group will 
help to prevent unnecessary redundancies and increase communications. 
The DCoE is collaborating with NIH on developing a research database, 
which may decrease the need to maintain several different databases.
    The U.S. Military Infectious Disease Research Program (MIDRP) is a 
joint Army/Navy program funded through the Army. To insure that 
research planning is coordinated between the major funders of malaria 
vaccine research, the U.S. Military Malaria Vaccine Program conducts an 
annual strategic review of its program by a Scientific Advisory Board. 
The membership of this board includes a broad range of internationally 
recognized experts including members from Vaccine Research Center at 
NIH; the Division of Intramural Research, National Institute of Allergy 
and Infectious Disease (NIAID), NIH; industry and academia, and the 
Bill and Melinda Gates supported Malaria Vaccine Initiative (MVI). 
Furthermore, a permanent member of the NIAID staff sits on the U.S. 
Army Medical Research and Materiel Command's Executive Advisory Panel. 
A broad strategic review was conducted recently by the Institute of 
Medicine (Battling Malaria Strengthening the U.S. Military Malaria 
Vaccine Program) and included a distinguished panel of both 
international experts and members from NIH, industry, and academia. The 
close review and coordination insures that there is no duplication of 
effort. The U.S. Army receives funding from the MVI. The U.S. Army 
malaria drug development program was also reviewed by the Institute of 
Medicine (Saving Lives, Buying Time, Economics of Malaria Drugs in an 
Age of Resistance). This program is coordinated and relies heavily on 
industry to bring anti-malarial drugs to the market. Essentially every 
U.S. Food and Drug Administration approved anti-malarial drug has been 
advanced, if not discovered by contribution from the U.S. Military 
Malaria Drug Program.

                               CAREGIVERS

    Question. General Schoomaker, while attention must be focused on 
the resilience training of our servicemembers and their families, I 
also suspect that caring for our wounded takes a considerable toll on 
our caregivers. What efforts are underway to address the well-being of 
our caregivers in order to retain these critical personnel?
    Answer. In 2006, the Army recognized that there was a need for 
educating and training its healthcare providers on the signs and 
symptoms of Compassion Fatigue and Burnout. It began deploying mobile 
training teams through the Soldier and Family Support Branch, U.S. Army 
Medical Department Center and School, to various Medical Treatment 
Facilities (MTFs) to train healthcare providers on the prevention and 
treatment of Compassion Fatigue and Burnout.
    In June 2008, the Army implemented a mandatory Provider Resiliency 
Training (PRT) program to educate and train all MTF personnel, to 
include support staff, on the signs and symptoms of Compassion Fatigue 
and Burnout. Below is a brief description of the phased implementation 
the PRT program:
  --Phase I of the program focuses on organizational and personal 
        assessment of Compassion Fatigue and Burnout using the 
        Professional Quality of Life Scale (ProQol) which measures 
        Compassion Fatigue, Burnout, and Compassion Satisfaction. Over 
        55,000 medical personnel completed the survey and were provided 
        a 30-minute introductory training session on provider 
        resiliency.
  --Phase II involves developing a resiliency-based self-care plan 
        through 2-hour classroom training with PRT trainers based at 
        each major MTF.
  --Phase III is an annual reassessment of an individual's stress 
        levels and adjustment to his/her self-care plan based on the 
        reassessment.
    The Institute of Surgical Research at the Brooke Army Medical 
Center also offers a pilot provider resiliency program that supplements 
the above PRT program. This program provides a Respite Center for its 
healthcare providers. Providers have the opportunity to receive 
educational classes on meditation, Alpha-Stim therapy (microcurrent 
electrical therapy for acute or chronic pain) and relaxation.

                         COMPETING INITIATIVES

    Question. General Schoomaker, do you have any competing initiatives 
to the new health system architecture development efforts, such as a 
different Unified User Interface, or a separate electronic health 
record?
    Answer. No. I am not aware of any competing initiatives. Army 
leadership understands the importance of a coherent, central enterprise 
architecture.

                      NEW ENTERPRISE ARCHITECTURE

    Question. General Schoomaker, how do you ensure Service specific 
needs are incorporated in the new enterprise architecture and how do 
you make sure they don't drive up costs throughout the system?
    Answer. There is an established governance process by which the 
Services provide feedback on health information technology matters. 
This process is being improved to better meet the needs of the 
enterprise. However, a governance process for the new enterprise 
architecture has not yet been established. Once the process is 
established, the Army looks forward to full and active participation.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

                        ENTERPRISE ARCHITECTURE

    Question. In your opinion, what additional steps need to be taken 
to ensure that electronic medical information is available to VA?
    Answer. We currently exchange an enormous amount of information 
with the VA, some of which are computable through the bidirectional 
health information exchange (BHIE). Clearly more can be done, and one 
recommendation we have is to accelerate the overhaul of our BHIE 
framework to a National Health Information Network (NHIN) compliant 
exchange. Not only would this conversion improve the data exchange 
between VA and DOD, but it would also allow us to exchange information 
with other Federal and civilian healthcare organizations. Given that 
over 60 percent of our 9.2 million DOD beneficiaries receive care from 
the civilian healthcare sector, we have a growing need to be able to 
exchange information. Furthermore, this is a great opportunity for DOD 
and VA to help execute President Obama's vision for electronic health 
records in the United States and to establish a national model for 
Health Information Exchange. Given the establishment of joint VA-DOD 
Federal healthcare facilities, we will need to migrate to an 
interoperable information system that is more closely coupled to meet 
healthcare, business, and benefits requirements.
    Question. How are each of your services obtaining medical records 
for servicemembers who receive contract care and how big of a problem 
is this for creating a complete record of care?
    Answer. Many facilities currently receive a fax or e-fax from the 
managed care contractor or from the facility that provided the care. 
Some facilities manually attach the records into our electronic health 
record, but others do not. This process varies from treatment facility 
to treatment facility. There is also no enterprise referral and 
authorization system that interfaces with our electronic health record, 
which is a problem. Our adoption of a National Health Information 
Network will help to address this problem. Further, as part of the 
managed care support contracts we should require TRICARE contractors to 
collect and send medical records electronically back to DOD. 
Furthermore, our central document management system (HAIMS) under 
development by TMA for military treatment facilities should allow 
TRICARE contractors to submit consult results to AHLTA. This capability 
would provide an automated method for tracking and incorporating 
consult results into AHLTA as the comprehensive electronic health 
record repository.

                            JAG PROSECUTIONS

    Question. JCS Chairman Mullen has said publically he's trying to 
break the stigma of psychological health in the active force, yet the 
JAGs are still prosecuting as a ``crime'' depressed people who attempt 
suicide. While the Surgeons General aren't responsible for the UCMJ, it 
seems to me that they might be concerned about JAG prosecutions of 
people who have severe mental distress while serving or after serving 
in combat.
    Generals, do you think that the continued criminal prosecution of 
troops who commit suicide is a problem for the military's efforts to 
break the stigma of psychological health?
    Answer. From a healthcare perspective as The Surgeon General of the 
Army, I acknowledge that charges of this sort are not helpful to a 
patient's mental state and probably increase the stress the Soldier is 
under. The Army and the DOD are working to deal honestly and directly 
with the behavioral health needs of our Soldiers and Families. This 
requires that our Soldiers are forthcoming about their own personal 
histories of behavioral health challenges and actively seek the care of 
available professional mental health providers both in garrison and on 
deployments when/if they encounter problems. We cannot help to remove 
the stigma associated with behavioral health and its treatment without 
this proactive approach. Such charges could be counterproductive to the 
creation of such an environment of trust and healing.
    As a Commander, I understand the necessity of good order and 
discipline. Commanders decide whether to refer cases for prosecution in 
the military justice system. In every case involving misconduct, the 
background and needs of the individual must be weighed along with the 
needs of the Army and the Nation it protects. Commanders and senior 
leaders weigh these competing needs in the context of often complex 
cases involving allegations of serious misconduct and equally serious 
potential psychiatric explanations for this behavior, which may or may 
not amount to a lack of competence or capacity or negate individual 
responsibility. All leaders work together in due process under the 
Uniform Code of Military Justice (UCMJ) where the advice and findings 
of medical professionals is certainly heard so we do the right thing 
for the Soldier and the Army. Finally, I assure you that each case is 
judged on its own merits by individual commanders after a thorough 
review of the facts, and after advice and counsel by a judge advocate.
    I must note that there is no offense under the UCMJ for attempted 
suicide. There is an offense for malingering, which can include self-
injury with intent to avoid duty or service, and another for self-
injury without intent to avoid service. I note that while these are 
technically options under the UCMJ, I am unaware of Soldiers being 
charged for attempted suicide and, as a result, do not believe it to be 
a problem as the question suggests.

          VISION CENTER OF EXCELLENCE AND EYE TRAUMA REGISTRY

    Question. The NDAA fiscal year 2008 Section 1623, required the 
establishment of joint DOD and VA Vision Center of Excellence and Eye 
Trauma Registry. Since then, I am not aware of any update on the 
budget, current and future staffing for fiscal year 2009, the costs of 
implementation of the information technology development of the 
registry, or any associated construction costs for placing the 
headquarters for the Vision Center of Excellence at the future site of 
the Walter Reed National Medical Center in Bethesda.
    What is the status on this effort?
    Answer. As the Army Surgeon General and Commanding General of the 
U.S. Army Medical Command, I do not have an active role in the 
establishment of the joint DOD and VA Vision Center of Excellence and 
Eye Trauma Registry. Responsibility for this organization and the 
registry belongs to the Office of the Assistant Secretary of Defense 
for Health Affairs.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

                               DEPLOYMENT

    Question. Over the past few years, new programs have been 
implemented to assess the health of soldiers after deployment. With the 
large group of Guardsmen alerted for deployment and who have been 
deployed, including many from my home state of Mississippi, I am 
concerned about the continuum of care upon their return into their 
communities. Are you confident that their medical needs are being met 
after returning from deployment?
    Answer. During the current conflict, the Department of Defense 
(DOD) developed new strategies to support Soldiers upon redeployment. 
As a result of these initiatives, I am extremely confident our Reserve 
Component (RC) Soldiers' medical and dental needs are being met.
    Prior to demobilization, each Soldier completes a Post Deployment 
Health Assessment (PDHA) using DD Form 2795 which includes a 
questionnaire completed by the Soldier and a face-to-face interview 
with a privileged healthcare provider. This is the best opportunity for 
the Soldier to document any health concerns related to their 
deployment. If significant concerns exist, the Soldier may remain on 
Active Duty for treatment. It may however be advantageous for some RC 
wounded warriors, at their discretion, to be released from active duty 
before the optimal medical benefit has been attained. This option does 
not release DOD from its moral obligation to render care for conditions 
sustained in the line of duty. Care for lesser concerns occurs when the 
Soldier returns home using the 180-day Transitional Assistance 
Management Program (TAMP) as a TRICARE benefit.
    Also at the demobilization station, each Soldier receives a dental 
exam as part of the Dental Demobilization Reset (DDR) program. 
Treatment is also now available to Soldiers at the demobilization 
station. However, treatment that would cause a delay in returning a 
Soldier home is deferred and provided at their home station using the 
Army Selected Reserve Dental Readiness System (ASDRS).
    Each Soldier must complete a Post Deployment Health Re-Assessment 
(PDHRA) using DD Form 2900 between 90-180 days after demobilization and 
complete another interview. This is a key opportunity for Soldiers to 
highlight issues they did not document at demobilization or surface 
after returning home. This documentation is critical to establish a 
line of duty connection, enabling continuing medical benefits through 
TRICARE and VA eligibility. Reserve Component Soldiers may also be 
voluntarily returned to active duty for medical treatment if we 
identify that treatment is warranted for a medical issue incurred while 
on active duty.
    All Soldiers undergo annual Periodic Health Assessments (PHA), 
where the Soldier completes an on-line questionnaire and is assessed by 
a provider using the latest recommendations of the U.S. Preventive 
Services Task Force.
    The PDHA, PDHRA, and PHA create a system of continuous visibility 
of the medical concerns of our Soldiers and provide regular 
opportunities for Soldiers to raise deployment-related concerns.
                                 ______
                                 
