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



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2011

                              ----------                              


                       WEDNESDAY, MARCH 10, 2010

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:13 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Daniel K. Inouye (chairman) 
presiding.
    Present: Senators Inouye, Murray, and Cochran.

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF VICE ADMIRAL ADAM M. ROBINSON, JR., 
            SURGEON GENERAL, DEPARTMENT OF THE NAVY

             OPENING STATEMENT OF CHAIRMAN DANIEL K. INOUYE

    Chairman Inouye. The hearing will come to order.
    This morning, we will review the Department of Defense's 
medical programs.
    And we'll have two panels. First, we'll hear from the 
Surgeon Generals of the services: General Schoomaker, Admiral 
Adam Robinson, Jr., and General Charles Green. Then we'll hear 
from the Chiefs of the Nurse's Corps, General Patricia Horoho, 
Admiral Karen Flaherty, and General Kimberly Siniscalchi.
    And I'd like to welcome all of you this morning, and I'd 
like to welcome back General Schoomaker, Admiral Robinson, and 
a special welcome to General Green, when he gets here.
    Welcome, sir.
    General Green. Thank you. My apologies.
    Chairman Inouye. This is your first hearing, and we look 
forward to working together.
    The subcommittee holds a special hearing each year for an 
opportunity to discuss the critically important issues related 
to healthcare, the well-being of our servicemembers and their 
families. As such, the Surgeons General and the Chiefs of the 
Nurse's Corps have been called upon to share their insight on 
areas that need improvement and areas that see continuing 
success and progress.
    Military medicine is a critical element in our defense 
strength and an essential component of the benefits provided to 
our servicemembers and their families. We must ensure that the 
most advanced treatment and technology is being used by 
expertly trained personnel, and, on the battlefield, at the 
same time, providing sufficient capacity to care for 
servicemembers and their families at home.
    Our ability to care for our wounded on the modern 
battlefields is a testament both to hard work and dedication of 
our men and women in uniform and to the application of new 
technology, which is a hallmark of the United States Armed 
Forces. It is also due to the dedicated men and women in our 
Medical Service Corps that are deploying with our soldiers, 
airmen, sailors, and marines.
    On average, over 50 percent of our current Active Duty 
Medical Service Corps have deployed at least once. Numerous 
specialties have had multiple deployments. This tempo is making 
it more challenging to recruit and to retain qualified medical 
personnel into the services, and is presenting new stress for 
our caregivers who move from treating injured servicemembers on 
the battlefield to treating them back at home.
    We are concerned about the number of deployments for all 
servicemembers, but today I'd like to take this opportunity to 
highlight the impact on our medical personnel.
    Our medical personnel rely on a small pool of resources for 
deployment. While the total medical workforce is over 255,000, 
many of these individuals are civilians or contractors, and do 
not deploy. Therefore, the total pool of deployable military 
medical personnel is only 177,000 plus. In 2009, 12,700 medical 
personnel were deployed, over 7 percent of the pool. These 
numbers present serious challenges to the men and women 
testifying before us. It falls on them to ensure a proper 
balance of care at home and treatment on the battlefield, all 
the while furthering our advances in training and technology, 
and providing care for our caregivers.
    To help meet these needs, our medical service personnel 
must be provided sufficient resources. The fiscal year 2011 
budget before us goes a long way in providing these resources. 
The Department has made substantial progress in moving programs 
into the base budget that were initially funded through 
supplementals.
    Determining that medical research and prevention for 
injuries such as traumatic brain injury (TBI), psychological 
health, prosthetic, eye injuries, and hearing loss, and so much 
more, our co-budget responsibility of the Department of Defense 
(DOD) is essential in addressing the numerous issues facing our 
families and members.
    In addition, we're aware that resources are required to 
achieve a world-class facility at the new Walter Reed National 
Military Medical Center. We also understand that more will be 
required as we continue to identify the long-term needs of both 
our wounded and our nonwounded servicemembers and their 
families.
    These are some of the issues we'll discuss this morning, 
and I look forward to your testimony and note that your full 
statements will be made part of the record.
    And may I call upon you, Admiral Robinson, for the opening 
statement.

        SUMMARY STATEMENT OF VICE ADMIRAL ADAM M. ROBINSON, JR.

    Admiral Robinson. Thank you very much, sir.
    Good morning, Chairman Inouye, Senator Cochran, Senator 
Murray, distinguished members of the subcommittee. I want to 
thank you for your unwavering support of Navy medicine--
particularly as we continue to care for those who go in harm's 
way--their families, and all beneficiaries. I am honored to be 
with you today to provide an update on the state of Navy 
medicine, including some of our accomplishments, our challenges 
and our strategic priorities.
    Navy medicine: world-class care anytime, anywhere. This 
poignant phrase is arguably the most telling description of 
Navy medicine's accomplishments in 2009 and continues to drive 
our operational tempo and priorities for the coming years and 
beyond.
    Throughout the last year, we saw challenges and 
opportunities and, moving forward, I anticipate the pace of 
operations and demands will continue to increase. We have been 
stretched in our ability to meet our increasing operational and 
humanitarian assistance requirements, as well as maintain our 
commitment to provide care to a growing number of 
beneficiaries. However, I am proud to say that we are 
responding to this demand with more flexibility and agility 
than ever before.
    The foundation of Navy medicine is force health protection; 
it's what we do and why we exist. Nowhere is our commitment 
more evident than in Iraq and Afghanistan. During my October 
2009 trip to theater, I again saw the outstanding work of our 
medical personnel. The Navy medicine team is working side by 
side with Army and Air Force medical personnel and coalition 
forces to deliver outstanding healthcare to our troops and 
civilians alike.
    As our wounded warriors return from combat and begin the 
healing process, they deserve a seamless and comprehensive 
approach to their recovery. We want them to mend in body, mind, 
and spirit.
    Our patient and family centered approach brings together 
medical treatment providers, social workers, case managers, 
behavioral health providers, and chaplains. We are working 
closely with our line counterparts with the Marine Corps 
Wounded Warrior regiments and Navy's Safe Harbor, to support 
the full-spectrum recovery process for sailors, marines, and 
their families.
    We must act with a sense of urgency to continue to help 
build resiliency among our sailors and marines, as well as the 
caregivers who support them. We are aggressively working to 
reduce the stigma surrounding psychological health and 
operational stress concerns which can be a significant barrier 
to seeking mental health services.
    Programs such as Navy operational stress control, Marine 
Corps combat operational stress control, FOCUS--that is, 
families over coming under stress--caregiver occupational 
stress control, and our suicide prevention programs are in 
place and maturing to provide support to personnel and their 
families.
    An important focus area for all of us continues to be 
caring for our warriors suffering with traumatic brain injury. 
We are expanding TBI training to healthcare providers 
throughout the fleet and the Marine Corps. We are also 
implementing a new in-theater TBI Surveillance Program and 
conducting important research. We are also employing a strategy 
that is both collaborative and integrative by actively 
partnering with the other services, the Defense Center of 
Excellence for Psychological Health and Traumatic Brain Injury, 
the Department of Veterans Affairs, and leading academic 
medical and research centers, to make the best care available 
to our warriors.
    We must continue to recognize the occupational stress on 
our caregivers. They are subject to the psychological demands 
of exposure to trauma, loss, fatigue, and inner conflict. This 
is why our caregiver occupational stress control programs are 
so important to building and sustaining the resiliency of our 
providers.
    Mental health specialists are being placed in operational 
environments and forward deployed to provide services where and 
when they are needed. The Marine Corps is sending more mental 
health teams to the front lines, with the goal of better 
treating an emotionally strained force.
    Operational stress control and readiness teams, known as 
OSCAR, will soon be expanded to include the battalion level. 
This will put mental health support services much closer to 
combat troops.
    A mobile care team of Navy medicine mental health 
professionals is currently deployed to Afghanistan, conducting 
mental health surveillance, commander leadership consultation, 
and coordination of mental healthcare for sailors throughout 
the area of responsibility (AOR).
    As you know, an integral part of Navy medicine, or Navy's 
maritime strategy is humanitarian assistance and disaster 
relief. In support of Operation Unified Response, Haiti, Navy 
medicine answered the call. We deployed Comfort from her home 
port in Baltimore, within 77 hours of the order, and ahead of 
schedule. She was on station in Port-au-Prince, 5 days later. 
And from the beginning, the operational tempo onboard Comfort 
was high, and our personnel have been challenged, both 
professionally and personally. For many, this will, indeed, be 
a career-defining experience. And I spoke to the crew as they 
were preparing to get underway, and related just how important 
this mission is and why it is a vital part of Navy's maritime 
strategy.
    I am encouraged with our recruiting efforts within Navy 
medicine, and we are starting to see the results of new 
incentive programs. But, while overall manning levels for both 
officer and enlisted personnel are relatively high, ensuring we 
have the proper specialty mix continues to be a challenge in 
both the Active and Reserve components.
    Several wartime critical specialties, as well as advanced 
practice nursing and physicians assistants, are undermanned. We 
are facing shortfalls for general dentists, oral maxillofacial 
surgeons, and many of our mental health specialists, including 
clinical psychologists and social workers. We continue to work 
hard to meet this demand, but fulfilling the requirements among 
these specialties is expected to present a continuing 
challenge.
    Research and development is critical to Navy medicine's 
success and our ability to remain agile to meet the evolving 
needs of our warfighter. It is where we find solutions to our 
most challenging problems and, at the same time, provide some 
of medicine's most significant innovations and discoveries.
    Research efforts targeted at wound management, including 
enhanced wound repair and reconstruction, as well as extremity 
and internal hemorrhage control and phantom limb pain in 
amputees, present definitive benefits. These efforts support 
our emerging expeditionary medical operations and aid in 
support to our wounded warriors.
    Clearly, one of the most important priorities for 
leadership of all the services is the successful transition to 
the Walter Reed National Military Medical Center on board the 
campus at the National Naval Medical Center. We are working 
diligently with the lead DOD organizations, the Joint Task 
Force National Capital Medical, to ensure that this significant 
and ambitious project is executed without any disruption to 
services to our sailors, marines, and their families, and all 
of our beneficiaries for whom we are privileged and honored to 
serve.
    In summary, I believe that we are at an important 
crossroads for military medicine. How we respond to the 
challenges facing us today will likely set the stage for 
decades to come. Commitment to our wounded warriors and their 
families must never waiver, and our programs of support and 
hope must be built and sustained for the long haul. And the 
long haul is the rest of this century, when the young wounded 
warriors of today mature into our aging heroes in the latter 
part of this century. They will need our care and support, as 
well as their families, for a lifetime.

                           PREPARED STATEMENT

    On behalf of the men and women of Navy medicine, I want to 
thank the subcommittee for their tremendous support, their 
confidence and their leadership. It has been my pleasure to 
testify today, and I look forward to your questions.
    Thank you very much.
    [The statement follows:]

        Prepared Statement of Vice Admiral Adam M. Robinson, Jr.