           Questions Submitted by Senator Christopher S. Bond

                        SERVICEMEMBERS TREATMENT

    Question. Thank you for your service and for taking the time to 
present to us your insights into our medical service programs. I know 
the U.S. Army takes the health of our warfighters personally, and it is 
clear that our active and reserve medical practitioners are the best in 
the world.
    Johns Hopkins Medical Center defines osteoarthritis as a type of 
arthritis characterized by pain and stiffness in the joints, such as 
those in the hands, hips, knees, spine or feet, due to breakdown of 
cartilage; the gradual breakdown of cartilage that occurs with age and 
is due to stress on a joint.
    Many of our active, reserve, and former servicemembers are 
currently struggling with cases of severe ligament and joint damage 
that will later manifest themselves into long term cases of 
osteoarthritis.
    Our service men and women bear the largest physical burden during 
combat. I am concerned with the large amount of weight our warfighters 
are forced to carry across considerable distances and unforgiving 
terrain. Particularly, I am concerned with the physical toll that war 
exacts from our men and women, most notably in the forms of 
osteoarthritis that arise when injuries go untreated during combat.
    Is the U.S. Army doing everything it can to properly treat our 
servicemembers' injured limbs and joints while they are simultaneously 
fighting in austere environments in order to lessen the chance that 
these particular injuries will manifest themselves into debilitating 
cases of osteoarthritis later in life?
    Answer. This challenge of equipping Soldiers on the battlefield 
with the right technology and level of protection--without overloading 
them, is a difficult one. The U.S. Army Research Institute of 
Environmental Medicine (USARIEM) has an extensive research program 
aimed at documenting the physiological demands of war fighting, 
identifying biomedical solutions that facilitate meeting those demands, 
and optimizing the health and performance of Warriors during 
operational missions and garrison training.
    Arthritis is a degeneration of bone and cartilage that results in 
progressive wearing down of joint surfaces. Arthritis in a non-
rheumatoid patient under 50 is almost uniformly due to post-traumatic 
conditions. Treatment of injuries leading to arthritis in young people 
has to do with prevention as well as acute and chronic treatment to 
mitigate progression. In 2008, U.S. Army orthopedic surgeons performed 
over 5,000 knee arthroscopies on Soldiers. These joint procedures do 
not necessarily delay the progression of arthritis. In addition, joint 
preserving techniques such as cartilage implants and alignment 
procedures like osteotomies or knee replacement procedures can 
substantially prolong the useful and functional years of a Soldier's 
joints. Optimal outcomes from these procedures require coordination 
between orthopedic surgeons and physical therapists. The bottom line is 
we do not know how treatment interventions impact long term outcomes.
    Currently, a team from the University of Pittsburgh is conducting 
research on the injury prevention and performance enhancement practices 
used by 101st Airborne (Air Assault) Soldiers at Fort Campbell, 
Kentucky. The comprehensive assessment initially evaluated Soldiers' 
nutrition, anaerobic/aerobic capacity, strength, body composition, 
balance/agility, etc. Based upon those findings, new training programs 
were developed. Soldiers participated in an 8-week physical training 
course, and then a reassessment was conducted. Initial reports are 
positive and show a decrease in injury rates and an improvement in 
overall unit performance.
    We know that prevention is a key component to mitigate the 
progression of arthritis and Soldiers who train and condition properly 
are much less likely to sustain an injury during or after deployment. 
To that end, the Army is doing several things to improve the medical 
readiness of the force. First, the Army is in the process of changing 
the physical fitness doctrine and training programs to better prepare 
Soldiers for the demands of military operations. ``Physical Readiness 
Training'' (PRT) is the emerging U.S. Army physical training doctrine 
designed by the U.S. Army Physical Fitness School to improve Soldiers' 
physical capability for military operations. PRT follows the exercise 
principles of progressive overload, regularity, specificity, precision, 
variety, and balance. The Army plans to begin implementing the new PRT 
doctrine across the Force over the next year.
    In the meantime, units across the Army have physical therapists 
assigned to special operations units, Initial Entry Training, and 
Brigade Combat Teams that use a sports medicine approach to identify, 
treat, and rehabilitate musculoskeletal injuries expeditiously--which 
is critical in a wartime environment as Soldiers are able to stay 
healthy and ``in the fight.'' Treatments for Soldiers with 
musculoskeletal injuries include joint manipulation, specific 
therapeutic exercises, soft tissue mobilization as well as a variety of 
modalities to mitigate pain, promote healing, and prevent reoccurrence.
    Programs focusing on injury prevention and performance enhancement 
emphasize core strengthening, aerobic endurance, muscular strength and 
power, muscular endurance (anaerobic endurance), and movement 
proficiency (incorporates balance, flexibility, coordination, speed and 
agility) to better prepare Soldiers to physically withstand the rigors 
of combat.
    The U.S. Military Health System is doing a tremendous amount to 
preserve the active function of Soldiers with limb injuries but more 
research efforts on clinical outcomes is necessary to determine if what 
we are doing makes a difference. By making sure Soldiers receive early 
identification and treatment of their musculoskeletal injuries and 
improving Soldiers' physical strength and conditioning, we also improve 
the overall medical readiness of our Force.
                                 ______
                                 
             Questions Submitted by Senator Mitch McConnell

                            SOLDIER SUICIDES

    Question. LTG Schoomaker, Congress has established a national 
suicide hotline for returning troops, as well as increased funding for 
mental health for active military personnel. However, there remains a 
high number of soldier suicides. What preventative measures is DOD 
taking to address this problem? What, if any, legislative action would 
DOD need Congress to take to expand suicide awareness and education on 
posts?
    Answer. The Army has been vigorously pursuing suicide prevention 
and intervention efforts. Nevertheless the number of suicides continues 
to rise, which is an issue of great concern to us.
    In March 2009, the Vice Chief of Staff of the Army established a 
new Suicide Prevention Task Force to integrate all of the efforts 
across the Army. A Suicide Prevention General Officer Steering 
Committee (GOSC) was previously established in March 2008. The GOSC's 
efforts are ongoing, with a focus on targeting the root causes of 
suicide, while engaging all levels of the chain-of-command.
    From February 15, 2009 to March 15, 2009, the Army conducted a 
total Army ``stand-down'' to ensure that all Soldiers learned not only 
the risk factors of suicidal Soldiers, but how to intervene if they are 
concerned about their buddies. The ``Beyond the Front'' interactive 
video is the core training for this effort. It was followed by chain 
teaching which focuses on a video ``Shoulder to Shoulder; No Soldier 
Stands Alone'' and vignettes drawn from real cases. The Army continues 
to use the ACE ``Ask, Care, Escort'' tip cards and strategy.
    The Army established the Suicide Analysis Cell at the Center for 
Health Promotion and Preventive Medicine (CHPPM) in July 2008. This is 
a suicide prevention analysis and reporting cell that has 
epidemiological consultation capabilities. The Cell gathers suicidal 
behavior data from numerous sources, including the Army Suicide Event 
Report (ASER), The U.S. Army Criminal Investigation Division Reports, 
AR 15-6 investigations, and medical and personnel records.
    The Army Suicide Prevention Plan's overarching strategies include: 
(1) raising Soldier and Leader awareness of the signs and symptoms of 
suicide and improving intervention skills, (2) providing actionable 
intelligence to Leaders regarding suicides and attempted suicides; (3) 
improving Soldiers' access to comprehensive care; (4) reducing the 
stigma associated with seeking mental healthcare; and (5) improving 
Soldiers' and their Families' life skills. In the fall of 2008, the 
Army Science Board studied the issue of suicides in the Army. While 
their report has not been officially released, it reiterated the Army's 
strategies and the need for a comprehensive multi-disciplinary 
approach. It did not find easy, simple solutions to the problem.
    The Army has also developed a Memorandum of Agreement (MOA) with 
the National Institutes of Mental Health (NIMH), which was signed in 
the fall of 2008. This is an ongoing, 5-year research effort to better 
understand the root causes of suicide and develop better prevention 
efforts. This NIMH effort is being coordinated with the CHPPM Suicide 
Analysis Cell, as well as with suicide prevention efforts from the 
Walter Reed Army Institute of Research (WRAIR).
    These extensive new efforts build upon: (1) development and 
deployment of numerous updated training and education efforts, 
including Battlemind and the Chain Teach Program on mTBI/PTSD; (2) 
widespread training of Soldiers by Chaplains and behavioral health 
providers; (3) robust combat stress control efforts and Chaplain 
presence in theater; (4) hiring and recruiting additional behavioral 
health providers; (5) ``Strong Bonds'', a relationship-building program 
developed by the Chaplains; (6) surveillance of all completed suicides 
and serious suicide attempts via the Army Suicide Event Report; and (7) 
suicide risk assessment screening of all Soldiers who enter the Warrior 
Transition Units (WTUs).
    We are also partnering with the Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury to work on identifying 
best practices for the identification and intervention of mental health 
issues that include suicide, PTSD, TBI, and depression. Both the Army 
and the DOD are studying the addition of tools which will further query 
Soldiers for symptoms of suicide and depression. All suicide screening 
tools must be evaluated carefully for sensitivity, specificity, and 
positive and negative predictive values.
    An enhanced and integrated public health approach is needed. We 
must continue to emphasize Leadership involvement, reducing stigma, 
training and education, access to mental health care, and a 
multidisciplinary community approach to suicide prevention.
    We must continue to: (1) expand the capacity for behavioral health 
treatment throughout the system; (2) improve continuity of care between 
different helping agencies and providers; (3) improve training of all 
medical personnel and Chaplains in identification and mitigation of 
risky behaviors; and (4) continue a multi-pronged approach to decrease 
stigma and encourage help-seeking behavior.
    Awareness and education are needed across the nation, as well as on 
military installations. I am currently unaware of any legislative 
action required to expand suicide awareness and education on military 
posts.

            IRELAND ARMY HOSPITAL/BLANCHFIELD ARMY HOSPITAL

    Question. LTG Schoomaker, what are the authorized manning levels 
for nurses and medical personnel at the Ireland Army Hospital at Fort 
Knox and Blanchfield Army Hospital at Fort Campbell? Is there a minimum 
threshold that must be met under Army rules, regulations or custom? Is 
that threshold being met at Ireland and Blanchfield Hospitals and is it 
sufficient?
    Answer. The Army Medical Command is meeting minimum staffing 
requirements at both Blanchfield and Ireland Army Hospitals. Across the 
command we face staffing challenges due to medical personnel deploying 
in support of contingency operations, lack of some specialty provider 
backfills from the Reserve Component, and difficulty with recruiting 
civilian and/or contract providers in and around some military 
communities. Despite these obstacles, we are able to staff our 
treatment facilities and deliver high-quality, evidence-based care to 
our deserving beneficiaries.
    The authorized manning levels for nurses and medical personnel at 
the Ireland Army Hospital at Fort Knox and Blanchfield Army Hospital at 
Fort Campbell are as follows:
Ireland Army Hospital
    Nurse Authorizations: 57 Military, 87 Civilian equals 144 total
    Medical Authorizations: 37 Military, 16 Civilian equals 53 total
    Other Medical ancillary personnel that clinically support patients 
equals 406
    Grand total of authorized clinical nurses, physicians and other 
ancillary personnel equals 603
Blanchfield Army Hospital
    Nurse Authorizations: 83 Military, 195 Civilian equals 278 total
    Medical Authorizations: 84 Military, 20 Civilian equals 104 total
    Other Medical ancillary personnel that clinically support patients 
equals 635
    Grand total of authorized clinical nurses, physicians and other 
ancillary personnel equals 927.
    Authorization numbers above do not include counts of non-clinically 
focused personnel, in such purely administrative mission areas such as 
Logistics, Medical Library, Quality Mgt, File Clerks/Transcription, 
Environmental Services (Housekeeping/Linen Mgt/Facilities), Patient 
Admin Medical Records, Patient Affairs, Uniform Business Office, Third 
Party Collections, and Troop Command.
    Finally, clinical staffing levels for a hospital are a function of 
the reliant population to be supported and/or workload demand. Where 
work centers are open 24/7, there are always minimum staffing 
requirements independent of workload. All direct patient care units 
requiring 24/7 staffing at Fort Knox and Fort Campbell have sufficient 
workload and staffing levels that exceed required manning thresholds 
and minimums.