                              INTRODUCTION

    Chairman Inouye, Senator Cochran, distinguished Members of the 
Subcommittee, I am honored to be with you today to provide an update on 
the state of Navy Medicine, including some of our accomplishments, 
challenges and strategic priorities. I want to thank the Committee 
Members for your unwavering support of Navy Medicine, particularly as 
we continue to care for those who go in harm's way, their families and 
all beneficiaries.
    Navy Medicine--World Class Care . . . Anytime, Anywhere. This 
poignant phrase is arguably the most telling description of Navy 
Medicine's accomplishments in 2009 and continues to drive our 
operational tempo and priorities for the coming year and beyond. 
Throughout the last year we saw challenges and opportunities; and 
moving forward, I anticipate the pace of operations and demands placed 
upon us will continue to increase. Make no mistake: We have been 
stretched in our ability to meet our increasing operational and 
humanitarian assistance requirements, as well as maintain our 
commitment to provide Patient and Family-Centered care to a growing 
number of beneficiaries. However, I am proud to say to that we are 
responding to this demand with more flexibility and agility than ever 
before. We are a vibrant, world-wide healthcare system fully engaged 
and integrated in carrying out the core capabilities of the Maritime 
Strategy around the globe. Regardless of the challenges ahead, I am 
confident that we are well-positioned for the future.
    Since becoming the Navy Surgeon General in 2007, I have invested 
heavily in our strategic planning process. How we accomplish our 
mission is rooted in sound planning, sharp execution and constructive 
self-assessment at all levels of our organization. I challenged our 
leadership to create momentum and establish a solid foundation of 
measurable progress. It's paying dividends. We are seeing improved and 
sustained performance in our strategic objectives. Just as importantly, 
our planning process supports alignment with the Department of Navy's 
Strategic Plan and Operations Guidance.
    Navy Medicine's commitment to Patient and Family-Centered Care is 
also reflected in our resourcing processes. An integral component of 
our Strategic Plan is providing performance incentives that promote 
quality and directly link back to workload and resources. We are 
evolving from a fiscal planning and execution process rooted in 
historical data, to a system which links requirements, resources and 
performance goals. This transformation properly aligns authority, 
accountability and financial responsibility with the delivery of 
quality, cost-effective healthcare.
    The President's budget for fiscal year 2011 adequately funds Navy 
Medicine to meet its medical mission for the Navy and Marine Corps. The 
budget also provides for the maintenance of our facilities. We are, 
however, closely assessing the resource impacts associated with 
Operation Unified Response, in Haiti. While seeking reimbursement as 
appropriate from U.S. Southern Command in accordance with DOD 
direction, we are working to mitigate any potential impacts--both in 
the short-term and long-term. We are cross-leveling personnel, meaning 
that we are assigning personnel within Navy Medicine to ensure 
effective use of existing resources, while leveraging support from the 
Navy Reserve, the other Services and our civilian network partners, as 
needed, and when conditions warrant.

                        FORCE HEALTH PROTECTION

    The foundation of Navy Medicine is Force Health Protection. It's 
what we do and why we exist. In executing our Force Health Protection 
mission, the men and women of Navy Medicine are engaged in all aspects 
of expeditionary medical operations in support of our warfighters. The 
continuum of care we provide includes all dimensions of physical and 
psychological well-being. This is our center of gravity and we have and 
will continue to ensure our Sailors and Marines are medically and 
mentally prepared to meet their world-wide missions.
    Nowhere is our commitment to Force Health Protection more evident 
than in our active engagement in military operations in Iraq and 
Afghanistan. As these overseas contingency operations evolve, and in 
many respects become increasingly more dangerous, we are seeing 
burgeoning demand for expeditionary combat casualty care in support of 
joint operations. I recently returned from a trip to Afghanistan and I 
again saw the outstanding work of our medical personnel. The Navy 
Medicine team is working side-by-side with Army and Air Force medical 
personnel and coalition forces to deliver outstanding healthcare to our 
troops and civilians alike.
    We must continue to be innovative and responsive at the deckplates 
and on the battlefield. Since the start of Operation Enduring Freedom 
and Operation Iraqi Freedom, the Marine Corps has fielded new combat 
casualty care capabilities which include: updated individual first aid 
kits with combat gauze, advanced tourniquets, use of Tactical Combat 
Casualty Care principles, troop training in Combat Lifesaver, and the 
use of Factor VII--a blood clotting agent used in trauma settings. In 
addition, Navy Fleet Hospital transformation has redesigned 
expeditionary medical facilities that are lighter, modular, more 
mobile, and interoperable with other Services' facilities.
    Our progress is also evident in the innovative work undertaken by a 
Shock Trauma Platoon (STP) 2 years ago in Afghanistan. This team, 
comprised of two physicians, two nurses, a physician assistant and 14 
corpsmen, essentially created a mobile emergency room--a seven-ton 
truck with a Conex container and welded steel plates--that went into 
combat to administer more expedient and effective care in austere 
settings. This prototype led to the creation of the Mobile Trauma Bay 
(MTB), a capability that both Marine Corps and Navy Medicine leadership 
immediately recognized as vital to the warfighter and an unquestionable 
life-saver on the battlefield. MTB use has already been incorporated 
into our Afghanistan shock trauma platoon operations, and they are 
already positively impacting forward resuscitative and stabilization 
care. We understand that the Marine Corps has fully embraced the MTB 
concept and is planning to add additional units in future POM 
submissions.

             HUMANITARIAN ASSISTANCE AND DISASTER RESPONSE

    An integral part of the Navy's Maritime Strategy is humanitarian 
assistance and disaster response. In the wake of the devastating 
earthquake in Haiti earlier this year, our Nation moved forward with 
one of the largest relief efforts in our history to save lives, deliver 
critically needed supplies and provide much-needed hope. The response 
was rapid, as Navy deployed ships and expeditionary forces, comprised 
of more than 10,000 personnel, to provide immediate relief and support 
for the Haitian people. In support of Operation Unified Response, Navy 
Medicine answered the call. We deployed USNS Comfort (T-AH 20) from her 
homeport in Baltimore within 77 hours and ahead of schedule--going from 
an industrial shipboard site to a ready afloat Naval hospital, fully 
staffed and equipped. She was on station in Port-au-Prince 5 days later 
and treating patients right away. From the beginning, the operational 
tempo onboard USNS Comfort has been high with a significant trauma and 
surgical caseload. Medical teams from the ship are also ashore to help 
in casualty evaluation, triage crush wounds, burn injuries and other 
health issues. Providing care around the clock, our personnel have been 
challenged both professionally and personally. For many, this will be a 
career-defining experience and certainly reflects the Navy's commitment 
as a ``Global Force for Good.'' I spoke to the crew as they were 
preparing to get underway, and personally related just how important 
this mission is and why it is a vital part of the Navy's Maritime 
Strategy.
    We train so we are mission ready and USNS Comfort was well-prepared 
for this challenging deployment as a result of her crew's participation 
in Continuing Promise (April-June 2009), a humanitarian and civic 
assistance mission, in partnership with nations of the Caribbean and 
Latin America, to provide medical, dental, veterinary, educational and 
engineering programs both ashore and afloat.
    We are continuing to respond to requirements from the Commander, 
U.S. Southern Command in order to put the proper supporting medical 
elements in the area of operations. Navy Medicine additional support 
includes the deployment of a Forward Deployed Preventive Medicine Unit 
(FDPMU) and augmented Casualty Receiving and Treatment Ship (CRTS) 
medical staff capabilities onboard U.S.S. Bataan (LHD 5). We also 
recognize the potential psychological health impact on our medical 
personnel involved in this humanitarian assistance mission and have 
ensured we have trained Caregiver Occupational Stress Control (CgOSC) 
staff onboard.
    Navy Medicine is inherently flexible and capable of meeting the 
call to support multiple missions. I am proud of the manner in which 
the men and women of Navy Medicine leaned forward in response to the 
call for help. In support of coordination efforts led by the Department 
of State and the U.S. Agency for International Development, and in 
collaboration with nongovernmental organizations, both domestic and 
international, our response demonstrated how the expeditionary 
character of our Naval and Marine forces is uniquely suited to provide 
assistance during interagency and multinational efforts.

                            CONCEPT OF CARE

    Navy Medicine's Concept of Care is Patient and Family-Centered 
Care. It is at the epicenter of everything we do. This concept is 
elegant in its simplicity yet extraordinarily powerful. It identifies 
each patient as a participant in his or her own healthcare and 
recognizes the vital importance of the family, military culture and the 
military chain of command in supporting our patients. My goal is for 
this Concept of Care--this commitment to our patients and their 
families--to resonate throughout our system and guide all our actions. 
It is enabled by our primary mission to deliver force health protection 
and a fully ready force; mutually supported by the force multipliers of 
world class research and development, and medical education. It also 
leverages our emphasis on the health and wellness of our patients 
through an active focus on population health.

                         CARING FOR OUR HEROES

    When our Warriors go into harm's way, we in Navy Medicine go with 
them. At sea or on the ground, Sailors and Marines know that the men 
and women of Navy Medicine are by their side ready to care for them. 
There is a bond of trust that has been earned over years of service 
together, and make no mistake, today that bond is stronger than ever. 
Our mission is to care for our wounded, ill and injured, as well as 
their families. That's our job and it is our honor to have this 
opportunity.
    As our Wounded Warriors return from combat and begin the healing 
process, they deserve a seamless and comprehensive approach to their 
recovery. We want them to mend in body, mind and spirit. Our focus is 
multidisciplinary-based care, bringing together medical treatment 
providers, social workers, case managers, behavioral health providers 
and chaplains. We are working closely with our line counterparts with 
programs like the Marine Corps' Wounded Warrior Regiments and the 
Navy's Safe Harbor to support the full-spectrum recovery process for 
Sailors, Marines and their families.
    Based on the types of injuries that we see returning from war, Navy 
Medicine continues to adapt our capabilities to best treat these 
conditions. When we saw a need on the West Coast to provide expanded 
care for returning Wounded Warriors with amputations, we established 
the Comprehensive Combat and Complex Casualty Care (C\5\) Program at 
Naval Medical Center, San Diego, in 2007. C\5\ manages severely injured 
or ill patients from medical evacuation through inpatient care, 
outpatient rehabilitation, and their eventual return to active duty or 
transition from the military. We are now working to expand utilization 
of Project C.A.R.E--Comprehensive Aesthetic Recovery Effort. This 
initiative follows the C\5\ model by ensuring a multidisciplinary 
approach to care, yet focuses on providing state-of-the-art plastic and 
reconstructive surgery for our Wounded Warriors at both Naval Medical 
Center San Diego and Naval Medical Center Portsmouth, with potential 
future opportunities at other treatment facilities.
    We have also significantly refocused our efforts in the important 
area of clinical case management at our military treatment facilities 
and major clinics serving Wounded Warriors to ensure appropriate case 
management services are available to all who need them. The Clinical 
Case Management Program assists patients and families with clinical and 
non-clinical needs, facilitating communication between patient, family 
and multi-disciplinary care team. Our clinical case managers 
collaborate with Navy and Marine Corps Recovery Care Coordinators, 
Federal Recovery Coordinators, Non-Medical Care Managers and other 
stakeholders to address Sailor and Marine issues in developing Recovery 
Care Plans. As of January 2010, 192 Clinical Case Managers are assigned 
to Military Treatment Facilities and ambulatory care clinics caring for 
over 2,900 Sailors, Marines and Coast Guardsmen.

             PSYCHOLOGICAL HEALTH AND POST-TRAUMATIC STRESS

    We must act with a sense of urgency to help build resiliency among 
our Sailors and Marines, as well as the caregivers who support them. We 
recognize that operational tempo, including the number and length of 
deployments, has the potential to impact the psychological health of 
service members and their family members. We are aggressively working 
to reduce the stigma surrounding psychological health and operational 
stress concerns which can be a significant barrier to seeking mental 
health services for both military personnel and civilians. Programs 
such as Navy Operational Stress Control, Marine Corps Combat 
Operational Stress Control, FOCUS (Families Overcoming Under Stress), 
Caregiver Occupational Stress Control (CgOSC), and our suicide 
prevention programs (A-C-T Ask-Treat-Care) are in place and maturing to 
provide support to personnel and their families.
    The Navy Operational Stress Control program and Marine Corps Combat 
Operational Stress Control program are the cornerstones of the 
Department of the Navy's approach to early detection of stress injuries 
in Sailors and Marines and are comprised of:
  --Line led programs which focus on leadership's role in monitoring 
        the health of their people.
  --Tools leaders may employ when Sailors and Marines are experiencing 
        mild to moderate symptoms.
  --Multidisciplinary expertise (medical, chaplains and other support 
        services) for more affected members.
    Decreasing the stigma associated with seeking psychological 
healthcare requires a culture change throughout the Navy and Marine 
Corps. Confronting an ingrained culture will take time and active 
leadership support. Stigma reducing interventions span three major 
fronts: (1) education and training for individual Sailors and Marines 
that normalizes mental healthcare; (2) leadership training to improve 
command climate support for seeking mental healthcare; and (3) 
encouragement of care outreach to individual Sailors, Marines, and 
their commands. This past year saw wide-spread dissemination of 
Operational Stress Control (OSC) doctrine as well as a Navy-wide 
education and training program that includes mandatory Navy Knowledge 
Online courses, instructor led and web-based training.
    Navy Medicine ensures a continuum of psychological healthcare is 
available to service members throughout the deployment cycle--pre-
deployment, during deployment, and post-deployment. We are working to 
improve screening and surveillance using instruments such as the 
Behavior Health Needs Assessment Survey (BHNAS) and Post-Deployment 
Health Assessment (PDHA) and Post-Deployment Health Reassessment 
(PDHRA).
    Our mental health specialists are being placed in operational 
environments and forward deployed to provide services where and when 
they are needed. The Marine Corps is sending more mental health teams 
to the front lines with the goal of better treating an emotionally 
strained force. Operational Stress Control and Readiness (OSCAR) teams 
will soon be expanded to include the battalion level, putting mental 
health support services much closer to combat troops. A Mobile Care 
Team (MCT) of Navy Medicine mental health professionals is currently 
deployed to Afghanistan to conduct mental health surveillance, command 
leadership consultation, and coordinate mental healthcare for Sailors 
throughout the AOR. In addition to collecting important near real-time 
surveillance data, the MCT is furthering our efforts to decrease stigma 
and build resilience.
    We are also making mental health services available to family 
members who may be affected by the psychological consequences of combat 
and deployment through our efforts with Project FOCUS, our military 
treatment facilities and our TRICARE network partners. Project FOCUS 
continues to be successful and we are encouraged that both the Army and 
Air Force are considering implementing this program. We also recognize 
the importance of the counseling and support services provided through 
the Fleet and Family Support Centers and Marine Corps Community 
Services.
    Beginning in 2007, Navy Medicine established Deployment Health 
Centers (DHCs) as non-stigmatizing portals of care for service members 
staffed with primary care and psychological health providers. We now 
have 17 DHCs operational. Our healthcare delivery model supports early 
recognition and treatment of deployment-related psychological health 
issues within the primary care setting. Psychological health services 
account for approximately 30 percent of all DHC encounters. We have 
also increased mental health training in primary care, and have 
actively partnered with Line leaders and the Chaplain Corps to develop 
combat and operational stress control training resources. Awareness and 
training are keys to our surveillance efforts. Over 4,000 Navy Medicine 
providers, mental health professionals, chaplains and support personnel 
have been trained to detect, screen and refer personnel who may be 
struggling with mental health issues.
    We must continue to recognize the occupational stress on our 
caregivers. They are subject to the psychological demands of exposure 
to trauma, loss, fatigue and inner conflict. This is why our Caregiver 
Occupational Stress Control programs are so important to building and 
sustaining the resiliency of our providers. We cannot overlook the 
impact on these professionals and I have directed Navy Medicine 
leadership to be particularly attuned to this issue within their 
commands.

                         TRAUMATIC BRAIN INJURY

    While there are many significant injury patterns in theatre, an 
important focus area for all of us remains Traumatic Brain Injury 
(TBI). Blast is the signature injury of OEF and OIF--and from blast 
injury comes TBI. The majority of TBI injuries are categorized as mild, 
or in other words, a concussion. Yet, there is much we do not yet know 
about these injuries and their long-term impacts on the lives of our 
service members.
    The relative lack of knowledge about mild TBI amongst service 
members and healthcare personnel represents an important gap that Navy 
Medicine is seriously addressing. We are providing TBI training to 
healthcare providers from multiple disciplines throughout the fleet and 
the Marine Corps. This training is designed to educate personnel about 
TBI, introduce the Military Acute Concussion Exam (MACE) as a screening 
tool for mild TBI, inform providers about the Automated Neurocognitive 
Assessment Metric (ANAM) test, and identify a follow-up for assessment 
including use of a repeatable test battery for identification of 
cognitive status. We have recently established and are now expanding 
our TBI program office to manage the implementation of the ANAM as a 
pre-deployment test for service members in accordance with DOD policy. 
This office will further develop models of assessment and care as well 
as support research and evaluation programs.
    All the Services expect to begin implementation of a new in-theater 
TBI surveillance system which will be based upon incident event 
tracking. Promulgated guidelines will mandate medical evaluation for 
all service members exposed within a set radius of an explosive blast, 
with the goal to identify any service member with subtle cognitive 
deficits who may not be able to return to duty immediately.
    Navy Medicine has begun implementing the ANAM assessment at the 
DHCs and within deploying units as part of an Assistant Secretary of 
Defense (Health Affairs) mandate. We have also partnered with Line 
leadership, or operational commanders, to identify populations at risk 
for brain injury (e.g., front line units, SEAL units, and Navy 
Explosive Ordinance Disposal units). In addition, an in-theater 
clinical trial for the treatment of vestibular symptoms of blast-
exposure/TBI was completed at the USMC mTBI Center in Al Taqqadum, 
Iraq.
    Both our Naval Health Research Center and Navy-Marine Corps Public 
Health Center are engaged with tracking TBI data through ongoing 
epidemiology programs. Goals this year include the establishment of a 
restoration center in-theatre to allow injured Sailors and Marines a 
chance to recover near their units and return to the fight.
    Additionally, the National Naval Medical Center's Traumatic Stress 
and Brain Injury Program provides care to all blast-exposed or head-
injured casualties returning from theatre to include patients with an 
actual brain injury and traumatic stress. Navy Medicine currently has 
TBI clinics at San Diego, Portsmouth, Camp Pendleton and Camp Lejeune 
with plans for further expansion reflecting our commitment to the 
treatment of this increasingly prevalent injury.
    We are employing a strategy that is both collaborative and 
integrative by actively partnering with the other Services, Defense 
Center of Excellence for Psychological Health and Traumatic Brain 
Injury, the Veterans Administration, and leading academic medical and 
research centers to make the best care available to our Warriors 
afflicted with TBI.

              EXCELLENCE IN RESEARCH AND DEVELOPMENT (R&D)

    Research and development is critical to Navy Medicine's success and 
our ability to remain agile to meet the evolving needs of our 
warfighters. It is where we find solutions to our most challenging 
problems and, at the same time, provide some of medicine's most 
significant innovations and discoveries. Our R&D programs are truly 
force-multipliers and enable us to provide world-class healthcare to 
our beneficiaries.
    The approach at our research centers and laboratories around the 
world is straightforward: Conduct health and medical research, 
development, testing, evaluation and surveillance to enhance deployment 
readiness. Each year, we see more accomplishments which have a direct 
impact on improving force health protection. The contributions are many 
and varied, ranging from our confirmatory work in the early stages of 
the H1N1 pandemic, to the exciting progress in the development of a 
malaria vaccine. Research efforts targeted at wound management, 
including enhanced wound repair and reconstruction as well as extremity 
and internal hemorrhage control, and phantom limb pain in amputees, 
present definitive benefits. These efforts also support our emerging 
expeditionary medical operations and aid in support to our Wounded 
Warriors.

                         THE NAVY MEDICINE TEAM

    Navy Medicine is comprised of compassionate and talented 
professionals who continue to make significant contributions and 
personal sacrifices to our global community. Our team includes our 
officers, enlisted personnel, government civilian employees, contract 
workers and volunteers working together in a vibrant healthcare 
community. All have a vital role in the success of our enterprise. Our 
priority is to maintain the right workforce to deliver the required 
medical capabilities across the enterprise, while using the appropriate 
mix of accession, retention, education and training incentives.
    Overall, I am encouraged with our recruiting efforts within Navy 
Medicine and we are starting to see the results of new incentive 
programs. But while overall manning levels for both officer and 
enlisted personnel are relatively high, ensuring we have the proper 
specialty mix continues to be a challenge. Several wartime critical 
specialties including psychiatry, family medicine, general surgery, 
emergency medicine, critical care and perioperative nursing, as well as 
advanced practice nursing and physician assistants, are undermanned. We 
are also facing shortfalls for general dentists, oral maxillofacial 
surgeons, and many of our mental health specialists including clinical 
psychologists and social workers. We have increasing requirements for 
mental health professionals as well as for Reserve Component Medical 
Corps, Dental Corps, Medical Service Corps and Nurse Corps officers. We 
continue to work hard to meet this demand, but fulfilling the 
requirements among these specialties is expected to present a 
continuing challenge.
    I want to also reemphasize the priority we place on diversity. We 
are setting the standard for building a diverse, robust, innovative 
healthcare workforce, but we can do more in this important area. Navy 
Medicine is stronger and more effective as a result of our diversity at 
all levels. Our people are our most important resource, and their 
dignity and worth are maintained through an atmosphere of service, 
professionalism, trust and respect.

                     PARTNERSHIPS AND COLLABORATION

    Navy Medicine continues to focus on improving interoperability with 
the Army, Air Force, Veterans Administration (VA), as well other 
Federal and civilian partners to bring operational efficiencies, 
optimal technology and training together in support of our patients and 
their families, our missions, and the national interests. Never has 
this collaborative approach been more important, particularly as we 
improve our approaches to ensuring seamless transitions for our 
veterans.
    We remain committed to resource sharing agreements with the VA and 
our joint efforts in support of improving the Disability Evaluation 
System (DES) through the ongoing pilot program at several MTFs. The 
goal of this pilot is to improve the disability evaluation process for 
service members and help simplify their transitions. Together with the 
VA and the other Services, we are examining opportunities to expand 
this pilot to additional military treatment facilities. Additionally, 
in partnership with the VA, we will be opening the James A. Lovell 
Federal Health Care Center in Great Lakes, Illinois--a uniquely 
integrated Navy/VA medical facility.
    We also look forward to leveraging our inter-service education and 
training capabilities with the opening of the Medical Education and 
Training Campus (METC) in San Antonio in 2010. This new tri-service 
command will oversee the largest consolidation of service training in 
DOD history. I am committed to an inter-service education and training 
system that optimizes the assets and capabilities of all DOD healthcare 
practitioners yet maintains the unique skills and capabilities that our 
hospital corpsmen bring to the Navy and Marine Corps--in hospitals, 
clinics at sea and on the battlefield.
    Clearly one of the most important priorities for the leadership of 
all the Services is the successful transition to the Walter Reed 
National Military Medical Center onboard the campus of the National 
Naval Medical Center, Bethesda. We are working diligently with the lead 
DOD organization, Joint Task Force--National Capital Region Medical, to 
ensure that this significant and ambitious project is executed properly 
and without any disruption of services to our Sailors, Marines, their 
families, and all our beneficiaries for whom we are privileged to 
serve.

                            THE WAY FORWARD

    I believe we are at an important crossroads for military medicine. 
How we respond to the challenges facing us today will likely set the 
stage for decades to come. Commitment to our Wounded Warriors and their 
families must never waver and our programs of support and hope must be 
built and sustained for the long-haul--and the long-haul is the rest of 
this century when the young Wounded Warriors of today mature into our 
aging heroes in the years to come. They will need our care and support 
as will their families for a lifetime. Likewise, our missions of 
cooperative engagement, through humanitarian assistance and disaster 
response, bring opportunities for us, our military and the Nation. It 
is indeed a critical time in which to demonstrate that the United 
States Navy is truly a ``Global Force for Good.''
    Navy Medicine is a vibrant, world-wide healthcare system comprised 
of compassionate and talented professionals who are willing to make 
contributions and personal sacrifices. This team--our team--including 
officer, enlisted, civilians, contractors, and volunteers work together 
as a dynamic healthcare family. We are all essential to success.
    Navy Medicine will continue to meet the challenges ahead and 
perform our missions with outstanding skill and commitment. On behalf 
of the men and women of Navy Medicine, I want to thank the Committee 
for your tremendous support, confidence and leadership. It has been my 
pleasure to testify before you today and I look forward to your 
questions.