                                PTSD/TBI

    Question. LTG Schoomaker, what are the typical steps taken for 
soldiers who may have post-traumatic stress disorder (PTSD) and 
traumatic brain injuries (TBI) to ensure they get the proper care? Are 
there any further legislative steps that Congress could take to improve 
screening and the delivery of care to soldiers with PTSD and TBI?
    Answer. Army Leadership is taking aggressive, far-reaching steps to 
ensure an array of behavioral health services are available to Soldiers 
and their Families to help those dealing with PTSD and other 
psychological effects of war.
    The following list of continually evolving programs and initiatives 
are examples of the integrated and synchronized web of behavioral 
health services in place to help Soldiers and their Families heal from 
the effects of multiple deployments and high operational stress:
  --The Post Deployment Health Assessment (PDHA), originally developed 
        in 1998, was revised and updated in 2003. All Soldiers receive 
        the PDHA upon re-deployment, usually in the Theater of 
        Operations shortly prior to departure.
  --In the fall of 2003, the first Mental Health Assessment Team (MHAT) 
        deployed into Theater. Never before had the mental health of 
        combatants been studied in a systematic manner during conflict. 
        Four subsequent MHATs in 2004, 2005, 2006, and 2007 continue to 
        build upon the success of the original and further influence 
        our policies and procedures not only in theater, but before and 
        after deployment as well. Based on MHAT recommendations, the 
        Army has improved the distribution of behavioral health 
        providers and expertise throughout the theater. Access to care 
        and quality of care have improved as a result. An MHAT is 
        currently in Iraq, and will be deploying to Afghanistan within 
        the next 3 months.
  --In 2004, researchers at the Walter Reed Army Institute of Research 
        (WRAIR) published initial results of the groundbreaking ``Land 
        Combat Study'' which has provided insights related to care and 
        treatment of Soldiers upon return from combat and led to 
        development of the Post Deployment Health Reassessment (PDHRA).
  --In 2005, the Army rolled out the PDHRA. The PDHRA provides Soldiers 
        the opportunity to identify any new physical or behavioral 
        health concerns they may be experiencing that may not have been 
        present immediately after their redeployment. This assessment 
        includes an interview with a healthcare provider and has been a 
        very effective new program for identifying Soldiers who are 
        experiencing some of the symptoms of stress-related disorders 
        and getting them the care they need before their symptoms 
        manifest as more serious problems. We continue to review the 
        effectiveness of the PDHRA and have added and edited questions 
        as needed.
  --In 2006 the Army Medical Command (MEDCOM) piloted a program at Fort 
        Bragg intended to reduce the stigma associated with seeking 
        mental healthcare. The Respect-Mil pilot program integrates 
        behavioral healthcare into the primary care setting, providing 
        education, screening tools, and treatment guidelines to primary 
        care providers. It has been so successful that medical 
        personnel have implemented this program at 15 sites across the 
        Army. Another 17 sites should implement it in 2009.
  --Also in 2006, the Army incorporated into the Deployment Cycle 
        Support program a new training program developed at WRAIR 
        called ``BATTLEMIND'' Training. Prior to this war, there were 
        no empirically validated training strategies to mitigate 
        combat-related mental health problems. This post-deployment 
        training is being evaluated by MEDCOM personnel using 
        scientifically rigorous methods, with good initial results. It 
        is a strengths-based approach highlighting the skills that 
        helped Soldiers survive in combat instead of focusing on the 
        negative effects of combat ( www.battlemind.org).
  --Two DVD/CDs that deal with Family deployment issues are now 
        available: an animated video program for 6 to 11 year olds, 
        called ``Mr. Poe and Friends,'' and a teen interview for 12 to 
        19 year olds, ``Military Youth Coping with Separation: When 
        Family Members Deploy.'' Viewing the interactive video programs 
        with children can help decrease some of the negative outcomes 
        of family separation. Parents, guardians and community support 
        providers will learn right along with the children by viewing 
        the video and discussing the questions and issues provided in 
        the facilitator's guides with the children during and/or after 
        the program. This reintegration family tool kit provides a 
        simple, direct way to help communities reduce tension and 
        anxiety, use mental health resources more appropriately, and 
        promote healthy coping mechanisms for the entire deployment 
        cycle that will help Families readjust more quickly on 
        redeployment.
  --In mid-July 2007 the Army launched a PTSD and mTBI Chain Teaching 
        Program that reached more than one million Soldiers, a measure 
        that will help ensure early intervention. The objective of the 
        chain teaching package was to educate all Soldiers and Leaders 
        on PTSD and TBI so they can help recognize, prevent and treat 
        these debilitative health issues.
  --In 2008 the Department of Defense revised Question #21, the 
        questionnaire for national security positions regarding mental 
        and emotional health. The revised question now excludes non-
        court ordered counseling related to marital, family, or grief 
        issues, unless related to violence by members; and counseling 
        for adjustments from service in a military combat environment. 
        Seeking professional care for these mental health issues should 
        not be perceived to jeopardize an individual's professional 
        career or security clearance. On the contrary, failure to seek 
        care actually increases the likelihood that psychological 
        distress could escalate to a more serious mental condition, 
        which could preclude an individual from performing sensitive 
        duties.
  --In 2008, the Army began piloting Warrior Adventure Quest (WAQ). WAQ 
        combines existing high adventure, extreme sports and outdoor 
        recreation activities (i.e., rock climbing, mountain biking, 
        paintball, scuba, ropes courses, skiing, and others) with a 
        Leader-led after action debriefing (L-LAAD). The L-LAAD is a 
        Leader decompression tool that addresses the potential impact 
        of executing military operations and enhances cohesion and 
        bonding among and within small units. L-LAAD integrates WAQ and 
        bridges operational occurrences to assist Soldiers transition 
        their operational experiences into a ``new normal'', enhancing 
        military readiness, reintegration, and adjustment to garrison 
        or ``home'' life.
  --Beginning February 15, 2009, the Army started a 30 day ``stand-
        down'' to ensure that all Soldiers learned not only the risk 
        factors of suicidal Soldiers, but how to intervene if they are 
        concerned about their buddies. The ``Beyond the Front'' 
        interactive video is the core training for this effort. It will 
        be followed by a chain teach which focuses on a video 
        ``Shoulder to Shoulder; No Soldier Stands Alone'' and vignettes 
        drawn from real cases.
    Presently, we are partnering with the Defense Centers of Excellence 
for Psychological Health and Traumatic Brain Injury and working to 
identify best practices for the identification and intervention for 
mental health issues that include suicide, PTSD, TBI, and depression. 
We are also directing special attention to the processes and procedures 
by which we transfer care for affected Soldiers as they redeploy or 
move from one installation to another or one treatment facility to 
another.
    I am not aware of any legal or regulatory obstacles that impede our 
efforts to improve screening and the delivery of care to Soldiers with 
PTSD or TBI.

            IRELAND ARMY HOSPITAL/BLANCHFIELD ARMY HOSPTIAL

    Question. LTG Schoomaker, do the Ireland and Blanchfield hospitals 
refer soldiers to regional hospitals that specialize in brain and 
spinal cord injury rehabilitation? What formal partnerships are 
established between post hospitals and regional hospitals in Kentucky 
to ensure soldiers with these conditions are given the best care? If 
there are no formal partnerships, what is the process for establishing 
such an affiliation?
    Answer. Yes, both Blanchfield Army Community Hospital and Ireland 
Army Community Hospital refer Soldiers to specialized hospitals for 
brain and spinal cord injury rehabilitation. Both hospitals use the 
Department of Veterans Affairs Polytrauma Centers and other Veterans 
Affairs medical centers within the region, such as the DVA Medical 
Center in Memphis, Tennessee.
    At Blanchfield Army Community Hospital, we use two facilities in 
Nashville, Skyline and Vanderbilt University Medical Center, for 
beneficiaries with brain and spinal cord injuries. These facilities are 
in the TRICARE Managed Care Support Contracts network.
    At Ireland Army Community Hospital, Soldiers with brain and spinal 
cord injuries are regularly referred to regional resources such as 
Frazier Rehabilitative Services, located in Louisville, Kentucky for 
comprehensive TBI services as well as to the program at the University 
of Kentucky at Lexington.
    The criteria for selection of the appropriate facility includes the 
Soldier's unique needs, the ability of the brain and spinal cord injury 
program to accommodate those needs and related considerations such as 
the Soldier's hometown and location of family.
    The primary mechanism for establishing relationships with regional 
hospitals is through the Managed Care Network established by our 
TRICARE Region business partner. The TRICARE Managed Care Support 
Contractor contacts area facilities to establish the relationship. When 
Ireland or Blanchfield hospital identifies a facility that is not part 
of the network, we notify TRICARE with a request that the facility be 
contacted and considered for credentialing to network status.

                           DOD/VA FACILITIES

    Question. LTG Schoomaker, per the Wounded Warrior legislation 
enacted in 2007 and the Dole-Shalala Commission's recommendations that 
were reported in 2007, improvements were to be made to the coordination 
between DOD and VA facilities to better care for our injured troops who 
are transitioning between the two healthcare systems. What steps have 
already taken place to improve coordination between the two 
Departments? What steps remain? Are these provisions sufficient to 
provide a seamless transition for wounded warriors from the DOD to the 
VA system? Does DOD need further legislation to improve matters? If so, 
what?
    Answer. On October 12, 2007, the Vice Chief of Staff of the Army 
(VCSA), General Cody requested assistance from the Acting Secretary, 
Department of Veterans Affairs (VA) to reduce transition obstacles 
between the DOD managed care system and the VA system of care. The VCSA 
specifically asked the VA Secretary to support three initiatives to 
ease servicemember transition. The three initiatives include: co-
locating one Veterans Benefits Administration (VBA) Counselor with the 
Army Nurse Case Managers at each Warrior Transition Unit (WTU), provide 
Social Workers (MSW) at seven Army Installations which include, Forts 
Drum, Stewart, Campbell, Benning, Knox, Riley, and Fort Bliss, and 
provide VBA Counselors at all Soldier Family Assistance Centers 
(SFACs).
    As of February 2009, there are 57 VA Regional Offices and 10 
Satellite VA Offices established at Military Treatment Facilities to 
provide VA expert counsel on Veterans Benefit Administration (VBA) 
compensation and entitlement benefits programs as well as clinical care 
offered to Warriors in Transition (WTs) and their Families by the 
Veterans Health Administration (VHA). The VBA has representatives at 
all 35 WTUs. For those WTs that are assigned to Community Based WTU's 
(CBWTUs), the VA has contracted service providers to care for their 
administrative and clinical needs. The DVA does not intend to place VA 
Liaisons in overseas assignments. However, the VA has numerous outreach 
programs such as www.va.gov, direct mail pieces, booklets, pamphlets, 
videos, and broadcast shows on AFN (Armed Forces Network) to assist 
Service and Family Members at remote locations. Soldiers and family 
members may also contact the VA via telephone worldwide at 800-827-
1000.
    The Army has also assigned liaison officers to the four VA poly-
trauma centers (Richmond, Virginia; Tampa, Florida; Palo Alto, 
California; and Minneapolis, Minnesota). Furthermore, we have assigned 
60 advocates from the Army Wounded Warrior Program to 51 VA medical 
centers to assist Soldiers and Veterans receiving care.
                                 ______
                                 
          Questions Submitted to Vice Admiral Adam M. Robinson
            Questions Submitted by Chairman Daniel K. Inouye