    Chairman Inouye. I thank you very much, Admiral.
    Before we proceed, I must apologize to my vice chairman for 
overlooking his presence. May I call upon the vice chairman for 
his opening statement.
    Senator Cochran. Mr. Chairman, thank you very much.
    It's a pleasure to join you in welcoming the leaders of our 
doctors and nurses who serve in the military forces. We 
appreciate their sacrifice and their service and their 
leadership in helping ensure that, here at home and around the 
world, our servicemen and women get the best medical care 
available. We look forward to working with you in the 
appropriations process to identify priorities, to make sure 
that we have money where the needs are, and living up to the 
commitment that we all feel toward our servicemembers and their 
families who sacrifice so much for the security interests of 
our country.
    Thank you very much for your service and for your presence 
here today.
    Chairman Inouye. Senator Murray.
    Senator Murray. Mr. Chairman, I will pass on an opening 
statement.
    I just want to thank all of our witnesses today, and for 
having this important hearing.
    Chairman Inouye. Thank you. Thank you very much.
    And I'd like to now call upon the Surgeon General of the 
Army, General Schoomaker.

STATEMENT OF LIEUTENANT GENERAL ERIC B. SCHOOMAKER, 
            M.D., Ph.D., SURGEON GENERAL; AND 
            COMMANDER, U.S. ARMY MEDICAL COMMAND, 
            DEPARTMENT OF THE ARMY
    General Schoomaker. Chairman Inouye, Vice Chairman Cochran, 
Senator Murray, and other distinguished members of the Defense 
Subcommittee, thank you for inviting us here to discuss the 
Defense Health Program and our respective service medical 
programs.
    Now, in my third congressional hearing cycle as the Army 
Surgeon General and the Commanding General of the Army Medical 
Command, I can tell you that these hearings are valuable 
opportunities for me to talk about the accomplishments and 
challenges of Army medicine, and to hear--for all of us to hear 
your collective perspectives regarding military health 
promotion and healthcare.
    You and your staff members ask some difficult questions, 
but these questions help keep us focused on those whom we 
serve: our soldiers, sailors, airmen, marines, coast guardsmen, 
our family members, our retirees, and the American public at 
large.
    Sir, you earlier introduced her, but I wanted to take this 
opportunity to welcome and introduce my chief of the Army Nurse 
Corps, returning from a very successful command of the Western 
Regional Medical Command, headquartered at Fort Lewis, 
Washington, and covering the western third of the United 
States, including Alaska, Major General Patty Horoho. I'm 
pleased to say that she'll be joining me on my staff as our 
Deputy Surgeon General, as of the 1st of April, when David 
Rubenstein leaves a very successful tour to take command of the 
Army Medical Center and School in San Antonio, Texas.
    And so, Patty, welcome, and we're glad to have you on the 
staff.
    I'm pleased to tell you that the President's budget 
submission for fiscal year 2011 fully funds the Army Medical 
Department's needs. Your support of the President's proposed 
budget will be greatly appreciated.
    One particular area of special interest to this 
subcommittee is our comprehensive effort to improve warrior 
care from the point of injury through evacuation and inpatient 
treatment to rehabilitation and return to duty or to productive 
citizens' lives. We, in Army medicine, continue to focus our 
efforts on our ``warriors in transition,'' which is the term we 
apply to our wounded and injured soldiers. And I want to thank 
the Congress for its unwavering support of this effort.
    The support of this subcommittee has allowed us to hire 
additional providers to staff our warrior transition units, the 
units to which these warriors in transition are assigned, to 
conduct relevant medical research, and to build even healing 
campuses across the Army.
    I'm convinced the Army has made some lasting improvements 
there. The most important improvement may be the change of 
mindset from a focus on disability to an emphasis on ability 
and achievement. Each of these warriors has the opportunity and 
the resources to create their own future as soldiers or as 
productive private citizens. I should say, in this forum, sir, 
lessons which you, yourself, taught us following your own 
battle injuries in--in World War II, Mr. Chairman.
    In keeping with our focus on preventing injury and illness, 
Army leadership is currently engaged in an all-out effort to 
change the Department of Defense's culture regarding traumatic 
brain injury, or TBI, especially the milder form, which we call 
``concussion.'' Our goal is nothing less than a cultural change 
in the management of soldiers after potential concussive 
events. Every warrior requires appropriate treatment to 
minimize concussive injury and to maximize recovery. To achieve 
this goal, we are educating the force so as to have trained and 
prepared soldiers, leaders, and medical personnel to provide 
early recognition, treatment, and tracking of concussive 
injuries, ultimately designed to protect warrior health.
    Traumatic brain injury is a disruption of brain function 
that results from a blow or a jolt to the head or a penetrating 
head injury. These occur in combat, they occur on our highways, 
on our training posts, and on sports fields across the Nation. 
It's not a phantom condition that is exhibited by a weak 
servicemember who's trying to get out of a deployment. A 
servicemember who's behaving badly or irregularly may be 
struggling and needs help, and we feel very strongly that we 
need to do everything we can to take care of these warriors who 
need help. Leaders at all levels must ensure that individuals 
are aware of, and are willing to take advantage of, available 
treatments and counseling options.
    Our concern is--and this has been documented in a number of 
studies that we've conducted, including those in the 
battlefield--that our soldiers and other servicemembers are not 
coming forward for treatment after the time of an incident. 
This results in delay in identification, and it compliments the 
treatment course back here in the United States. We know that 
early detection leads to early treatment and improved outcomes. 
However, undiagnosed concussion leads to symptoms affecting 
operational readiness on the battlefield and the risk of 
recurrent concussion during the healing period, which can then 
lead to more long-term permanent brain impairment.
    An overview of the education program that we've worked on 
here is included in this packet, ``Brain Injury Awareness 
Toolkit,'' which we have available for you and your staffs 
after the hearing.
    The Army is issuing very direct standards and protocols to 
Commanders and healthcare providers in the field, similar to 
actions taken after aviation incidents. We have automatic 
grounding and medical assessments which are required for any 
soldiers that meets specified criteria.
    The end state of these efforts is that every servicemember 
sustaining a potential concussion will receive early detection, 
state-of-the-art treatment, and return-to-duty evaluation, with 
long-term digital healthcare record tracking of their 
management.
    Treatment of mild traumatic brain injury, or concussion, is 
an emerging science. We feel strongly that the Army is leading 
the way in implementing these new treatment protocols for the 
Department of Defense, and that the Department of Defense and 
the military health system (MHS) is leading the Nation in this 
regard. I truly believe that this evidence-based directive 
approach to concussive management is going to change the 
military culture regarding head injuries and significantly 
impact the well-being of the force.
    In closing, I'm very optimistic about the next 2 years. We 
have weathered some very serious challenges to the trust that 
you all have in Army medicine. Logic would not predict that we 
would be doing as well as we are, and attracting and retaining 
and career-developing such a talented team of uniformed and 
civilian medical professionals. However, we continue to do so, 
year after year, a tribute to all of our Officer Corps and the 
leadership of our Noncommissioned Officer Corps and our 
military and civilian workforce. Their continued leadership and 
dedication are essential for Army medicine to remain strong, 
for the Army to remain healthy and resilient, and for the 
Nation to endure.
    I personally feel very privileged to serve with these men 
and women in Army medicine, as soldiers, as Americans, and as 
global citizens.

                           PREPARED STATEMENT

    We thank you for holding this hearing and for your 
unwavering support of the military health system and of Army 
medicine, and I look forward to answering your questions.
    Thank you, sir.
    Chairman Inouye. I thank you very much, General.
    [The statement follows:]

      Prepared Statement of Lieutenant General Eric B. Schoomaker

    Chairman Inouye, Vice Chairman Cochran, and distinguished members 
of the Defense Subcommittee, thank you for inviting us to discuss the 
Defense Health Program and our respective Service medical programs. Now 
in my third Congressional hearing cycle as the Army Surgeon General and 
Commanding General, U.S. Army Medical Command (MEDCOM), I can tell you 
that these hearings are valuable opportunities for me to talk about the 
accomplishments and challenges of Army Medicine and to hear your 
collective perspectives regarding military healthcare. You and your 
staff members ask some difficult questions, but these questions help 
keep us focused on those we serve--the Soldiers, Sailors, Marines, 
Airmen, Coast Guardsmen, Family members, and Retirees as well as the 
American public. I hope you also find these hearings beneficial as you 
review the President's budget submission, which this year fully funds 
the Army Medical Department's needs, and determine priorities and 
funding levels for the next fiscal year.
    The U.S. Army Medical Department is a complex, globally-deployed, 
and world class team. My command element alone, the MEDCOM, is an $11 
billion international health improvement, health protection, emergency 
response and health services organization staffed by 70,000 dedicated 
Soldiers, civilians, and contractors. I am in awe at what these 
selfless servants have done over the past years--their accomplishments 
have been quietly, effectively, powerfully successful. While we have 
experienced our share of crises and even tragedies, despite 8 years of 
continuous armed conflict for which Army Medicine bears a heavy load, 
every day our Soldiers and their Families are kept from injuries, 
illnesses, and combat wounds through our health promotion and 
prevention efforts; are treated in cutting-edge fashion when prevention 
fails; and are supported by an extraordinarily talented medical force 
to include those who serve at the side of the Warrior on the 
battlefield. We mourn the loss of 26 teammates in the Fort Hood 
shootings--six dead and 20 wounded--but are inspired by the resolve 
shown by their units to continue their missions and the exemplary 
performance of the 467th and 1908th Medical Detachments serving in 
Afghanistan today.
    One particular area of special interest to this subcommittee is our 
comprehensive effort to improve warrior care from point of injury 
through evacuation and inpatient treatment to rehabilitation and return 
to duty. I am convinced the Army has made some lasting improvements, 
and I was recently heartened to read the comments of a transitioning 
Warrior that reinforced these perceptions. She commented:

    ``As I look back in the past I am able to see with a reflective eye 
. . . the people that have helped me fight this battle, mostly my chain 
of command, who have always stood beside me instead of in front of me. 
They have gone out of their way to do what was best for me and I cannot 
say I would be here still if I hadn't had such wonderful support . . . 
This is my story at the WTB and all in all, I just had to make aware to 
everyone that has helped that I am very grateful and I truly appreciate 
all of the work you have done for me.''

    There is nothing more gratifying than to care for these wounded, 
ill, and injured heroes. We in Army Medicine continue to focus our 
efforts on our Warriors in Transition and I want to thank Congress for 
your unwavering support. The support of this committee has allowed us 
to hire additional providers, staff our warrior transition units, 
conduct relevant medical research, and build healing campuses. In the 
remainder of my testimony today, I will discuss how we are providing 
optimal stewardship of the investment the American public and this 
Committee has made in Army Medicine.
    We lead and manage Army Medicine through the Kaplan & Norton 
Balanced Scorecard performance improvement framework that I introduced 
to you in last year's testimony. The Scorecard balances missions and 
resources across a broad array, while ensuring that near-term measures 
of success are aligned with longer-term, more strategic results. This 
balancing is depicted on the Scorecard's Strategy Map, which shows how 
we marshal our resources, train and develop our people, and focus our 
internal processes and efforts so as to balance competing goals. 
Ultimately our means, ways, and ends contribute toward accomplishing 
our mission and achieving our strategic vision. The five strategic 
themes that guide our daily efforts are: Maximize Value in Health 
Services, Provide Global Operational Forces, Build the Team, Balance 
Innovation with Standardization, and Optimize Communication and 
Knowledge Management. Although distinct themes, they inevitably overlap 
and weave themselves through everything we do in Army Medicine.
    The first strategic theme--Maximize Value in Health Services--is 
built on the belief that providing high quality, evidence-based 
services is not only the right for our Soldiers and Families; it 
results in the most efficient use of resources within the healthcare 
system, thus delivering value to not only our Patients, but indeed, the 
Nation. In fact, what we really want to do is move from a healthcare 
system to a system for health.
    We have resisted simply inventing a new process, inserting a new 
diagnostic test or therapeutic option in vacuo or adding more layers of 
bureaucracy but are truly adding value to the products we deliver, the 
care we provide, and the training of our people. This requires focusing 
on the clinical outcome for the patient and the community and 
maintaining or even reducing the overall resource expenditure needed to 
achieve this objective. It has occurred through adoption of evidence-
based practices and reducing unwarranted practice variation--even 
``unwarranted administrative practice variation'' for the transactional 
processes in our work. As one example of this, Army Medicine is 
expanding upon our Performance Based Budget model to link resources to 
clinical and quality outputs. 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, namely, the prevention of disease and evidence-
based treatments for some of the most common and onerous chronic 
illnesses. The measures are very specifically defined, thus permitting 
comparison across health plans. Since 2007, we have been providing 
financial incentives to our hospitals, clinics and clinicians for 
superior compliance in key HEDIS measures. Currently, we track nine 
measures and compare our performance to national benchmarks. Our 
performance has improved on each measure, in one case by 63 percent. We 
have demonstrated that these incentives work to change organizational 
behavior to achieve desired outcomes in our health system. Put quite 
simply, our beneficiaries, patients and communities are receiving not 
only better access to care but better care--objectively measured.
    As the DOD budget and health-/healthcare-related costs come under 
increasing scrutiny, this element of our strategy will be even more 
critical for us. As the United States struggles to address improvements 
in health and healthcare outcomes while stabilizing or reducing costs 
of our national system of care, we in Army Medicine and the Military 
Health System will surely keep the goal of maximizing value in our 
cross-hairs . . . or we will find our budgets tightening without a way 
to measure the effects on our patients' and our communities' health and 
well-being.
    All of these remarkable achievements would be without meaning or 
importance to our Soldiers, their Families and our patients if we do 
not provide access and continuity of care, especially within the direct 
care system of our medical centers, community hospitals, health 
centers, and clinics. I am looking carefully at my commanders' 
leadership and success in ensuring that their medical and dental 
treatment facilities provide timely access and optimize continuity of 
care. We have undertaken major initiatives to improve both access and 
continuity--this is one of the Army Chief of Staff's and my top 
priorities. After conducting thorough business case analyses, Army 
Medicine is expanding product lines in some markets and expanding 
clinical space in others. At 14 locations, we are establishing 
Community Based Primary Care Clinics by leasing and operating clinics 
located in off-post communities that are close to where active duty 
Families live, work, and go to school. These clinics will provide a 
patient-centered medical home for Families and will provide a range of 
benefits:
  --Improve the readiness of our Army and our Army Family;
  --Improve access to and continuity of care;
  --Reduce emergency room visits;
  --Improve patient satisfaction;
  --Implement Best Practices and standardization of services;
  --Increase physical space available in military treatment facilities 
        (MTFs); and
  --Improve physical and psychological health promotion and prevention.
    Along with the rest of the Military Health System, Army Medicine is 
embracing the Patient-Centered Medical Home concept, which is a 
recommended practice of the National Committee for Quality Assurance 
and is endorsed by a number of medical associations, several large 
third-party payers, and many employers and health plans. The Patient-
Centered Medical Home improves patient satisfaction through its 
emphasis on appropriate access, continuity and quality, and effective 
communication. The goal is simple: consult with one consistent primary 
care provider-nurse team for all your medical needs. The seven core 
features of the Medical Home are:
  --Personal Primary Care Provider (primary care manager/team);
  --Primary Care Provider Directed Medical Practice (the primary care 
        manager is team leader);
  --Whole Person Orientation (patient centered, not disease or provider 
        centered);
  --Care is Coordinated and/or Integrated (across all levels of care);
  --Quality and Safety (evidenced-based, safe medical care);
  --Enhanced Access (meets access standards from the patient 
        perspective); and
  --Payment Reform (incentivizes the development and maintenance of the 
        medical home).
    I look for 2010 to be the year Army Medicine achieves what we set 
out to improve 2 years ago in access and continuity, key elements of 
our covenant with the Army Family, led by our Chief of Staff and 
Secretary of the Army.
    Unlike civilian healthcare systems that can focus all of their 
energy and resources on providing access and continuity of care, the 
Military Health System has the equally important mission to Provide 
Global Operational Forces.
    The partnership between and among the medical and line leadership 
of Operations Iraqi Freedom and Enduring Freedom, Central Command, Army 
Forces Command, U.S. Army Reserve Command, National Guard Bureau, Army 
Medical Department Center and School, Medical Research and Materiel 
Command, Army G3/5/7, and others has resulted in a dynamic 
reconfiguration of the medical formations and tactics, techniques, and 
procedures required to support the deployed Army, joint and coalition 
force. Army Medicine has never missed movement and we continue to 
achieve the highest survivability rate in the history of warfare. Army 
Medicine leaders have never lost sight of the need to first and 
foremost make a difference on the battlefield.
    This will not change--it will even intensify in 2010 as the 
complexity of the missions in Afghanistan increases. And this is 
occurring even while the need to sustain an Army and joint force which 
is responsibly withdrawing from Iraq puts more pressure on those medics 
continuing to provide force health protection and care in Operation 
Iraqi Freedom. This pressure on our All-Volunteer Army is 
unprecedented. Healthcare providers, in particular, are subject to 
unique strains and stressors while serving in garrison as well as in 
deployed settings. The MEDCOM has initiated a defined program to 
address provider fatigue with current efforts focused on sustaining the 
healthy force and identifying and supporting higher risk groups. MEDCOM 
has a healthy healthcare workforce as demonstrated by statistically 
significant lower provider fatigue and burnout than: The Professional 
Quality of Life Scale (ProQol) norming sample of 1,187 respondents; and 
Sprang, Clark and White-Woosley's study of 222 civilian behavioral 
health (BH) providers. But as our Chief of Staff of the Army has told 
us: this is not an area where we just want to be a little better than 
the other guy--we want the healthiest and most resilient healthcare 
provider workforce possible.
    The Provider Resiliency Training (PRT) Program was originally 
designed in 2006, based on Mental Health Advisory Team findings. The 
U.S. Army Medical Department Center and School (AMEDDC&S) developed a 
military-specific model identifying ``provider fatigue'' as the 
military equivalent of compassion fatigue. In June of 2008, MEDCOM 
implemented a mandated PRT program to educate and train all MTF 
personnel to include support staff on the prevention and treatment of 
signs and symptoms of provider fatigue. The stated goal of PRT is to 
mitigate the negative effects of exposure to combat, to deployment, to 
secondary trauma from caring for the casualties of war as well as the 
unremitting demand for healthcare services and from burnout. All will 
ultimately improve organizational effectiveness. The AMEDDC&S currently 
offers three courses in support of the MEDCOM PRT: the Train the 
Trainer Course; the Professional Resiliency Resident Course; and the 
PRT Mobile Training.
    None of our goals and themes would be achievable without the right 
mix of talented professionals within Army Medicine and working with 
Army Medicine; what our Balanced Scorecard refers to as Build The Team: 
a larger, more inclusive joint medical team; an adaptive and responsive 
interagency team (VA, DHS, DHHS/NIH/NIAID, CDC, USDA, etc.); an 
effective coalition team; and a military-civilian/academic-operational 
team. The teams we build must be aligned with the Army, Defense, and 
National Military Strategy and long-term goals, not based solely on 
personalities and the arcane interests of a few. My Deputy Surgeon 
General, subordinate leaders, and others have been increasingly more 
deliberate and disciplined in how we form and sustain these critical 
partnerships.
    Effective joint, interagency and coalition team-building has been a 
serious challenge for some time now. I see the emphasis on our ability 
to craft these teams grow in 2010. The arrival of September 15, 2011--
the deadline for the 2005 BRAC--will be one of the key milestones and 
tests of this skill. My regional commanding generals in San Antonio and 
Washington, DC have taken lead roles in this endeavor. Let there be no 
question among those who underestimate our collective commitment to 
working as a team and our shared vision to serve the Nation and protect 
and care for the Warriors and his or her Family--we are One Team!
    In addition to building external teams, we need to have the right 
mix and quality of personnel internal to Army Medicine. In fiscal year 
2010 and continuing into fiscal year 2011 the Army requested funding 
for programs to improve our ability to attract and retain the 
professional workforce necessary to care for our Army. Our use of 
civilian hiring incentives (Recruiting, Retention, and Relocation) 
increased in fiscal year 2010 by $90 million and should increase by an 
additional $30 million in fiscal year 2011. In fiscal year 2011, 
civilian hiring incentives will equate to 4.8 percent of total civilian 
pay. We have instituted and funded civilian recruiting programs at the 
MEDCOM, regional, and some local levels to seek qualified healthcare 
professionals. For our military workforce, we are continuing our 
successful special salary rates, civilian nurse loan repayment 
programs, and civilian education training programs. Additionally, our 
Health Professional Scholarship Program and loan repayments will 
increase in fiscal year 2010 by $26 million and continue into fiscal 
year 2011. This program supports 1,890 scholarships and 600 
participants in loan repayments--it is as healthy a program as it has 
ever been. Let me point out that our ability to educate and train from 
within the force--through physician, nursing, administrative, medic and 
other programs in professional education--is a vital capability which 
we cannot permit to be degraded or lost altogether. In addition to 
providing essential enculturation for a military healthcare provider, 
administrator and leader, these programs have proven to be critical for 
our retention of these professionals who are willing to remain in 
uniform, to deploy in harm's way and to assume many onerous duties and 
assignments in exchange for education in some of the Nation's best 
programs. Army and Military Graduate Medical, Dental, Nursing and other 
professional education has undoubtedly played a major role in our 
remaining a viable force this far into these difficult conflicts.
    The theme of evidence-based practice 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 practices 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 Balance Innovation with 