    Question. Admiral Robinson, North Chicago Veterans Center is 
scheduled to merge with the Naval Health Clinic Great Lakes on October 
1, 2010. Aside from technology requirements, there are several 
regulatory and legislative challenges that remain unresolved. Could you 
please describe each of the outstanding issues, the difference between 
the VA and the Department's positions and a timeline for their 
resolution?
    Answer. Legislation addressing the four issues was introduced as an 
amendment to the National Defense Authorization Act (NDAA) 2009 but was 
not included. H.R. 1267 was introduced by Congresswoman Bean (D-IL) and 
Congressman Kirk (R-IL) to the House of Representatives on March 3, 
2009. H.R. 1267 was based on an old legislative version and does not 
contain the Department of Navy and Veteran's Affairs agreed upon 
language. Senators Durbin (D-IL) and Akaka (D-HI) are currently working 
on introducing the legislation on the Senate side and this version 
contains the agreed upon language. Strategies to reconcile language 
differences between the two versions are underway. There is 
anticipation that the legislative package could be passed within 30-40 
days as part of a Defense supplemental bill.
    The legislation will address four challenges to Great Lakes/North 
Chicago integration:
  --Designation of the Federal Health Care Center (FHCC) as a Uniformed 
        Treatment Facility.--Legislative relief is required for the 
        designation of the FHCC as a Uniformed Treatment Facility 
        (UTF). This will determine the cost of available care to DOD 
        beneficiaries. If UTF designation is not achieved, the FHCC 
        will require cost shares for retired TRICARE beneficiaries 
        using the VA portion of the FHCC. Beneficiaries over age 65 
        enrolled in TRICARE for Life will not be eligible to use the VA 
        portion of the FHCC without significant cost shares. VA and DOD 
        concur on the need for UTF designation.
  --Permission to transfer all DOD civilian employees into the VA 
        personnel system.--Legislative relief is required to establish 
        a single integrated personnel system that transfers DOD 
        civilian employees into the VA personnel system. This will 
        streamline management functions and reduces the disparity in 
        pay and benefits for individuals working side by side. NHCGL 
        civilian personnel are appointed under Title 5 authority while 
        VA employees are appointed under Title 38. Approximately 450 
        civilian NHCGL employees will be impacted by this transfer. 
        This includes those working in the Recruit and Student Medical 
        and Dental Clinics on DOD property. The proposed Senate 
        legislation contains language designed to protect DOD civilians 
        transitioning into the VA personnel system by eliminating 
        probationary periods for those that have already completed this 
        as a DOD employee. Additionally, staff will retain at least the 
        same pay and seniority (tenure) as they have in the DOD system.
      Long-term success depends on identifying and retaining adequate 
        numbers of leadership positions for uniformed staff at the 
        FHCC. An organizational leadership structure addressing this 
        requirement is in draft form.
      Both DOD and VA support the Transfer of Personnel with the agreed 
        upon language as contained in the bill sponsored by Senator 
        Durbin. The National AFGE does not concur, as they do not 
        support the Title 38 appeal process with the loss of Merit 
        Systems Protection Board appeal rights currently afforded for 
        the Hybrid Title 38 and Title 5 employees.
  --Create a funding mechanism to provide a single unified funding 
        stream to the FHCC.--The VA and DOD have separate 
        appropriations for meeting the healthcare missions of each 
        agency. Each have multiple funding streams that support the 
        various cost components, that when combined, currently comprise 
        the totality of funding required to meet the healthcare mission 
        assigned to each facility. The intent at the FHCC is to have a 
        single budget at the FHCC for the management of all medical and 
        dental care for all beneficiaries. To create a single budget, 
        the proposed solution is to extend Joint Incentive Fund (JIF) 
        authority with the intent to use this authority for dual agency 
        funding of the FHCC. The VA fully supports this but DOD has 
        expressed concern about using this mechanism to fund the FHCC. 
        A JIF-like alternative is being considered by DOD and VA.
  --Create a legislative mechanism to allow DOD to transfer the Navy 
        Ambulatory Care Clinic, parking structure, support facilities, 
        and related personal property and medical equipment to the VA 
        if desired at a later date.--Both VA and DOD agree with the 
        need to establish a transfer mechanism. DOD plans to retain 
        ownership of the new Ambulatory Care Clinic initially. The 
        transfer of personal property is dependent on the ability of VA 
        systems to effectively track the property and provide 
        accountable data back to DOD. Logistics staff on Navy and VA 
        sides are analyzing this.
    NDAA 2009 Section 706 requires nine specific areas be addressed in 
a written agreement for a Combined Federal Medical Facility. An 
Executive Sharing Agreement (ESA) is currently being written to address 
all nine areas. Target date for SECDEF/SECVA signature on this document 
is November 2009. The framework of this document is dependent on the 
legislative issues as indicated above.
    Question. Admiral Robinson, what are the specific mechanisms in 
place to ensure coordination at the planning, budgeting, and technical 
levels between the various federal agencies (including NIH) on areas 
like Traumatic Brain Injury or Malaria research? Are there examples of 
DOD, VA, or NIH dollars being moved or redundant activities being 
terminated as a result of these coordination efforts?
    Answer. In regards to malaria research, the Navy has a long history 
of recognizing the importance of coordination in those areas mentioned 
by the Senator. For the past 2 years, the Navy and the Army have run a 
joint program, the U.S. Military Malaria Vaccine Program. Leaders of 
this program are members of the Federal Malaria Vaccine Coordination 
Committee (FMVCC) chaired by USAID which provides a forum for 
interagency collaboration and coordination in this important area of 
research so that resources are optimized and overlap minimized.
    The Navy collaborates with USAID, NIAID, CDC, and indirectly with 
NIST on several vaccine projects including recombinant protein-based 
vaccines, adenovirus-vectored vaccines, an attenuated whole sporozoite 
vaccine and the development of field testing sites in Africa and 
elsewhere.
    The military uniquely targets its funding for developing vaccines 
for deployed military populations and civilian travelers where the 
required level and duration of protection required is much higher, and 
is currently significantly underfunded for the mission. Currently, the 
vaccine products in development by all federal agencies except DOD are 
aimed at the vulnerable populations of children and pregnant women in 
malaria endemic countries. The primary non-government funding source, 
the Bill and Melinda Gates Foundation, likewise supports this 
humanitarian mission.
    For TBI, Navy medicine works closely with the Defense Center of 
Excellence (DCoE) for Psychological Health and Traumatic Brain Injury 
to coordinate TBI programs. BUMED also collaborates with NIH, CDC, the 
Uniformed Services University, the Army and Air Force, and the VA for 
TBI initiatives. The DCoE is planning to fund a central database at NIH 
which will also include Navy TBI information, for example. In addition, 
Navy medicine is responsible for tracking/surveillance for TBI and is 
developing and testing an automated neurocognitive test instrument, 
called Braincheckers. The Naval Health Research Center is conducting 
TBI research projects related to surveillance and force protection. The 
Naval Medical Research Center recently completed a study on the effect 
of acute blast exposure on cognition in Marine Corps Breachers, an 
effort funded jointly by the Defense Advanced Research Projects Agency 
and the Office of Naval Research. The BUMED consultant for TBI programs 
meets regularly with counterparts in the other services, the DCoE, NIH, 
CDC, and VA to discuss new collaborative efforts.
    Question. Admiral Robinson, while attention must be focused on the 
resilience training of our service members and their families, I also 
suspect that caring for our wounded takes a considerable toll on our 
care givers. What efforts are underway to address the well-being of our 
caregivers in order to retain these critical personnel?
    Answer. Navy Medicine is dedicated to doing what is right for our 
active duty and retired Sailors, Marines and their families; and, we 
are just as committed to doing what is right for our caregivers. 
Occupational stress and compassion fatigue can undermine professional 
and personal performance, impact job satisfaction, and result in poor 
retention. The Navy Medicine Caregiver Occupational Stress Control 
(OSC) Program, sometimes called ``Care for the Caregiver'', comprises 
several strategies designed to enhance individual resilience, 
strengthen unit cohesion, and support command level assessment of the 
work environments of caregivers. A main strategy of the Navy Medicine 
Caregiver OSC program is to provide Navy Medicine personnel 
multidisciplinary occupational stress training that matches the 
treatment facility OPTEMPO and creating trained intervention teams, 
with a mix of officer and enlisted, at our major treatment facilities. 
This strategy will provide staff with skills and knowledge about the 
stress continuum model, stress first-aid, buddy care assessment and 
intervention, self-care/compassion fatigue skills, work-environment 
assessment, and education outreach. The foundation of dedication, 
knowledge, skills, and passion that results in Navy Medicine's superior 
quality of care is also the foundation of caring for our caregivers.
Program Elements:
    ``Rule Number Two'' Lecture Series.--Started in January 2008 to 
educate Navy Medicine Leaders about the operational and occupation 
stress on caregivers and leadership strategies to mitigate that stress.
    Caregiver Occupational Stress Training Teams.--Completed training 
of 90 team members for 15 medical treatment facilities in January 2009. 
Expanded MTF team training started in March 2009 designed to have 20 or 
more stress and coping peer trainers at each MTF.
    All Hands Awareness Training.--Medical treatment facility (MTF) 
focused training to initiate all hands awareness and core peer support 
skills started in February 2009.
    Caregiver OSC Training Resources.--Caregiver OSC video vignettes 
and Corpsmen focused graphic training novel in production.
    Caregiver Stress Assessment.--Navy Medicine wide assessment of 
caregiver resilience and stress.
    Question. Admiral Robinson, the Department and the VA are working 
on creating an interoperable medical health record that will allow for 
a seamless transition for our service members and also provide 
continuity of care at joint DOD/VA facilities like the future James A 
Lovell Federal Health Care Center. I understand that premature steps 
have been taken to procure systems for the Lovell Center that would 
repeat the mistakes of focusing on site specific fixes rather than our 
joint enterprise as a whole. Since Navy is an equal partner in this 
endeavor with the VA, could you please detail us on the current 
situation, the path forward, and how it integrates into the overarching 
medical enterprise architecture?
    Answer. The electronic medical record is an area where there is 
pressure to move to one system or the other. Neither AHLTA nor VISTA 
can sustain the requirements of both DOD and VA. The IM/IT solution 
being crafted must sustain missions of both organizations. The FHCC 
establishment date of October 1, 2010 creates mounting time pressures. 
The time passage of pending Congressional legislation is crucial to 
implementing the full vision of this project. Because Great Lakes is 
being touted as the model for future fully integrated federal 
healthcare, there is enormous self-imposed pressure to do it right. 
System solutions (financial reconciliation, electronic medical record, 
information management, etc.) cannot be local fixes, but must be 
crafted in a manner that lends to exportability throughout the 
enterprise.
    Question. Admiral Robinson, how do you ensure Service specific 
needs are incorporated in the new enterprise architecture and how do 
you make sure they don't drive up costs throughout the system?
    Answer. The Navy will engage with the central program offices 
developing the solutions to make sure that they meet the needs of the 
Navy as well as being in line with the direction of the TriCare 
Management Activity. If the needs are a part of the overarching 
architecture then that should not drive up the cost any more than would 
occur as both agencies are charged with more and more sharing of 
patient data between DOD and VA. The Navy was identified as the first 
service branch to complete a single site integration with a VA facility 
but Army and Air Force are in the queue with four proposed integration 
sites.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

    Question. JCS Chairman Mullen has said publically he's trying to 
break the stigma of psychological health in the active force, yet the 
JAGs are still prosecuting as a ``crime'' depressed people who attempt 
suicide. While the Surgeons General aren't responsible for the UCMJ, it 
seems to me that they might be concerned about JAG prosecutions of 
people who have severe mental distress while serving or after serving 
in combat. Do you think that the continued criminal prosecution of 
troops who commit suicide is a problem for the military's efforts to 
break the stigma of psychological health?
    Answer. The decision whether to court-martial a sailor and, if so, 
for what offense, is within the sole discretion of the cognizant 
commander, usually with the benefit of input from a judge advocate. 
However, our research covering the last 5 years does not reveal any 
instance of a Sailor being charged with a criminal offense relating to 
a failed suicide attempt.
    Even in those cases where a Sailor is determined to be free of any 
serious mental defect, the Uniform Code of Military Justice does not 
criminalize suicide or attempted suicide. A charge does exist to 
address malingering (feigning a debilitating condition or intentionally 
inflicting self-injury specifically to avoid duty). Similarly, a charge 
exists to address self-injury in those cases where it is prejudicial to 
good order and discipline. Either of those charges, in certain 
circumstances, could conceivably support a prosecution arising out of a 
failed suicide attempt where a commander believes that the attempt was 
actually an attempt to avoid duty or was otherwise prejudicial to good 
order and discipline.
    In cases where a Sailor's mental health is in question, the Manual 
for Courts-Martial requires the commander contemplating charges to 
request a mental health inquiry pursuant to Rule for Court-Martial 
(RCM) 706. Although the RCM 706 request is issued by the commander, the 
need for the request, if not immediately identified by the commander 
him/herself, may be raised by any investigating officer, the trial 
counsel, defense counsel, military judge, or a member of the court-
martial, if one is already in progress. Pursuant to the rule, the 
Sailor's mental health will be evaluated by a board which must normally 
include at least one psychiatrist or clinical psychologist, and may 
also include one or more physicians.
    If a 706 board determines that a Sailor was unable to appreciate 
the wrongfulness of his actions at the time of the alleged offense, or 
does not currently have the mental capacity to assist in his own 
defense, depending on the stage of the proceedings, charges may be 
dismissed; or the determination may result in a finding of not guilty 
due to lack of mental responsibility. In any case, such determination 
would act as a bar to conviction, if not prosecution. If a 706 board 
determines that no mental defect exists that would affect the Sailor's 
mental responsibility at the time of the alleged offense or his ability 
to assist in his own defense, there is nothing to preclude lawful 
prosecution.
    Question. In your opinion, what additional steps need to be taken 
to ensure that electronic medical information is available to VA?
    Answer. Currently we use the Bidirectional Health Information 
Exchange (BHIE) but it is considered inadequate as not all of the data 
is available in an easy to read format. BHIE, or a modernized 
replacement of BHIE, needs to be made more robust and improvements made 
in the presentation of the data to the provider. Establishment of 
trusted networks between the DOD and VA would allow greater access to 
the data by both agencies. Differences in the information assurance 
regulations of both Departments, and between the military Services, 
makes this a cumbersome, time consuming, and difficult process.
    Question. How are each of your services obtaining medical records 
for service members who receive contract care and how big of a problem 
is this for creating a complete record of care?
    Answer. There is limited information sharing for patients who 
receive care in the direct care system but who may also receive some 
care in the civilian health care sector. For example, in some cases a 
military healthcare provider may refer a patient to a civilian 
healthcare specialist for a consult. These consult results are 
frequently only returned to the military provider in the form of a 
written document. In some cases they may be sent as a fax or as an 
email message (or attachment to an email message).
    Regardless of whether the information is received in paper form or 
via an electronic transfer of a scanned document, there are limitations 
as to how that information can be incorporated into AHLTA (Armed Forces 
Health Longitudinal Technology Application). Those limitations make it 
difficult for military healthcare providers to access that information 
effectively.
    In order to address the current limitations, DOD is pursuing a 
number of initiatives. We are implementing a capability to capture 
scanned documents and other images as part of our electronic health 
record. And, we will index those documents so that they are readily 
retrievable by military healthcare providers. We are also piloting a 
more robust interchange capability with the civilian sector through the 
Nationwide Health Information Network (NHIN) initiative. As the 
civilian healthcare providers adopt electronic health records, we will 
be able to take advantage of the NHIN infrastructure to share 
information in a more flexible form.
    Question. The NDAA fiscal year 2008 Section 1623, required the 
establishment of joint DOD and VA Vision Center of Excellence and Eye 
Trauma Registry. Since then, I am not aware of any update on the 
budget, current and future staffing for fiscal year 2009, the costs of 
implementation of the information technology development of the 
registry, or any associated construction costs for placing the 
headquarters for the Vision Center of Excellence at the future site of 
the Walter Reed National Medical Center in Bethesda. What is the status 
on this effort?
    Answer. As the DOD/VA Vision Center of Excellence is an Army run 
program, they will best be able to provide the status of this effort.
                                 ______
                                 