Standardization so that all of our patients are receiving the best care 
and treatment available. Standardization efforts include:
  --The MEDCOM AHLTA Provider Satisfaction (MAPS) initiative.
  --Care of combat casualties through the Joint Theater Trauma System 
        (JTTS), enabled by the use of a Joint Theater Trauma Registry 
        (JTTR)--both of which I will discuss further below--which 
        examines every casualty's care and outcome of that care, 
        including en route care during medical evacuation (MEDEVAC) 
        with an eye toward standardizing care around the best 
        practices.
  --The Virtual Behavioral Health Pilot (aka Comprehensive Behavioral 
        Health Integration) being conducted at Schofield Barracks and 
        Fort Richardson.
  --Our initiative to reduce Ventilator Associated Pneumonia events in 
        our ICUs by adopting not only industry best practices, but 
        sending out an expert team of MEDCOM professionals to evaluate 
        our own best practices and barriers to success.
  --Our standardized events-driven identification and management of 
        mild TBI/concussion on the battlefield coupled with early 
        diagnosis and treatment of Post-Traumatic Stress Reactions/
        Acute Stress Reactions as close in time and space to the events 
        which lead to these reactions.
    Programs which are in the process of maturing into best practices 
for more widespread dissemination are:
  --The Confidential Alcohol Treatment & Education Pilot (CATEP).
  --The standardized and now automated Comprehensive Transition Plan 
        for Warriors In Transition in our WTUs and CBWTUs.
  --A standardized program to ``build trust in Army Medicine'' through 
        hospitality and patient/client/customer service in our medical, 
        dental, and veterinary treatment facilities and throughout the 
        MEDCOM.
  --Standardized support of our Active, National Guard, and Reserve 
        forces engaged in the reiterative, cyclic process of the Army 
        Force Generation Model (ARFORGEN) including but not restricted 
        to preparation for combat medics and medical units, Soldier 
        Readiness Processing of deploying units, ensuring full medical 
        readiness of the force, restoration of dental and behavioral 
        health upon redeployment, support of the total Army Family 
        while Soldiers are deployed, and provision of healthcare for 
        mobilized and demobilizing Reserve Component Soldiers and their 
        Families.
    These and many other standardized efforts reflect a change in how 
we do the business of Army Medicine. We can no longer pride ourselves 
on engaging in a multiplicity of local ``science projects'' being 
conducted in a seemingly random manner by well-meaning and creative 
people but without a focus on added value, standard measures of 
improved outcomes, and sustainability of the product or process. Even 
the remarkably agile response to the behavioral health needs-assessment 
and ongoing requirements at Fort Hood following the tragic shooting 
were conducted in a very deliberate and effective fashion which 
emphasized unity of command and control, alignment of all efforts and 
marshalling of resources to meet a well-crafted and even exportable 
community behavioral health plan.
    The emphasis which Army Medicine leaders have placed on 
disciplining these innovative measures so as to harvest best practices, 
subject them to validation at other sites, and rapidly proliferate them 
across the MEDCOM and Army in a standard fashion has been remarkable. 
It is the essence of Optimizing Communication and Knowledge Management.
    Many of our goals, internal processes and enablers, and resource 
investments are focused on the knowledge hierarchy: collecting data; 
coalescing it into information over time and space; giving it context 
to transform it into knowledge; and applying that knowledge with 
careful outcome measures to achieve wisdom. This phenomenon of guiding 
clinical management by the emergence of new knowledge is perhaps best 
represented by Dr. Denis Cortese, former President and Chief Executive 
Officer of the Mayo Clinic. He laid out this schematic earlier this 
year after participating in a set of workshops which centered on 
healthcare reform. We participated to explore how the Federal system of 
care might contribute to these changes in health improvement and 
healthcare delivery.
    What Dr. Cortese depicted is a three-domain ideal representation of 
healthcare delivery and its drivers. We share this vision of how an 
ideal system should operate. His notion is that this system of care 
should focus on optimizing individual health and healthcare needs, 
leveraging the knowledge domain to drive optimal clinical practices. 
This transition from the knowledge domain to the care delivery domain 
now takes 17 years. The clinical practice domain then informs and 
drives the payer domain to remunerate for effective clinical outcomes. 
What occurs too often today is what I call ``widget-building'' or 
``turnstile'' medical care which chases remuneration for these 
encounters--too often independent of whether it is the best treatment 
aimed at the optimal outcome. To transform from a healthcare system to 
a system for health, we need to change the social contract. No longer 
should we be paid for building widgets (number of clinic visits or 
procedures), rather, we should be paid for preventing illness and 
promoting healthy lifestyles. And when bad things happen to good 
people--which severe illness and injury and war continuously challenge 
us with--we should care for these illnesses, injuries and wounds by the 
most advanced evidence-based practices available, reducing unwarranted 
variation in practice whenever possible.
    Our Military Health System is subtly different in that we have two 
practice domains--garrison and battlefield. Increasingly, we leverage 
the clinical domain to provide feedback into the knowledge domain--with 
the help of the electronic health record--AHLTA--and specialized 
databases. We do this in real time and all under the umbrella of the 
regulatory domain which sets and enforces standards.
    The reengineering of combat trauma care borne of rapid turnaround 
of new-found, data-driven knowledge to new materiel and doctrinal 
solutions is one of the premier examples of this concept. The simplest 
example is our continuous re-evaluation of materials and devices 
available to Soldiers, combat life savers, combat medics and the trauma 
team at the point of injury and in initial trauma management and the 
intellectual framework for their application to rapidly improve 
outcomes from combat-injured Warriors.
    After making the first major change in 40 years to the field 
medical kit--the Improved First Aid Kit (IFAK)--we have modified the 
contents of the kit at least three times since May 2005 based upon 
ongoing reviews of the effectiveness of the materials and head-to-head 
comparisons to competing devices or protocols. In like fashion, we have 
modified protocols for trauma management through active in-theater and 
total systemic analyses of the clinical outcomes deriving from the use 
of materials and protocols.
    The specialized system in this endeavor is a joint and inter-agency 
trauma system which creates the equivalent of a trauma network 
available for a major metropolitan area or geographic region in the 
United States but spread across three continents, 8000 miles end-to-
end--the Joint Theater Trauma System (JTTS). Staffed and led by members 
of the Army, Navy, Marine Corps and Air Force, it is truly a joint 
process. It is centered on the U.S. Army Institute of Surgical Research 
in San Antonio, Texas. The specialized database in this effort and an 
essential element of the JTTS is the Joint Theater Trauma Registry 
(JTTR)--a near-comprehensive standardized database which has been 
developed for each casualty as soon as possible in the treatment 
evacuation chain--usually at level II or III healthcare in theater. One 
of the most important critical applications of the JTTS and JTTR at 
present is the ongoing analysis of MEDEVAC times and the casualties 
being managed during evacuation. This is our effort to minimize the 
evacuation time for casualty in a highly dispersed force which is 
subjected in Afghanistan to the ``tyranny of terrain and weather.''
    The decisions about where and how many trauma teams should be 
placed around the theater of operation as well as where to place 
MEDEVAC crews and aircraft is a delicate balancing act--one which 
balances the risk of putting care providers and MEDEVAC crews and 
helicopters at risk to the enemy and the elements with the risk of loss 
of life and limb to Warriors whose evacuation may be excessively 
prolonged. The only way to fully understand these competing risks is to 
know the outcomes of care and evacuation by injury type across a wide 
range of MEDEVAC missions. This analysis will help us understand if we 
still require a ``Golden Hour'' for every casualty between initial 
management at the point of injury and arrival at a trauma treatment 
site (like an Army Forward Surgical Team, the Marine Forward 
Resuscitative Surgical System or a Combat Support Hospital) or whether 
we now have a ``Platinum 15 Minutes'' at the point of injury which 
extends the Golden Hour.
    This methodology and these casualty data are being applied to the 
next higher level of inquiry: how do we prevent injury and death of our 
combatants from wounds and accidents at the point of potential injury? 
Can we design improved helmets, goggles, body armor, vehicles and 
aircraft to prevent serious injuries? These questions are answered not 
only through the analysis of wound data, both survivable and non-
survivable, through the JTTS and data from the virtual autopsy program 
of the Office of the Armed Forces Medical Examiner, but also by 
integrating these data with information from the joint operational, 
intelligence, and materiel communities to enable the development of 
improved tactics, techniques, and procedures and materiel improvements 
to protective equipment worn by the Warriors or built into the vehicles 
or aircraft in which they were riding. This work is performed by the 
Joint Trauma Analysis and Prevention of Injury in Combat program, a 
component of the DOD Blast Injury Research Program directed by the 
National Defense Authorization Act for 2006. To date it has been an 
effective means of improving the protection of Warriors and preventing 
serious injury and death even as the enemy devises more lethal and 
adaptive weapons and battlefield tactics, techniques, and procedures.
    We in Army Medicine are applying these knowledge management tools 
and approaches to the improvement of health and the delivery of 
healthcare back home as well. We are coupling these knowledge 
management processes with a funding strategy which incentivizes our 
commanders and clinicians to balance productivity--providing episodes 
of care--with optimal outcome: the right kind of prevention and care.
    Among our greatest team achievements in 2009 was our effort to 
better understand how we communicate effectively with our internal and 
external stakeholders, patients, clients and customers. We adopted a 
formal plan to align our messages--ultimately all tied to Army goals 
and those on our Balanced Scorecard. Our creation of a Strategic 
Communications Directorate to ensure alignment of our key messages, to 
better understand and use social media, to expedite cross-talk and 
learning among such diverse groups as the Office of Congressional 
Liaison, Public Affairs, Protocol, Medical History, the Borden 
Institute, the AMEDD Regiment and others speaks directly to these 
efforts.
    While we are still in the ``advanced crawl/early walk'' phase of 
knowledge management, we know from examples such as the Joint Theater 
Trauma System and the Performance Based Budget Model that we can move 
best practices and newly found evidence-based approaches into common or 
widespread use if we aggressively coordinate and manage our efforts and 
promote transparency of data and information and the knowledge which 
derives from it. We have begun a formal process under the Strategy and 
Innovation Directorate to move the best ideas in both clinical and 
transactional processes into standard practices across the MEDCOM in a 
timely way. This will be achieved through a process to identify, 
validate, and transfer best practices. We endeavor to be more agile and 
adaptive in response to a rapidly changing terrain of U.S. and Federal 
healthcare and operational requirements for a Nation at war.
    In closing, I am very optimistic about the next 2 years. We have 
weathered some serious challenges to trust in Army Medicine. Logic 
would not predict that we would be doing as well as we are in 
attracting, retaining and career developing such a talented team of 
uniformed and civilian medical professionals. However, we continue to 
do so year after year--a tribute to all our Officer Corps, the 
leadership of our Non-Commissioned Officers, and our military and 
civilian workforce. The results of our latest Medical Corps Graduate 
Medical Education Selection Board and the Human Capital Distribution 
Plan show continued strength and even improvements over past years. The 
continued leadership and dedicated service of officers, non-
commissioned officers, and civilian employees are essential for Army 
Medicine to remain strong, for the Army to remain healthy and strong, 
and for the Nation to endure. I feel very privileged to serve with the 
men and women of Army Medicine during this historic period as Army 
Medics, as Soldiers, as Americans and as global citizens.
    Thank you for holding this hearing and your unwavering support of 
the Military Health System and Army Medicine. I look forward to working 
with you and your staff and addressing any of your concerns or 
questions.