              Questions Submitted by Senator Thad Cochran

    Question. The Active Duty Navy has only had a 39 percent completion 
rate on the Post Deployment Health Reassessment form (PDHRA). This is 
the lowest of all the Services. What are the reasons for this low 
input? Is it an issue of resources?
    Answer. Navy is committed to protecting and promoting the long term 
health of our Sailors, especially those facing post deployment stress 
challenges. Navy leadership led efforts to increase the completion rate 
of the Post Deployment Health Reassessment (DD 2900). These efforts 
included communicating its importance; issuing PDHRA guidance and 
lessons learned; distributing by name lists of Sailors required to 
complete the PDHRA to individual commands; and committing human and 
fiscal resources to the administration and execution of the program.
    As of March 24, 2009, the Medical Readiness Reporting System 
(MRRS), Navy's designated database for PDHRA compliance tracking, 
indicates a Navy-wide compliance rate of 57.4 percent, with the Active 
Component (AC) at 46 percent and the Reserve Component (RC) at 93.4 
percent. Navy, in an effort to ensure no Sailor is overlooked, used two 
indicators to identify Sailors required to complete the PDHRA. These 
``identifiers'' are a previously completed Post Deployment Health 
Assessment (DD 2796) or a Sailor's concurrent receipt of Hardship Duty 
and Imminent Danger Pays. It has since been determined that the use of 
these two identifiers ``cast the net'' too wide and erroneously 
identified persons who do not meet current criteria for completion of 
the PDHRA as set forth in DOD Instruction 6490.3, Deployment Health, 
and OPNAVINST 6100.3, The Deployment Health Assessment (DHA) Process. 
(This erroneous identification affected the active component almost 
exclusively and accounts for some of the difference in active and 
reserve reported compliance rates.)
    Approximately 25 percent of the overdue PDHRAs for USN personnel 
are identified by the two pays and the vast majority (approximately 73 
percent) of overdue PDHRAs for USN personnel is due to the completion 
of a PDHA. Navy has taken a conservative approach to reporting PDHRA 
compliance. For example, all Sailors have been individually canvassed 
to confirm the requirement for the Deployment Health Assessment process 
followed by a manual check of records for the presence of a completed 
DD 2900. Additionally, early in the DHA administrative process, many 
Sailors who made routine ship deployments erroneously completed a post 
DHA. Correcting these data entries has proven to be a time consuming, 
manpower intensive effort.
    A more accurate method to determine Navy PDHRA compliance is being 
implemented. This new method will eliminate those Sailors who are 
identified as overdue, but in actuality do not require a PDHRA (e.g., 
Shipboard Sailors). On March 10, 2009, the PDHRA compliance rate was 
calculated by the use of the more accurate method to identify Sailors 
required to complete the PDHRA: a completed Post-deployment Health 
Assessment (DD 2796) preceded by a Pre-deployment Health Assessment (DD 
2795). The PDHRA compliance rate was determined to be 78.4 percent for 
the Active Component and 96.8 percent for the Reserve Component with a 
Navy-wide level of 85.0 percent.
    Navy is making steady improvements in the PDHRA compliance rate. We 
are pressing to ensure that those Sailors who need the PDHRA complete 
the assessment and are working to correct the erroneous method for 
identifying Sailors required to complete the PDHRA. Efforts toward 
meeting objectives include:
  --In fiscal year 2006, Navy Medicine established Deployment Health 
        Centers (DHCs) with the primary mission to augment military 
        treatment facilities to ensure the availability of adequate 
        medical resources to support PDHRA compliance. There are 
        currently 17 DHCs with 117 medical contract positions, 
        including psychiatrists and psychologists, funded with annual 
        costs of $15 million.
  --MRRS now provides the capability to reconcile the overdue status of 
        Sailors if indicated by a previously completed PDHA not meeting 
        today's criteria.
  --The capability to reconcile the status of those erroneously 
        identified by the two pays will be implemented in MRRS in May.
  --Navy (BUMED) has identified the need for additional temporary 
        resources to clear any data entry backlogs that currently 
        exist.
    Navy's low compliance rate is not an issue of resources.
    Question. This Committee is aware of some of the challenges that 
the Great Lakes consolidation has come up against. Can you talk about 
some of the pressures that the Navy is experiencing with this 
consolidation? Would integration like Keesler-Biloxi make more sense 
than total consolidation?
    Answer. Cultural differences between the Navy and the VA are large, 
and they present challenges in establishing the template for future 
integrated federal healthcare facilities. This consolidation will not 
work unless each agency is willing to waive agency specific policies in 
order to accommodate the broader mission of the Federal Health Care 
Center (Health Care and Operational Readiness).
    The Great Lakes consolidation model was driven from the Health 
Executive Council (HEC) and Joint Executive Council (JEC) level to the 
deckplate level in Great Lakes and North Chicago. There is significant 
interest by Congressional and Senate members in executing a new model 
of interagency cooperation, and the North Chicago/Great Lakes 
consolidation is being looked at as the test bed.
    Navy Operational Readiness is our number one mission and our 
primary reason for existence. As we deal with Command and Control, IM/
IT, fiscal and clinical support decisions, this Operational Readiness 
mission has to constantly be re-affirmed as it is a new concept for the 
VA. The electronic medical record is an area where there is pressure to 
move to one system or the other. Neither AHLTA nor VISTA can sustain 
the requirements of both DOD and VA. The IM/IT solution being crafted 
must sustain missions of both organizations.
    The FHCC establishment date of October 1, 2010 creates mounting 
time pressures. The timely passage of pending Congressional legislation 
is crucial to implementing the full vision of this project. Because 
Great Lakes is being touted as the model for future fully integrated 
federal healthcare, there is enormous self-imposed pressure to do it 
right. System solutions (financial reconciliation, electronic medical 
record, information management, etc.) cannot be local fixes, but must 
be crafted in a manner that lends to exportability throughout the 
enterprise.
    The Keesler-Biloxi venture is not an integration. It is a joint 
side-by-side sharing relationship. Construction decisions made 5 years 
ago, along with direction from the HEC and JEC, are driving the need 
for a tighter integration in North Chicago. There is not enough 
physical space to accommodate two organizations (the original space 
plan was decreased by 50 percent) working side by side with all the 
necessary additional infrastructure (personnel, equipment, IM/IT 
systems and support services) required. We must integrate in a tighter 
fashion compared with Keesler-Biloxi.
                                 ______
                                 
             Questions Submitted by Senator Mitch McConnell

    Question. Congress has established a national suicide hotline for 
returning troops, as well as increased funding for mental health for 
active military personnel. However, there remains a high number of 
soldier suicides. What preventative measures is DOD taking to address 
this problem? What, if any, legislative action would DOD need Congress 
to take to expand suicide awareness and education on posts?
    What preventive measures is Navy taking to reduce suicides?
    Answer. The Navy recognizes that multiple demands on our Sailors 
has become a significant source of stress and limits the time available 
for addressing problems at an early stage. In response, the Navy is 
increasing dedicated resources to the development of leadership tools 
for Operational Stress Control (OSC) and suicide prevention. Current 
efforts focus on inspiring leaders to understand and take suicide 
prevention efforts as critical to their ability to do their jobs and 
missions. Other actions include:
  --The Chief of Naval Operations (CNO) directed the establishment of 
        the Navy Preparedness Alliance (NPA) to address a continuum of 
        care that covers all aspects of individual medical, physical, 
        psychological and family readiness across the Navy.
  --In February 2009, an interdisciplinary Suicide Prevention Cross 
        Functional Team was established to review current efforts, 
        identify gaps, and develop the way ahead.
  --Top leadership vigilance. CNO maintains awareness through monthly 
        and ad hoc suicide reports, quarterly Tone of the Force 
        reports, Behavioral Health Needs Assessment Surveys, and 
        targeted surveys of Sailors and Family members.
  --Increased Family Support. Navy hired 40 percent more professional 
        counselors to address Sailor and family needs, resulting in 
        improved staffing from 1,044 to 1,444 at Fleet and Family 
        Service Centers. A Family Outreach Working group was 
        established to improve suicide awareness communication and 
        education of family members.
  --Operational Stress Control (OSC), a comprehensive approach designed 
        to address the psychological health needs of Sailors and their 
        families, is a program led by operational leadership and 
        supported by Navy Medicine. To date, more than 13,000 Sailors 
        have received an initial OSC familiarization brief. Formal 
        training curriculum at key points throughout a Sailor's career 
        is under development. The OSC Stress Continuum Model has been 
        integrated into Fleet and Family Service Center programs and 
        education and training programs.
  --Reserve Psychological Health Outreach Coordinators Program was 
        implemented in 2008 and provides 2 coordinators and 3 outreach 
        team members (all licensed clinical social workers), to each of 
        the 5 Navy Reserve Regions, to engage in training, active 
        outreach, clinical assessment, referral to care, and ensure 
        follow up services for reserve Sailors.
  --Personal Readiness Summits and Fleet Suicide Prevention 
        Conferences/Summits are providing waterfront training 
        opportunities for leaders, command Suicide Prevention 
        Coordinators, and installation first responders.
  --Front Line Supervisor Training, train-the-trainer, has been 
        provided at six locations throughout CONUS with additional 
        training scheduled throughout 2009. The Front Line Supervisor 
        Training is an interactive half-day workshop designed to assist 
        deck-plate leaders in recognizing and responding to Sailors in 
        distress.
  --First Responder Seminars provide those individuals likely to 
        encounter a suicide crisis situation (security, fire, EMS, 
        medical, chaplains, or counselors) with a review of safety 
        considerations and de-escalation techniques.
  --Commands are required to have written command crisis response plans 
        to guide duty officer actions in response to a suicidal 
        individual or distress call. Navy has been training a network 
        of command Suicide Prevention Coordinators (SPC) to assist 
        Commanding Officers in implementing command level prevention 
        efforts and policy compliance.
  --Communications and outreach efforts continue. The new 
        www.suicide.navy.mil web URL went live in September 2008 to 
        provide an easy-to-remember link to helpful information. A new 
        four-poster series was distributed to all installations in 
        November 2008 along with a new tri-fold brochure. A new 
        training video will be distributed this summer.
  --Warrior Transition Program (WTP) provides a 3-day respite in Kuwait 
        to all Individual Augmentees returning from theater. Conducted 
        by counselors, chaplains, and peers, the WTP provides time for 
        reflection, rituals of celebration or grief, restoration of 
        normal sleeping patterns, and time to say good-byes.
  --Safe Harbor. Non-clinical Case Managers are assigned to individuals 
        who are severely or very severely ill or injured to provide 
        continued support through the treatment and transition process 
        and beyond.
  --Chaplain Support. Chaplain education in 2008 and 2009 focused on 
        Operational Stress Control for non-mental healthcare givers and 
        resilience and family care. The Chaplain Corps Human Care 
        initiative is working to understand, evaluate and realign 
        chaplain resources for efficient and effective care.
    Question. What, if any, legislative action would DOD need Congress 
to take to expand suicide awareness and education on posts?
    Answer. There are no legislative barriers to expanding suicide 
awareness and education on posts.
    Question. What are the typical steps taken for sailors who may have 
post-traumatic stress disorder (PTSD) and traumatic brain injuries 
(TBI) to ensure they get the proper care? Are there any further 
legislative steps that Congress could take to improve screening and the 
delivery of care to sailors with PTSD and TBI?
    Answer. Sailors and Marines are provided unit-level pre- and post-
deployment education about signs and symptoms of post-traumatic stress 
disorder and traumatic brain injury. Navy Medicine has developed the 
Stress Injury Model to promote early identification and appropriate 
referral; early identification of symptoms is the best way to mitigate 
the effects of combat stress.
    Unit medical personnel also receive training in PTSD and TBI 
surveillance. The Post-Deployment Health Assessment and Post-Deployment 
Health Reassessment contain screening questions specific to both PTSD 
and TBI, and can assist healthcare providers in making timely and 
appropriate referrals for specialty evaluation and treatment. After a 
diagnosis of PTSD or TBI is made the service member is offered the 
appropriate medical care. For those diagnosed with PTSD, care would 
include additional psychological assessment to rule out other mental 
health conditions followed by appropriate evidence-based cognitive 
therapies (e.g., Cognitive Processing Therapy, Prolonged Exposure). For 
those diagnosed with TBI, care may range from 7 days of rest to 
evacuation from theater and surgical treatment. Service Members 
diagnosed with TBI are assigned a medical case manager to assist with 
coordinating medical care. For those Sailors and Marines unable to 
remain on active duty, Navy Medicine has partnered with the VA to 
ensure a seamless, coordinated transition of care.
    Question. Per the Wounded Warrior legislation enacted in 2007 and 
the Dole-Shalala Commission's recommendations that were reported in 
2007, improvements were to be made to the coordination between DOD and 
VA facilities to better care for our injured troops who are 
transitioning between the two healthcare systems. What steps have 
already taken place to improve coordination between the two 
Departments?
    Answer.
Disability Evaluation System (DES) Pilot
    The Pilot originally began in 2007 and was expanded January 2009. 
Features of the pilot are:
  --Single physical exam serving DOD separation and VA disability 
        decisions; and
  --Single disability rating (by VA) used by DOD in separation/
        retirement decision and VA in benefits determination.
Case Management--Federal Recovery Coordinator Programs
    The Federal Recovery Coordination Program was created in late 2007 
and implemented in 2008 through the signing of two memoranda of 
understanding between DoN and DVA. The goal of the program is to 
provide assistance to recovering service members, veterans and their 
families through recovery, rehabilitation and reintegration and 
benefits.
    The first Recovery Coordinators were hired and trained in early 
2008 and placed at military treatment facilities where most newly 
evacuated wounded, ill or injured service members are taken. NNMC 
Bethesda and NMC San Diego have Recovery Coordinators assigned to work 
in their facilities. This program is fully supported and endorsed by 
both departments and additional Recovery Coordinators will be hired in 
2009.
    The FRC program also includes DOD liaisons and VA detailed staff.
  --1 Navy Liaison, 1 Army Liaison, 2 Marine Liaison Officers, 2 Public 
        Health Service staff members.
Post Traumatic Stress Disorder/Traumatic Brain Injury (PTSD/TBI)
    Established Defense Center of Excellence and appointed director; 
private sector benefactors building facility on Bethesda campus of 
National Military Medical Center. Both DOD and VA established a policy 
of Mental health access standards and standardized TBI definitions and 
reporting criteria.
    TBI questions added to Post Deployment Health Assessment and Post 
Deployment Health Reassessment which may trigger a referral.
DOD/VA Data Sharing
    Expanded the availability of DOD theater clinical data to all DOD 
and VA facilities. As of the beginning of 2008, added the bi-
directional transmission of provider/clinical note, problem lists, 
theater inpatient medical data from Landstuhl and medical images 
between three Military Treatment Facilities and the VA Polytrauma 
Centers
    DOD and VA have signed Information Technology (IT) Plan to support 
the Federal Recovery Care Coordinator program. A tri-fold on Wounded 
Warrior pay and travel entitlements (also on web).
    Question. What steps remain?
    Answer. Further growth and expansion of DES will greatly assist in 
this endeavor. Involvement of Case Mangers and education of both 
staff's on the intent of DES is critical to success.
    Further efforts to ensure smooth data sharing between DOD and VA 
are critical to the transition of care.
    Question. Are these provisions sufficient to provide a seamless 
transition for wounded warriors from the DOD to the VA system?
    Answer. Yes, although continued efforts to refine the processes 
supporting seamless transition should be encouraged.
    Question. Does DOD need further legislation to improve matters? If 
so, what?
    Answer. No needs identified at this time.
                                 ______
                                 