    Chairman Inouye. And now may I call upon General Green.

STATEMENT OF LIEUTENANT GENERAL (DR.) CHARLES B. GREEN, 
            SURGEON GENERAL, DEPARTMENT OF THE AIR 
            FORCE
    General Green. Chairman Inouye, Vice Chairman Cochran--
    Thank you, sir. I'm new at this, and please forgive me.
    Chairman Inouye, Vice Chairman Cochran, and distinguished 
members of the subcommittee, it's an honor and a privilege to 
appear before you representing the Air Force Medical Service. I 
look forward to working with you, and pledge to do all in my 
power to support the men and women of our Armed Forces and this 
great country. Thank you for your immeasurable contributions to 
the success of our mission.
    ``Trusted Care Anywhere'' is our vision for 2010 mission 
and beyond. Our nearly 60,000 total force medics contribute 
world-class medical capabilities to Air Force, joint, and 
coalition teams. Over 1,600 Air Force medics are currently 
deployed to 40 locations in 20 countries, delivering state-of-
the-art preventive medicine, rapid lifesaving care, and 
critical-care air evacuation. At home, our healthcare teams 
assure patient-centered care to produce healthy and resilient 
airmen and provide families and retirees with full-spectrum 
healthcare.
    Our success on the battlefield underscores our ability to 
provide ``Trusted Care Anywhere.'' Since 2001, we have air-
evacuated more than 70,000 patients from Afghanistan and Iraq. 
We have lost only four patients, and one dog. Joint and 
coalition medical teams have achieved a less than 10 percent 
died of wounds rate, the best survival rate in the history of 
war.
    In July, a British soldier sustained multiple gunshot 
wounds in Afghanistan. He was stabilized by medical teams on 
the ground, who replaced his blood more than 10 times and 
removed an injured lung. It took two airplanes, three aircrews 
to get the medical team and equipment in place, and another 
aircraft to fly the patient to Germany. Every member of the 
joint casualty care and air evacuation team selflessly gave 
their all to ensure this soldier received the critical care and 
compassionate support required. This was the first known 
successful air evacuation of a patient with a traumatic lung 
removal. The patient is doing well in Birmingham, England, 
today.
    In January 2010, a U.S. marine sustained dislocation of 
both knees, with loss of blood flow to his lower legs following 
an improvised explosive device (IED) attack in the Helmand 
Province. Casualty evacuation delivered the marine to our 
British partners at Camp Bastion, where surgeons restored blood 
flow to both legs, using temporary shunt procedures that our 
surgeons had shared in surgical journals. The marine was 
further evacuated to Craig Joint Theater Hospital at Bagram, 
where Air Force surgeons performed definitive vascular 
reconstruction. The marine is now recovering at National Naval 
Medical Center and is expected to have fully functional limbs.
    These success stories are possible only because of the 
tireless efforts of Air Force, Army, Navy, and coalition medics 
to continuously improve our care.
    Air Force medics are responding globally in humanitarian 
missions as well as on the battlefield. Over the last 6 months, 
we contributed significant support in Indonesia, to the 
treatment and evacuation of Haiti earthquake victims, and now 
have another expeditionary medical system (EMEDS) that should 
be arriving in Chile today.
    The Air Force Special Operations Command had 47 medics on 
the ground within 12 hours following the Haiti disaster, 
performing site assessments, preventive public health measures, 
and delivering lifesaving care. And Air Force EMEDS continues 
to coordinate care in Haiti today.
    At home, we're improving our patient and provider 
satisfaction through our patient-centered medical home, 
building strong partnerships between patients and their 
healthcare teams. We are seeing improved performance in 
healthcare continuity, in quality, access, and patient 
satisfaction, based on our medical-home efforts. We recognize 
the high OPSTEMPO and have identified high-risk groups to 
target interventions and training, improving both airmen and 
family resilience. Collaborative care, in the form of mental 
health providers embedded in our family health clinics is 
present at the majority of Air Force treatment facilities 
today.
    To achieve our vision of ``Trusted Care Anywhere,'' we 
require highly trained, current, and qualified providers. We 
are extremely grateful to this subcommittee for your many 
efforts to strengthen our recruiting and retention programs. 
Your support, in particular, for the Health Profession 
Scholarship Program, the Uniformed Services University, and 
other retention initiatives is making a huge difference.
    We are also indebted to private sector and Federal 
partners, who help us maximize resources, leverage new 
capabilities, and sustain clinical currency. Our research 
partners, with universities and private industry, ensure U.S. 
forces benefit from the latest medical technologies and 
clinical advancements, and research and regenerative medicine, 
directed energy, improved diabetes prevention and treatment, 
and state-of-the-art medical informatics shapes the future and 
allows Air Force medics to implementation innovative solutions.
    Our Centers for the Sustainment of Trauma and Readiness 
Skills at St. Louis University, University of Maryland, 
Baltimore Shock Trauma, and University of Cincinnati College of 
Medicine are all superb examples of what we can achieve through 
partnerships.
    We also actively partner with the VA to meet beneficiary 
needs, and now have five joint ventures, including Keesler Air 
Force Base, Mississippi, and soon will open our sixth, with the 
standup at Buckley Air Force Base, Colorado.

                           PREPARED STATEMENT

    The Air Force Medical Service is committed to the health 
and wellness of all entrusted to our care. We are, as our Chief 
says, all in to meet our Nation's call, and we will achieve our 
vision through determined, continuous improvement. We could not 
achieve our goals of better readiness, better health, better 
care, and best value for our heroes and their families without 
your support.
    Thank you, sir.
    Chairman Inouye. I thank you very much.
    [The statement follows:]

       Prepared Statement of Lieutenant General Charles B. Green

    ``Trusted Care Anywhere'' is the Air Force Medical Service's vision 
for 2010 and beyond. In the domain of Air, Space and Cyberspace, our 
medics contribute to the Air Force, Joint, and coalition team with 
world class medical capabilities. Our 60,000 high performing Total 
Force medics around the globe are trained and ready for mission 
success. Over 1,600 Air Force medics are now deployed to 40 locations 
in 20 countries, building partnership capability and delivering state 
of the art preventive medicine, rapid life-saving care, and critical 
air evacuation. In all cases, these efforts are conducted with joint 
and coalition partners. At home, our healthcare teams assure patient-
centered care to produce healthy and resilient Airmen, and provide our 
families and retirees with full spectrum healthcare.
    Today's focus is on world-class healthcare delivery systems across 
the full spectrum of our operations. From theater hospitals in Balad 
and Bagram, to the efforts of humanitarian assistance response teams, 
to the care of our families at home, we put patients first. We are 
transforming deployable capabilities, building patient-centered care 
platforms, and investing in our people, the foundation of our success. 
We are expanding collaboration with joint and coalition partners to 
collectively strengthen rapid response capabilities. Globally, Air 
Force medics are diligently working to balance the complex demands of 
multiple missions in current and expanding areas of operations.
    We are committed to advancing capabilities through education and 
training, research, and infrastructure recapitalization. Recent efforts 
in these areas have paid huge dividends, establishing new standards in 
virtually every major category of full spectrum care including 
humanitarian assistance. The strategic investments assure a trained, 
current, and deployable medical force today and tomorrow. They 
reinforce a culture of learning to quickly adapt medical systems and 
implement agile organizations to produce healthier outcomes in diverse 
mission areas.
    While we've earned our Nation's trust with our unique capabilities 
and the expertise of our people, we constantly seek to do better! I 
would like to highlight our areas of strategic focus and share some 
captivating examples of Air Force medics in action.

    TRANSFORMING EXPEDITIONARY MEDICINE AND AEROMEDICAL EVACUATION 
                              CAPABILITIES

    Our success on the battlefield underscores our ability to provide 
``Trusted Care, Anywhere.'' The joint and coalition medical teams bring 
wounded warriors from the battlefield to an operating room within an 
unprecedented 20 to 40 minutes! This rapid transfer rate enables medics 
to achieve a less than 10 percent died-of-wounds rate, the best 
survival rate ever seen in war.
    In late July, a British soldier sustained multiple gunshot wounds 
in Afghanistan. After being stabilized by medical teams on the ground, 
who replaced his blood supply more than 10 times, doctors determined 
the patient had to be moved to higher levels of care in Germany. It 
took two airplanes to get the medical team and equipment in place, 
another aircraft to fly the patient to Germany, three aircrews and many 
more personnel coordinating on the ground to get this patient to the 
next level of care. Every member of the joint casualty care and 
aeromedical evacuation teams selflessly gave their all to ensure this 
soldier received the compassionate care he deserved. After landing 
safely at Ramstein Air Base in Germany, the soldier was flown to 
further medical care at a university hospital by helicopter. This case 
highlights the dedication and compassion our personnel deliver in the 
complex but seamless care continuum. This tremendous effort contributes 
to our unprecedented survival rate.
    As evidenced in this story, our aeromedical evacuation system (AE) 
and critical care air transport teams (CCATT) are world-class. We 
mobilize specially trained flight crews and medical teams on a moment's 
notice to transport the most critical patients across oceans. Since 
November 2001, we have transported more than 70,000 patients from 
Afghanistan and Iraq.
    We are proud of our accomplishments to date, but strive for further 
innovation. As a result of battlefield lessons learned, we have 
recently implemented a device to improve spinal immobilization for AE 
patients that maximizes patient comfort and reduces skin pressure. We 
are working toward an improved detection mechanism for compartment 
syndrome in trauma patients. The early detection and prevention of 
excess compartment pressure could eliminate irreversible tissue damage 
for patients. In February 2010, a joint Air Force and Army team will 
begin testing equipment packages designed to improve ventilation, 
oxygen, fluid resuscitation, physiological monitoring, hemodynamic 
monitoring and intervention in critical care air transport.

             INFORMATION MANAGEMENT/INFORMATION TECHNOLOGY

    Our Theater Medical Information Program Air Force (TMIP AF) is a 
software suite that automates and integrates clinical care 
documentation, medical supplies, equipment, and patient movement. It 
provides the unique capabilities for in-transit visibility and 
consolidated medical information to improve command and control and 
allow better preventive surveillance at all Air Force deployed 
locations. This is a historic first for the TMIP AF program.
    Critical information is gathered on every patient, then entered 
into the Air Force Medical Service (AFMS) deployed system. Within 24 
hours, records are moved and safely stored at secure consolidated 
databases in the United States. During the first part of 2010, TMIP AF 
will be utilized in Aeromedical Evacuation and Air Force Special 
Operations areas.

           EXPEDITIONARY MEDICINE AND HUMANITARIAN ASSISTANCE

    We have also creatively developed our Humanitarian Assistance Rapid 
Response Team (HARRT), a Pacific Command (PACOM) initiative, to 
integrate expeditionary medical systems and support functions. The 
HARRT provides the PACOM Commander with a rapid response package that 
can deploy in less than 24 hours, requires only two C-17s for transport 
and can be fully operational within hours of arrival at the disaster 
site. This unique capability augments host nation efforts during the 
initial stages of rescue/recovery, thus saving lives, reducing 
suffering, and preventing the spread of disease. So far, HARRT 
successfully deployed on two occasions in the Pacific. Efforts are 
underway to incorporate this humanitarian assistance and disaster 
relief response capability into all AFMS Expeditionary Medical System 
(EMEDS) assets.
    Air Force medics contribute significant support to the treatment 
and evacuation of Haiti earthquake victims. The Air Force Special 
Operations Command sent 47 medics to support AFSOC troops on the ground 
within 12 hours following the disaster to perform site assessments, 
establish preventive public health measures, and deliver life-saving 
trauma care to include surgical and critical care support. This team 
was also instrumental in working with Southern Command and 
Transportation Command to establish a patient movement bridge 
evacuating individuals from Haiti via air transport.
    As part of the U.S. Air Force's total force effort, we sent our 
EMEDS platform into Haiti and rapidly established a 10-bed hospital to 
link the hospital ship to ground operations. The new EMEDS includes 
capabilities for pediatrics, OB/GYN and mental health. Personnel from 
five Air Force medical treatment facilities (MTFs) are supporting 
Operation Unified Response, as well as volunteers from the Air Reserve 
Forces.

 BUILD PATIENT-CENTERED CARE AND FOCUS ON PREVENTION TO OPTIMIZE HEALTH

    We are committed to achieving the same high level of trust with our 
patients at home through our medical home concept. Medical home 
includes initiatives to personalize care, and to improve health and 
resilience. We are also working hard to optimize our operations, reduce 
costs and improve patient access. We partner with our Federal and 
civilian colleagues to continuously improve care to all our 
beneficiaries.