      Questions Submitted to Lieutenant General James G. Roudebush
            Questions Submitted by Chairman Daniel K. Inouye

                      WELL-BEING OF OUR CAREGIVERS

    Question. General Roudebush, while attention must be focused on the 
resilience training of our Service members and their families, I also 
suspect that caring for our wounded takes a considerable toll on our 
caregivers.
    What efforts are underway to address the well-being of our 
caregivers in order to retain these critical personnel?
    Answer. The Air Force is also concerned about the stress 
experienced by our healthcare providers, as well as their exposure to 
the injured and killed. In order to address this concern, we provide 
awareness education to healthcare providers prior to deployment, and we 
closely monitor psychological symptoms post-deployment. These 
educational and surveillance processes are provided to all deploying 
Airmen via Landing Gear; the post-deployment health assessment; the 
post-deployment health reassessment. A study is currently underway at 
the theater hospital in Balad that assesses risks and protective 
factors in our deployed medics. Furthermore, the Air Force has hired 97 
additional contract mental health providers in the last year to improve 
access to mental healthcare and to spread out the workload for our busy 
uniformed mental health providers.

                         ENTERPISE ARCHITECTURE

    Question. How do you ensure Service specific needs are incorporated 
in the new enterprise architecture and how do you make sure they don't 
drive up costs throughout the system?
    Answer. The Air Force Medical Service has representation in the MHS 
integrated requirements and review working groups. These vetting bodies 
review the initial capability documents and analyze costing before 
recommending for inclusion in the Central Portfolio. As a general rule, 
we ensure cost is minimized by finding compatible Tri-Service solutions 
that use common standards that enhance interoperability.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

                                SUICIDES

    Question. JSC Chairman Admiral Mullen has said publicly he's trying 
to break the stigma of psychological health in the active force, yet, 
the Judge Advocates General are still prosecuting as a ``crime'' 
depressed people who attempt suicide. While the surgeons general aren't 
responsible for the enforcement of the Uniformed Code of Military 
Justice, it seems to me that they might be concerned about prosecutions 
of people who have severe mental distress while serving or after 
serving in combat.
    Generals, do you think that the continued criminal prosecution of 
troops who commit suicide is a problem for the military's efforts to 
break the stigma of psychological health?
    Answer. The Air Force is not aware of any instances in which an 
Airman has been prosecuted based solely on mental distress and/or a 
suicide attempt. AF leaders work hard to foster a ``wingman'' culture, 
in which Airmen look out for one another and seek timely help for both 
personal and psychological concerns. Our goal is to identify and 
address psychological concerns before they manifest themselves 
behaviorally in a way that threatens personal health or safety or that 
interferes with mission accomplishment. Should those efforts fail, we 
will continue to provide comprehensive, evidenced-based treatment.

                     ELECTRONIC MEDICAL INFORMATION

    Question. In your opinion, what additional steps need to be taken 
to ensure that electronic medical information is available to the 
Department of Veterans Affairs?
    Answer. Further interdepartmental collaboration on the creation of 
common data dictionaries and implementation of Services Oriented 
Architecture will set a firm footing towards sharing of our data. A 
dedicated integration program office and a sound funding strategy will 
do much to ensure data is available to our constituencies.

           ACCOUNTING FOR CONTRACT CARE IN THE MEDICAL RECORD

    Question. How are each of your Services obtaining medical records 
for Service members who receive contract care and how big of a problem 
is this for creating a complete record of care?
    Answer. There are two primary scenarios in which the Air Force 
Medical Service obtains medical records from contracted TRICARE network 
providers.
Scenario 1:
    Military Treatment Facility (MTF) enrolled Active Duty Service 
Members (ADSMs) referred to a contract TRICARE network provider for 
specialized health care not available at the MTF.
    Records capture process: Following the civilian medical 
appointment, the referral results or consultation report(s) are 
submitted to the referring MTF where they are reviewed by the referring 
provider and permanently filed in the ADSM's record. This process is 
not considered to be a significant Air Force Medical Service problem or 
challenge that would otherwise prevent or delay its ability to create a 
complete record of care.
Scenario 2:
    TRICARE Prime Remote (TPR) ADSMs enrolled to a TRICARE network 
primary care manager instead of an MTF provider.
    Records capture process: Health treatment records for Airmen 
assigned to geographically separated units (GSUs) or remote duty 
locations (e.g. recruiting squadrons, Military Entrance Processing 
Centers, unique military detachments, or other similar units without 
immediate military installation support), are usually maintained at the 
nearest Air Force MTF.
    Prior to PCS reassignment (from the TPR duty location or retirement 
or separation from the remote duty assignment), Airmen are required to 
``out-process'' through the MTF responsible for maintaining their 
military health treatment records. At the time of the MTF records 
department out-processing encounter, MTF records managers and the 
service member complete a records copy request form. The form is 
submitted to the Airman's contracted TRICARE network primary care 
manager. Upon receipt of the requested information, the medical 
document copies are added to the Airmen's health record and the 
complete health record is forwarded to the gaining MTF or to the Air 
Force Personnel Center (for separating and retiring Airmen).
    The Air Force continues to educate Airmen regarding installation 
out-processing procedures whenever and wherever possible. However, 
sometimes Airmen assigned to GSUs do not always visit or ``out-
process'' through the nearest Air Force MTF responsible for maintaining 
their military health treatment records. Consequently, the MTF doesn't 
always know to submit a records copy request to the Airman's contracted 
TRICARE network primary care manager. The records capture process for 
Airman assigned to TPR locations currently does not function as well as 
it should, and we are reviewing this process to identify improvement 
opportunities.

         VA VISION CENTER OF EXCELLENCE AND EYE TRAUMA REGISTRY

    Question. The fiscal year 2008 National Defense Authorization Act, 
Section 1623, required the establishment of a Joint Department of 
Defense and Department of Veteran's Affairs Vision Center of Excellence 
and Eye Trauma Registry. Since then, I am not aware of any update on 
the budget, current and future staffing for fiscal year 2009, the costs 
of implementation of the information technology development of the 
registry, or any associated construction costs for placing the 
headquarters for the Vision Center of Excellence at the future site of 
the Walter Reed National Medical Center in Bethesda, MD.
    What is the status on this effort?
    Answer. I believe Col. Donald A. Gagliano, the Executive Director 
for the DOD Vision Center of Excellence, addressed some of those issues 
during his March 17, 2009, testimony, and I would defer to the the Army 
as the lead agent to provide a more comprehensive response.
                                 ______
                                 
              Questions Submitted by Senator Thad Cochran

                  POST DEPLOYMENT HEALTH REASSESSMENT

    Question. One of the tools used to measure the health and well-
being of Service members after they return home is the Post Deployment 
Health Reassessment form, which everyone is asked to fill out 90 and 
190 days after their redeployment. As of January 30, the Air Force 
Reserve had the second lowest completion rate of this form at 46 
percent.
    What are some of the reasons for this low number of completed 
responses and what is the Air Force doing to help ensure returning 
Airmen and women receive needed care?
    Answer. Initial rollout of the Post Deployment Health Reassessment 
was made available to Reservists through the Reserve Component Periodic 
Health Assessment (RCPHA) system. However, this system proved unable to 
monitor completion of the PDHRA (Form 2900) or measure unit compliance. 
The system was abandoned in July 2008 and the Reserve migrated to the 
medical information system used by the Air Force active component. The 
migration resulted in corrupted and incomplete records, reflected in a 
7 percent indicated compliance rate immediately following the 
transition. Efforts to correct these errors have rapidly improved the 
indicated compliance rate, which is currently at 51 percent. By late 
summer we project our PDHRA compliance to be on par with the active 
duty and Air National Guard.

          KEESLER MEDICAL CENTER AND BILOXI VETERANS HOSPITAL

    Question. I understand the Department of Defense and the Department 
of Veterans Affairs are working to establish joint ventures in areas 
where both agencies have co-located facilities around the country. I 
would hope the goal of these joint ventures would be to increase the 
quality of care and efficiency without decreasing capability or 
capacity. I understand the Air Force has been working with the 
Department of Veterans Affairs to integrate Keesler Medical Center and 
the Biloxi Veterans Hospital.
    Can you give me your assessment on this process and if you believe 
it has been a good news story?
    Answer. Based on our experience to date, the joint venture process 
is effective and the results are good news stories across the board.
    When considering Joint Venture opportunities, the viability of a 
proposed joint facility is assessed across nine separate domains. 
Through this structured approach, the work group assesses the 
organizations' current relationship and the potential for a future 
joint relationship. Phase I and Ib sites are already joint facilities 
or are in the process of becoming joint facilities. The efforts at 
those sites have focused on further integration, and Keesler-Biloxi is 
part of that group. Detailed plans are complete for the integration of 
all clinical specialty services between Keesler Medical Center and 
Biloxi Veterans Hospital, with the exception of General Surgery, which 
will continue to be available at both facilities.
    All Phase II sites have the potential to increase their level of 
sharing and some sites may have the potential to become joint 
facilities. An example of Phase II efforts is the Colorado Springs 
Joint Market area, where the Air Force Academy's 10th Medical Group 
will share operating room time with the Eastern Colorado Health Care 
System.
    We anticipate all of our joint ventures will be win-win efforts 
that will improve efficiency and access to care for all participating 
facilities.

             JOINT AIR FORCE AND VETERANS AFFAIRS PROJECTS

    Question. I have been informed that it is intended these joint 
ventures, such as the Keesler-Biloxi project, will achieve complete 
consolidation, much of what's being attempted at Great Lakes in 
Illinois with the Navy.
    Do you believe that the different mission sets in the Department of 
Defense and the Department of Veterans Affairs make complete 
consolidation possible or logical at all locations?
    Answer. In our experience, despite disparate missions, joint 
venture sites have been very successful in taking care of their 
beneficiaries and provide a win-win scenario for both partners. We 
believe that there are many forms of joint ventures, and not all joint 
ventures are, or should be, considered for complete consolidation.
    We appreciate your interest in the good news story at Keesler. 
Keesler Medical Center (KMC) and VA Gulf Coast Veterans Health Care 
System (VAGCVHCS) have had a long history of sharing, but it wasn't 
until after Hurricane Katrina that the full benefits of DOD/VA sharing 
were explored. Dual VA CARES and DOD BRAC funding projects caused the 
two large medical centers to develop an integration plan as an official 
joint venture site. Using a ``Centers of Excellence'' (COE) model, all 
KMC and VA inpatient and outpatient clinical product lines are being 
realigned/shared at the site where either party has the greater 
capability. This produces a synergy between the combined staffs and 
maximizes capabilities for the patient. This approach also reduces or 
eliminates duplication of effort of similar services. For services that 
cannot be realigned or fully integrated, we emphasize exploiting any 
opportunity to open service availability for each other's 
beneficiaries. The only limits are access to care and service 
availability itself.
    At the same time, this model retains the independent daily 
governing structures of both facilities, allowing the Air Force and the 
VA to carry on their important and distinctive missions unimpeded. An 
Executive Management Team co-chaired by KMC Commander and VA Director 
provides oversight linkage for sharing initiatives.
    We currently have seven signed operational plans for ongoing shared 
services. These plans detail the scope of care, business office 
functions and other important aspects of treating each others' 
patients. The seven signed plans are: Orthopedics, dermatology, plastic 
surgery, pulmonology/pulmonology function tests, shared nursing staff, 
shared neurology technicians and laundry.
    We have eight more operational plans we anticipated being signed 
within the next 60 days: Women's health, sleep lab, radiation oncology, 
MRI, cardiac cathorization, patient transfer, urology and shared 
referral staff. All services that are sharing in these areas are doing 
so under our resource sharing agreement and draft operational plans.
    We anticipate taking on a significant amount of VA surgical and 
inpatient workload as the VA's CARES construction project will limit 
their operating room usage for several months in fiscal year 2010. The 
VA will be bringing many of their operating room personnel and 
inpatient nursing staff.
    In summary, the integration process has been a great success thus 
far, and we anticipate this joint venture will be a win-win proposition 
for both facilities.
                                 ______
                                 
             Questions Submitted by Senator Mitch McConnell

                                SUICIDES

    Question. Congress has established a national suicide hotline for 
returning troops, as well as increased funding for mental health for 
active military personnel. However, there remains a high number of 
Soldier suicides.
    What preventive measures is the Department of Defense (DOD) taking 
to address this problem?
    Answer. The DOD has established the Suicide Prevention and Risk 
Reduction Committee to monitor and address suicide trends across the 
DOD. The DOD has implemented the DOD Suicide Event Reporting System to 
improve data tracking, and hosts an annual DOD/Veterans Affairs suicide 
prevention conference that draws experts from around the world.
    The military Services each execute their own suicide prevention 
programs tailored to the needs and culture of their own Service. We are 
carefully studying each other's best practices to maximize the 
effectiveness of our programs. The Air Force Suicide Prevention Program 
(AFSPP) includes 11 initiatives that must be implemented by every Wing 
Commander. Our program focuses on a total community effort that has 
helped to reduce our suicide rate by 28 percent since it was 
implemented in 1996. The AFSPP is listed on the Department of Health 
and Human Services National Registry of Evidence-based Programs and 
Practices.
    Question. What, if any, legislative action would the Department of 
Defense need Congress to take to expand suicide awareness and education 
on posts?
    Answer. The Air Force defers to Department of Defense (DOD) on 
possible DOD legislative proposals. The Air Force Suicide Prevention 
Program (AFSPP) is intensely invested in awareness and education down 
to the grassroots level--the AFSPP is a commander's program that 
targets every Airman. Through our Landing Gear program, we teach all 
Airmen how to prepare for the psychological effects of deployment, how 
to recognize risk factors and to know when and how to get help for 
themselves or others. We have instilled a Wingman Culture in which we 
are each responsible for our fellow Airmen. The Air Force does not 
require any legislative action at this time to support the AFSPP, but 
we greatly appreciate the Congress' efforts to help us address this 
critical issue.

                                PTSD/TBI

    Question. What are the typical steps for Airmen who may has post-
traumatic stress disorder (PTSD) and traumatic brain injuries (TBI) to 
ensure they get the proper care?
    Answer. The Air Force uses a three-part strategy to address and 
manage PTSD, TBI and other deployment related health concerns. The 
first component of our strategy involves training and education efforts 
to enhance awareness and recognition of common deployment-related 
health concerns. The second component involves repeated health 
surveillance before, during, and after deployments, as well as 
annually. The final component involves intervention. Screening that 
identifies PTSD and TBI symptoms (as well as other health concerns) 
results in more thorough assessments and referrals to specialists when 
indicated. We work closely with the Defense Center of Excellence for 
Psychological Health and TBI as well as civilian subject matter experts 
to ensure our treatment efforts are in line with clinical practice 
guidelines and established standards of care.
    Question. Are there any further legislative steps that Congress 
could take to improve screening and the delivery of care to Airmen with 
post-traumatic stress disorder (PTSD) and traumatic brain injuries 
(TBI)?
    Answer. The entire Department of Defense has put considerable 
resources and effort into addressing the identification and treatment 
of service members with PTSD and TBI in a very short period of time. 
Any additional legislative support for these critical issues would be 
best recommended by the newly formed Defense Center of Excellence for 
Psychological Health and TBI. However, we caution against proposed 
legislation that would mandate face-to-face provider-to-troop 
screenings for all redeploying military personnel, the majority of whom 
are not experiencing significant health concerns. We believe our 
existing program is successfully and expeditiously capturing those who 
need intervention and treatment. Expanding the program unnecessarily 
will further constrain resources needed to focus on those with 
identified health concerns.

                            WOUNDED WARRIOR

    Question. Per the Wounded Warrior legislation enacted in 2007 and 
the Dole-Shalala Commission's recommendations that were reported in 
2007, improvements were to be made to the coordination between the DOD 
and VA facilities to better care for our injured troops who are 
transitioning between the two healthcare systems.
    What steps have already taken place to improve coordination between 
the two departments? What steps remain? Are these provisions sufficient 
to provide a seamless transition for wounded warriors from the DOD to 
the VA system?
    Answer. With the passage of Wounded Warrior specific sections of 
the National Defense Authorization Acts of 2007 and 2008 and the 
creation of a joint DOD/VA disability evaluation system (DES) 
demonstration pilot, there now exists an unprecedented amount of 
cooperation, teamwork and cross-functional communication between the 
Services and the VA. Similar to our Army and Navy counterparts, the Air 
Force Medical Service is working very hard with the VA to ensure those 
Service Members who are ``medically'' separated or retired from the 
Armed Forces are fairly evaluated and receive the healthcare, 
compensation and benefits necessary to ensure a seamless lifestyle 
transition from military to civilian life.
    Representatives from each Service's medical and personnel 
headquarters offices (including physical evaluation board disability 
managers) routinely meet with VA and DOD policy officials to evaluate 
the joint departmental DES demonstration pilot targeted goals and 
objectives, review disability evaluation findings and trends, and 
analyze pilot metrics (including process timeliness). Furthermore, the 
VA/DOD DES demonstration pilot has expanded outside the greater 
Washington, DC, area (the initial VA/DOD demonstration pilot area) and 
now includes military installations throughout the Continental United 
States and Alaska. Within the Air Force, the participating VA/DOD DES 
pilot expansion sites include Andrews AFB, Maryland; Elmendorf AFB, 
Alaska; Keesler AFB, Mississippi; MacDill AFB, Florida; Travis AFB, 
California; and Vance AFB, Oklahoma; with other potential expansion 
sites currently being considered.
    The Office of the Assistant Secretary of Defense for Health Affairs 
(OASD/HA) has recently obligated an additional $5.5 million to enable 
our military treatment facilities to hire more Physical Evaluation 
Board Liaison Officers (PEBLOs). The PEBLOs are one of our most 
important non-clinical case managers. The individuals are responsible 
for providing Service Members traversing the DES with non-clinical 
benefits and referral support counseling.
    Additionally, at the direction of Mr. Michael Dominguez, Principal 
Deputy Under Secretary of Defense for Personnel and Readiness, the Air 
Force has created a centralized health treatment records disposition 
process designed to more efficiently transfer complete medical and 
dental treatment records for retiring and separating Airmen from the 
Air Force to the VA. This new process prohibits medical and personnel 
units at over 74 Air Force installations from directly sending health 
treatment records to the VA and instead funnels all health treatment 
records to a single military service personnel out-processing center 
before the records are forwarded to the VA. The process is designed to 
reduce the amount of ``orphaned'' or ``loose, late-flowing'' medical 
documents unintentionally separated from the Service Member's original 
health records package. This new process is also intended to ensure the 
medical and dental records for each retiring and separating Airman are 
shipped to the VA together and on-time. The main goal of the program is 
to ensure complete health treatments records for retiring or separating 
Airman are made available to the VA as soon as possible so VA benefits 
and disability compensation reviews can be completed with little to 
zero gaps in veteran benefits or healthcare coverage.
    With regard to what steps remain, everyday we move closer to 
totally transitioning from a paper-based health treatment record to an 
electronic health record. Billions of dollars and countless man-hours 
have been spent on improving and refining the information and 
technology necessary to make this transition a reality. The DOD and VA 
continue to improve and enhance their electronic health record computer 
systems, but we're still a few years away from an electronic health 
record system that offers unfettered bi-directional health information 
exchange between the two agencies.
    Working together with our parallel Service medics and with DOD and 
VA officials, I believe we're doing all we can to ensure the provisions 
identified in the NDAA of 2007, 2008, and 2009 are sufficient to 
provide a seamless transition for Wounded Warriors from the DOD to the 
VA system.
    Question. Does the Department of Defense need further legislation 
to improve matters? If so, what?
    Answer. Working together with our parallel Service medics and with 
DOD and VA officials, we're doing all we can to ensure the provisions 
identified in the NDAA of 2007, 2008, and 2009 are sufficient to 
provide a seamless transition for Wounded Warriors from the DOD to the 
VA system. The Air Force does not require any further legislative 
action at this time to improve transition between health systems.
                                 ______
                                 
     Questions Submitted to Rear Admiral Christine M. Bruzek-Kohler
            Questions Submitted by Chairman Daniel K. Inouye

    Question. Admiral Bruzek-Kohler, we recognize that Navy nurses play 
critical roles in supporting both Disaster Relief and Humanitarian 
Assistance missions. What staffing support have you received from the 
Air Force, Army, and civilian organizations to assist you in fulfilling 
the nursing need for these missions?
    Answer. Core nursing teams on these missions are composed of both 
active and reserve component Navy nurses. We are also supported by 
nursing colleagues from the Armed Services, U.S. Public Health Services 
(USPHS), Non Governmental Organizations (NGOs), and partner nation 
military nurses.
    From May 1 to September 25, 2008, USNS MERCY (T-AH 19) embarked a 
1,000-person joint, multi-national, Military Sealift Command Civilian 
Mariner, U.S. Public Health Service and non-governmental organization 
(NGO) team to conduct Pacific Partnership 2008 (PP08). The core nursing 
team consisted of active duty Navy and Air Force nurse corps officers. 
Additional nursing support was provided by Navy reservists. The nursing 
team was further augmented with partner nation military nurses from 
Australia, Canada, Indonesia, New Zealand, and the Republic of the 
Philippines, as well as NGO nurses from International Relief Teams, 
Project HOPE, and Operation Smile. Nursing specialties embarked for 
PP08 included medical-surgical, pediatric, neonatal intensive care, 
obstetric, critical care, and perioperative nursing.
    Certified registered nurse anesthetists and family, pediatric, and 
women's health nurse practitioners were also embarked.
    The USNS COMFORT (T-AH 20) is currently deployed in support of 
Continuing Promise 2009, a 4 month humanitarian assistance mission 
through Latin America and the Caribbean. Active and reserve component 
Navy nurses, as well as nurses from the U.S. Army and Air Force, USPHS, 
various NGOs, (to include Project Hope and Operation Smile) and Canada 
are embarked on this deployment.
    Question. Admiral Bruzek-Kohler, the University of Health Sciences 
(USU) has determined that conditions are not favorable for the creation 
of a Bachelors program in nursing at this time. What options for 
partnering with civilian Schools of Nursing have been discussed as a 
way to develop and recruit military nurse candidates?
    Answer. Navy nurses, at our hospitals in the United States and 
abroad, passionately support the professional development of America's 
future nursing workforce by serving as preceptors, mentors, and even 
adjunct faculty for a myriad of colleges and universities.
    Due to the vast array of clinical specialties available at our 
medical centers at Bethesda, Portsmouth, and San Diego, we have 
developed multiple Memoranda of Understandings (MOU) with surrounding 
colleges and universities to provide clinical rotations for nurses in 
various programs from licensed practical/vocational nursing, 
baccalaureate, and graduate degrees which include nurse practitioner 
and certified nurse anesthetist tracks.
    In completing their clinical rotations at our military treatment 
facilities, civilian nursing students are simultaneously exposed to the 
practice of Navy Nursing and our day to day interactions with members 
of the multidisciplinary Navy Medicine team. This exposure generates 
interest in career opportunities in both the active and reserve 
components of our Corps as well as in our federal civilian nursing 
workforce.
    The Nurse Corps Recruitment liaison officer in the Office of the 
Navy Nurse Corps at the Bureau of Navy Medicine and Surgery works with 
a speaker's bureau comprised of junior and mid-grade Nurse Corps 
officers throughout the country. These officers provide presentations 
on career opportunities in Navy nursing to students at colleges, high 
schools, middle and elementary schools. We recognize that the youth of 
America are contemplating career choices at a much younger age. Over 
the course of the past year, we have tailored our recruiting 
initiatives to engage this younger population.
    At a recent conference entitled ``Academic Partnerships Addressing 
the Military Nursing Shortage'' hosted by Dr. Ada Sue Hinshaw, Dean of 
the Graduate School of Nursing at the Unformed Services University of 
the Health Sciences (USUHS), the Navy Nurse Corps presented information 
on the state of our Corps and the incentive programs that we have 
successfully utilized to recruit nurses. The conference was sponsored 
by funding from the Office of the Assistant Secretary of Defense for 
Health Affairs and was attended by 35 Deans from Schools of Nursing, 
the Directors and Deputies from each of the Nurse Corps and leaders 
from national nursing organizations. The conference objectives 
included: building collaborative relationships among military nursing 
services and Schools of Nursing to foster education opportunities; 
exploring the types of educational programs in which additional 
military students can be enrolled and recommending the types of 
resources and incentives needed for the Schools of Nursing to be able 
to accommodate additional students. This meeting was very successful. 
USUHS also intends to conduct a survey to identify what incentives 
would be most attractive to recruit potential applicants into schools 
of nursing with obligations to serve in the military after graduation 
and successful licensure.
    Question. Admiral Bruzek-Kohler, Nurse Corps Officers are promoted 
to the senior rank of Captain (O-6) at a rate significantly less than 
their physician counterparts. Do you know if this promotion disparity 
has led to our more senior, experienced nurses leaving active duty 
service due to lack of promotion opportunities? What is your exit 
interview data telling you about why nurses are leaving active duty 
service?
    Answer. The Navy Nurse Corps has not identified promotion disparity 
as a factor in causing experienced nurses to leave active service.
    Exit interviews suggest that factors contributing to a decision to 
leave the service are often multi-faceted and maybe family related: 
spouse's employment, children's schools, and/or ill elderly parents.
    In May 2005, the Chief of Naval Personnel's Quick Poll of the Navy 
Medical Community identified the top five reasons for leaving the Navy 
Nurse Corps as: administrative barriers to doing one's job, civilian 
job opportunities, overall time spent away from home, impact of 
deployments on family, and the unpredictability of deployments.
    In fiscal year 2008, the Navy Nurse Corps implemented an incentive 
special pay targeted at retaining individuals with critical war-time 
specialties.
    The Bureau of Medicine and Surgery has contracted to do another 
retention poll and the results will be completed in late summer 2009.
    Question. Admiral Bruzek-Kohler, several professional nursing 
organizations have proposed that the Doctorate of Nursing Practice 
(DNP) be the entry level into practice for all advanced practice 
nurses. Many schools of nursing are proposing to convert their Master 
of Science nursing degrees to DNP programs over the next several years. 
The DNP educational track adds an extra year onto the typical Masters 
level curriculum plan. Has there been any discussion of how this might 
affect Duty under Instruction planning in upcoming years? Could 
offering this post-Master's education option serve as a retention tool 
for mid-levels officers who might otherwise choose to leave active duty 
service?
    Answer. The Navy Nurse Corps' Duty Under Instruction (DUINS) 
training plan is based on the projected losses in our nursing 
specialties, the number of nurses in each specialty training pipeline, 
and the overall nursing end-strength. The typical allotted training 
time is 24 months for completion of a Masters of Science in Nursing 
(MSN) and 48 months for a doctoral degree (Ph.D.). Post masters 
certificate programs are allotted 12-24 months for completion. DUINS 
exists as an avenue for the mid-level officer to apply for advanced 
education opportunities. This has served as an exceptional retention 
tool. Additionally, we have not appreciated a scarcity among quality 
MSN programs for our nurses to attend.
    The Doctorate of Nursing Practicum (DNP) curriculum of 36 months 
has an impact on DUINS, as it affects the overall number of training 
opportunities availed each year. Additionally, our current inventory of 
nursing specialties does not require the additional educational 
preparation conferred via a DNP. We are presently training master's 
prepared clinical nursing specialists and nurse practitioners to meet 
our military nursing requirements in only 24 months. They return to our 
deployable inventory of specialty nurses with greater knowledge and 
clinical expertise. If they were enrolled in a DNP program, they would 
still be matriculating and a lost deployable asset to the Navy Nurse 
Corps. Consideration of the DNP conferral via a post MSN certificate or 
bridge program may have greater appeal to the Navy Nurse Corps, as the 
officer would be lost from the deployable inventory for only 12-24 
months vice 36.
                                 ______
                                 
        Questions Submitted to Major General Patricia D. Horoho
            Questions Submitted by Chairman Daniel K. Inouye

                    HUMANITARIAN ASSISTANCE MISSIONS

    Question. General Horoho, we recognize that Navy nurses play 
critical roles in supporting both Disaster Relief and Humanitarian 
Assistance missions. What challenges have you encountered when faced 
with the need to train Army nurses to administer humanitarian nursing 
care, to include the need to provide shipboard training to assist with 
U.S. Navy missions?
    Answer. The Army Nurse Corps is focused on ensuring all nurse 
officers deploy with skill sets required for the specific mission, 
whether that mission is for combat or a humanitarian mission. As such, 
the ANC has training venues to train the nurse officers for missions 
when deploying with Forward Surgical Teams, Combat Support Hospital, 
and Brigade Combat Teams. The Navy has pre-deployment training venues 
to train care providers for shipboard missions. If needed, the ANC will 
ensure the nurse officers receive this training prior to any deployment 
in support of the Navy.

                       MILITARY NURSE CANDIDATES

    Question. General Horoho, the University of Health Sciences has 
determined that conditions are not favorable for the creation of a 
Bachelors program in nursing at this time. What options for partnering 
with civilian Schools of Nursing have been discussed as a way to 
develop and recruit military nurse candidates?
    Answer. The Army Nurse Corps, along with the Federal Nursing Chief 
partners, is actively building collaborative relationships among 
Military Nursing Services and Schools of Nursing to foster educational 
opportunities. The Uniformed Services University is taking the lead and 
has recently sponsored a conference that brought together the Deans 
from many prestigious Schools of Nursing throughout the nation to 
discuss partnering with Department of Defense assets. Additionally, the 
Army Nurse Corps is exploring the types of educational programs in 
which military students can be enrolled and evaluating the types of 
resources and incentives needed for civilian Schools of Nursing to 
accommodate additional students.

                     NURSE CORPS OFFICER PROMOTION

    Question. General Horoho, Nurse Corps Officers are promoted to the 
senior rank of Colonel (O-6) at a rate significantly less than their 
physician counterparts. Do you know if this promotion disparity has led 
to our more senior, experienced nurses leaving active duty service due 
to lack of promotion opportunities? What is your exit interview data 
telling you about why nurses are leaving active duty service?
    Answer. Our current exit survey data does not demonstrate that 
senior Army Nurse Corps Officers are leaving due to lack of promotion 
opportunities. Recent increases in authorizations for Colonel have 
improved promotion rates. However, we are validating all O-5 and O-6 
positions in order to optimize the force structure.
    Our exit surveys demonstrate that junior and mid-grade officers are 
leaving for a myriad of reasons to include a perceived lack of ability 
to remain in the clinical setting as they progress through their 
careers. To address this concern, we are developing a lifecycle that 
will enable more senior leaders to remain at the bedside to ensure we 
have the right mix of experience and leadership available to develop 
our junior officers and to ensure we provide world-class care.

                     DOCTORATE OF NURSING PRACTICE

    Question. General Horoho, several professional nursing 
organizations have proposed that the Doctorate of Nursing Practice 
(DNP) be the entry level into practice for all advanced practice 
nurses. Many schools of nursing are proposing to convert their Master 
of Science nursing degrees to DNP programs over the next several years. 
The DNP educational track adds an extra year onto the typical Masters 
level curriculum plan. Has there been any discussion of how this might 
affect Duty under Instruction planning in upcoming years? Could 
offering this post-Master's education option serve as a retention tool 
for mid-levels officers who might otherwise choose to leave active duty 
service?
    Answer. The Army Nurse Corps is actively evaluating the impact of 
the advent of the DNP educational track on our force modeling and 
selection opportunities. It is important that we maintain currency in 
our education options to maintain Long Term Health Education and 
Training as our primary retention and professional development tool. 
Both the Uniformed Services University Nurse Anesthesia Program and the 
U.S. Army Graduate Program in Anesthesia Nursing are transitioning to 
the DNP model to maintain their excellent standing in the civilian 
community.
                                 ______
                                 
      Questions Submitted to Major General Kimberly A. Siniscalchi
            Questions Submitted by Chairman Daniel K. Inouye

                             NURSE TRAINING

    Question. General Siniscalchi, we recognize that military nurses 
play critical roles in supporting both Disaster Relief and Humanitarian 
Assistant missions.
    What challenges have you encountered when faced with the need to 
train Air Force nurses to administer humanitarian nursing care, to 
include the need to provide shipboard training to assist with U.S. Navy 
missions?
    Answer. The fundamentals of nursing care remain the same regardless 
of environmental circumstance, whether humanitarian, disaster response, 
or contingency operations. Air Force nurses play an important role in 
joint operations. In 2008, U.S. Air Force nurses deployed aboard U.S. 
naval ships in support of numerous humanitarian missions including 
Pacific Partnership 2008. In addition to the standard medical 
deployment training, Air Force medics who are deployed onboard a U.S. 
Navy ship undergo ship-specific orientation to include: life raft 
training, ship fire drills, damage control training, and emergency ship 
egress.
    Additionally, Air Force nurses provided humanitarian support 
alongside U.S. Army personnel in South American locations during Joint 
Task Force Bravo and also to Central Command and European Command as 
part of a joint medical team in support of Operations IRAQI FREEDOM and 
ENDURING FREEDOM.

                PARTNERING WITH CIVILIAN NURSING SCHOOLS

    Question. General Siniscalchi, the University of Health Sciences 
has determined that conditions are not favorable for the creation of a 
Bachelors program in nursing at this time.
    What options for partnering with civilian Schools of Nursing have 
been discussed as a way to develop and recruit military nurse 
candidates?
    Answer. The USAF Nurse Corps is excited at the many opportunities 
to partner with our healthcare counterparts in civilian universities. 
As recently as March 14, Ada Sue Hinshaw, the Dean of the Graduate 
School of Nursing, Uniformed Services University, sponsored a 
conference that brought together Deans from Colleges of Nursing across 
the United States and the Tri-Service Military Nurse Corps Chiefs and 
their deputies. The conference was titled ``Conference for Academic 
Partnership Addressing the Military Nursing Shortage.'' The objective 
was to ``build collaborative relationships among military nursing 
services and schools of nursing to foster educational opportunities.'' 
It was an invaluable opportunity to share and discuss challenges, 
options, and ideas among key stakeholders.
    As the USAF Nurse Corps continues its collegial relationship with 
the University of Cincinnati, and as we establish a similar partnership 
with the Scottsdale Healthcare System in Scottsdale, Arizona, we are 
encouraged that our presence within these two exceptional civilian 
medical centers will also draw interest from local nursing students and 
staff.
    The USAF Nurse Corps is also at the precipice of establishing a 
first-ever Masters in Flight Nursing in collaboration with Wright State 
University in Dayton, Ohio.

                            NURSE RETENTION

    Question. General Siniscalchi, Nurse Corps officers are promoted to 
the senior rank of colonel (O-6) at a rate significantly less than 
their physician counterparts.
    Do you know if this promotion disparity has led to our more senior, 
experienced nurses leaving active duty service due to lack of promotion 
opportunities?
    Answer. The Air Force Nurse Corps has experienced disparity with 
promotion opportunity, and we believe it may be a factor in some senior 
nurses leaving active duty. However, we are working closely with 
Lieutenant General Newton, his team of personnelists and the Air Force 
Surgeon General to correct this disparity.
    Question. What is your exit interview data telling you about why 
nurses are leaving active duty service?
    Answer. We are currently exploring options to initiate/capture data 
from a Nurse Corps-wide survey, as well as a specific exit-survey. We 
look forward to obtaining data that will provide us with a more 
accurate picture of why nurses choose to separate from active duty.

                     DOCTORATE OF NURSING PRACTICE

    Question. General Siniscalchi, several professional nursing 
organizations have proposed that the Doctorate of Nursing Practice 
(DNP) be the entry level into practice for all advanced practical 
nurses. Many schools of nursing are proposing to convert their Master 
of Science nursing degrees to DNP programs over the next several years. 
The DNP educational track adds an extra year onto the typical Masters 
level curriculum plan.
    Has there been any discussion of how this might affect Duty under 
Instruction planning in upcoming years?
    Answer. One of the best recruiting tools in the Air Force is our 
educational opportunities. Our Nurse Corps officers have the ability to 
return to school full-time and earn a Masters and/or Doctoral degree. 
Most chief nurses use educational opportunities as an incentive to join 
when they do their recruiting interviews. The University of Health 
Sciences (USU) is uniquely situated in the Washington, DC, metropolitan 
area giving the university access to a variety of resources to include 
the National Institutes of Health, Office of the Secretary of Defense, 
Health Affairs, etc. Our students experience a very rigorous program 
that prepares them well for the future. Additionally, we are working 
very closely with Dean Hinshaw from USU to develop a curriculum in 
which our advance practice nurses can earn a Doctorate in Nursing 
Practice by 2015 as recommended by the American Nurses Association.
    Question. Could offering this post-Masters' education option serve 
as a retention tool for mid-level officers who might otherwise choose 
to leave active duty service?
    Answer. These opportunities for graduate education are significant 
retention tools, especially for our star performers. The University of 
Health Sciences (USU) allows our nurses to work with the other 
uniformed services in a very collaborative and joint way that is not 
possible in civilian universities. USU educational options are valuable 
in both recruitment and retention.

                          SUBCOMMITTEE RECESS

    Chairman Inouye. This subcommittee will reconvene on 
Wednesday March 25 at 10:30 a.m. At that time we'll receive 
testimony from the Guard and Reserve. Until then we'll stand in 
recess.
    [Whereupon, at 12:52 p.m., Wednesday, March 18, the 
subcommittee was recessed, to reconvene at 10:30 a.m., 
Wednesday, March 25.]
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