Family Health Initiative
    To achieve better health outcomes for our patients, we implemented 
the Family Health Initiative (FHI). FHI mirrors the American Academy of 
Family Physicians' ``Patient Centered Medical Home'' concept and is 
built on the team-approach for effective care delivery. The partnership 
between our patients and their healthcare teams is critical to create 
better health and better care via improved continuity, and reduce per 
capita cost.
    Our providers are given full clinical oversight of their care teams 
and are expected to practice to the full scope of their training. We 
believe the results will be high quality care and improved professional 
satisfaction. Two of our pilot sites, Edwards AFB, CA, and Ellsworth 
AFB, SD, have dramatically improved their national standings in 
continuity, quality, access to care, and patient satisfaction. Eleven 
other bases are implementing Medical Home, with an additional 20 bases 
scheduled to come on-line in 2010.
    We are particularly encouraged by the results of our patient 
continuity data in Medical Home. Previous metrics showed our patients 
only saw their assigned provider approximately 50 percent of the time. 
At Edwards and Ellsworth AFBs, provider continuity is now in the 80-90 
percent range.
    We still have work to do, such as developing improved decision 
support tools, case management support, and improved training. 
Implementing change of this size and scope requires broad commitment. 
The Air Force Medical Service has the commitment and is confident that 
by focusing on patient-centered care through Medical Home, we will 
deliver exceptional care in the years ahead.
    The Military Health System's Quadruple Aim of medical readiness, 
population health, experience of care and per capita cost serves us 
well. Patient safety remains central to everything we do. By focusing 
on lessons learned and sharing information, we continually strive to 
enhance the safety and quality of our care. We share our clinical 
lessons learned with the Department of Defense (DOD) Patient Safety 
Center and sister Services. We integrate clinical scenarios and lessons 
learned into our simulation training. We securely share de-identified 
patient safety information across the Services through DOD's web-based 
Patient Safety Learning Center to continuously improve safety.
Improving Resilience and Safeguarding the Mental Health of Our Airmen
    Trusted care for our beneficiaries includes improving resilience 
and safeguarding their mental health and well-being. We are engaged in 
several initiatives to optimize mental health access and support.
    Air Force post-deployment health assessment (PDHA) and post-
deployment health re-assessment (PDHRA) data indicates a relatively low 
level of self-reported stress. However, about 20-30 percent of service 
members returning from OIF/OEF deployments report some form of 
psychological distress. The number of personnel referred for further 
evaluation or treatment has increased from 25 percent to 50 percent 
over the past 4 years, possibly reflecting success in reducing stigma 
of seeking mental health support. We have identified our high-risk 
groups and can now provide targeted intervention and training.
    We recently unveiled ``Defenders Edge,'' which is tailored to 
security forces Airmen who are deploying to the most hostile 
environments. This training is intended to improve Airmen mental 
resiliency to combat-related stressors. Unlike conventional techniques, 
which adopt a one-on-one approach focusing on emotional vulnerability, 
``DEFED'' brings the mental health professional into the group 
environment, assimilating them into the security forces culture as 
skills are taught.
    Airmen who are at higher risk for post traumatic stress are closely 
screened and monitored for psychological concerns post-deployment. If 
treatment is required, these individuals receive referrals to the 
appropriate providers. In addition to standard treatment protocols for 
post traumatic stress disorder (PTSD), Air Force mental health 
professionals are capitalizing on state-of-the-art treatment options 
using Virtual Reality. The use of a computer-generated virtual Iraq in 
combination with goggles, headphones, and a scent machine allow service 
members to receive enhanced prolonged exposure therapy in a safe 
setting. In January 2009, 32 Air Force Medical Service therapists 
received Tri-Service training in collaboration with the Defense Center 
of Excellence at Madigan Army Medical Center. The system was deployed 
to eight Air Force sites in February 2009 and is assisting service 
members in the treatment of PTSD.
    Future applications of technology employing avatars and virtual 
worlds may have multiple applications. Service member and family 
resiliency will be enhanced by providing pre- and post-deployment 
education; new parent support programs may offer virtual parent 
training; and family advocacy and addiction treatment programs may 
provide anger management, social skills training, and emotional and 
behavioral regulation.

Rebuilding Our Capabilities by Recapturing Care and Reducing Costs
    Our patients appropriately expect AFMS facilities and equipment 
will be state-of-the art and our medical teams clinically current. They 
trust we will give them the best care possible. We are upgrading our 
medical facilities and rebuilding our capabilities to give patients 
more choice and increase provider satisfaction with a more complex case 
load. In our larger facilities, we launched the Surgical Optimization 
Initiative, which includes process improvement evaluations to improve 
operating room efficiency, enhance surgical teamwork, and eliminate 
waste and redundancy. This initiative resulted in a 30 percent increase 
in operative cases at Elmendorf AFB, Alaska, and 118 percent increase 
in neurosurgery at Travis AFB, California.
    We are engaged in an extensive modernization of Wright-Patterson 
Air Force Base Medical Center in Ohio with particular focus on surgical 
care and mental health services. We are continuing investment in a 
state-of-the-art new medical campus for SAMMC at Lackland AFB, TX. Our 
ambulatory care center at Andrews AFB, MD, will provide a key 
capability for the delivery of world-class healthcare in the National 
Capital Region's multi-service market.
    By increasing volume, complexity and diversity of care provided in 
Air Force hospitals, we make more care available to our patients; and 
we provide our clinicians with a robust clinical practice to ensure 
they are prepared for deployed operations, humanitarian assistance, and 
disaster response.

Partnering With Our Private Sector and Federal Partners
    Now more than ever, collaboration and cooperation with our private 
sector and Federal partners is key to maximizing resources, leveraging 
capabilities and sustaining clinical currency. Initiatives to build 
strong academic partnerships with St. Louis University, Wright State 
University (Ohio); University of Maryland; University of Mississippi; 
University of Nebraska-Lincoln; University of California-Davis and 
University of Texas-San Antonio, among others, bolster research and 
training platforms and ultimately, ensures a pipeline of current, 
deployable medics to sustain Air Force medicine.
    Our long history of collaborating with the Veterans Administration 
(VA) also enhances clinical currency for our providers, saves valuable 
resources, and provides a more seamless transition for our Airmen as 
they move from active duty to veteran status. The Air Force currently 
has five joint ventures with the VA, including the most recent at 
Keesler AFB, MS. Additional efforts are underway for Buckley AFB, CO, 
to share space with the Denver VA Medical Center, which is now under 
construction.
    The new joint Department of Defense-Veterans Affairs disability 
evaluation system pilot started at Malcolm Grow Medical Center at 
Andrews AFB, MD in November 2007. It was expanded to include Elmendorf 
AFB, AK; Travis AFB, CA and Vance AFB, OK; and MacDill AFB, FL, in May 
2009. Lessons learned are streamlining and expediting disability 
recovery and processing, and creating improved treatment, evaluation 
and delivery of compensation and benefits. The introduction of a single 
comprehensive medical examination and single-sourced disability rating 
was instrumental to improving the process and increasing the 
transparency. Services now allow members to see proposed VA disability 
ratings before separation.
    We continue to work toward advances in the interoperability of the 
electronic health record. Recent updates allow near real-time data 
sharing between DOD and Veterans Affairs providers. Malcolm Grow 
Medical Center, Wright-Patterson Medical Center, and David Grant 
Medical Center are now using this technology, with 12 additional Air 
Force military treatment facilities slated to come online. New system 
updates will enhance capabilities to share images, assessment reports, 
and data. All updates are geared toward producing a virtual lifetime 
electronic record and a nationwide health information network.

                      YEAR OF THE AIR FORCE FAMILY

    This is the ``Year of the Air Force Family,'' and we are working 
hand in hand with Air Force personnel and force management to ensure 
our Exceptional Family Member Program (EFMP) beneficiaries receive the 
assistance they need.
    In September 2009, the Air Force sponsored an Autism Summit where 
educational, medical, and community support personnel discussed 
challenges and best practices. In December 2009, the Air Force Medical 
Service provided all Air Force treatment facilities with an autism tool 
kit. The kit provided educational information to providers on diagnosis 
and treatment. Also, Wright-Patterson AFB, OH is partnering with 
Children's Hospital of Ohio in a research project to develop a 
comprehensive registry for autism spectrum disorders, behavioral 
therapies, and gene mapping.
    The Air Force actively collaborates with sister Services and the 
Defense Center of Excellence for Psychological Health and Traumatic 
Brain injury (DCoE) to offer a variety of programs and services to meet 
the needs of children of wounded warriors. One recent initiative was 
the ``Family Connections'' website with ``Sesame Street''-themed 
resources to help children cope with deployments and injured parents. 
In addition, DOD-funded websites, such as afterdeployment.org, 
providing specific information and guidance for parents/caregivers to 
understand and help kids deal with issues related to deployment and its 
aftermath.
    Parents and caregivers also consult with their child's primary care 
manager, who can help identify issues and refer the child for care when 
necessary. Other resources available to families include counseling 
through Military OneSource, Airman and Family Readiness Centers, 
Chaplains, and Military Family Life Consultants--all of whom may refer 
the family to seek more formal mental health treatment through 
consultation with their primary care manager or by contacting a TRICARE 
mental health provider directly.

       INVESTING IN OUR PEOPLE: EDUCATION, TRAINING, AND RESEARCH

Increased Focus on Recruiting and Retention Initiatives
    To gain and hold the trust of our patients, we must have highly 
trained, current, and qualified providers. To attract those high 
quality providers in the future, we have numerous efforts underway to 
improve recruiting and retention.
    We've changed our marketing efforts to better target recruits, such 
as providing Corps-specific DVDs to recruiters. The Health Profession 
Scholarship Program remains vital to attracting doctors and dentists, 
accounting for 75 percent of these two Corps' accessions. The Air Force 
International Health Specialist program is another successful program, 
providing Air Force Medical Service personnel with opportunities to 
leverage their foreign language and cultural knowledge to effectively 
execute and lead global health engagements, each designed to build 
international partnerships and sustainable capacity.
    The Nursing Enlisted Commissioning Program (NECP) is a terrific 
opportunity for Airmen. Several Airmen have been accepted to the NECP, 
completed degrees, and have been commissioned as Second Lieutenant 
within a year. To quote a recent graduate, 2nd Lt. April C. Barr, ``The 
NECP was an excellent way for me to finish my degree and gave me an 
opportunity to fulfill a goal I set as a young Airman . . . to be 
commissioned as an Air Force nurse.''
    For our enlisted personnel, targeted Selective Reenlistment 
Bonuses, combined with continued emphasis on quality of life, generous 
benefits, and job satisfaction have positively impacted enlisted 
recruiting and retention efforts.

Increasing Synergy to Strengthen GME and Officer/Enlisted Training
    We foster excellence in clinical, operational, joint and coalition 
partner roles for all Air Force Medical Service personnel. We are 
increasing opportunities for advanced education in general dentistry 
and establishing more formalized, tiered approaches to Medical Corps 
faculty development. Senior officer and enlisted efforts in the 
National Capital Region and the San Antonio Military Medical Center are 
fostering Tri-Service collaboration, enlightening the Services to each 
others' capabilities and qualifications, and establishing opportunities 
to develop and hone readiness skills.
    The Medical Education and Training Campus (METC) at Fort Sam 
Houston, Texas, will have a monumental impact on the Department of 
Defense and all military services. We anticipate a smooth transition 
with our moves completed by summer 2011. METC will train future 
enlisted medics to take care of our service members and their families 
and will establish San Antonio as a medical training center of 
excellence.
    Our Centers for the Sustainment of Trauma and Readiness Skills at 
St. Louis University, University of Maryland-Baltimore Shock Trauma and 
University of Cincinnati College of Medicine remain important and 
evolving training platforms for our doctors, nurses and medical 
technicians preparing to deploy. We recently expanded our St. Louis 
University training program to include pediatric trauma. Tragically, 
this training became necessary, as our deployed medics treat hundreds 
of children due to war-related violence.
    Partnerships with the University Hospital Cincinnati and 
Scottsdale, AZ, trauma hospitals allow the Air Force's nurse transition 
programs to provide newly graduated registered nurses 11 weeks of 
rotations in emergency care, cardiovascular intensive care, burn unit, 
endoscopy, same-day surgery, and respiratory therapy. These advanced 
clinical and deployment readiness skills prepare them for success in 
Air Force hospitals and deployed medical facilities, vital to the care 
of our patients and joint warfighters.

Setting Clear Research Requirements and Integrating Technology
    Trusted care is not static. To sustain this trust, we must remain 
agile and adaptive, seeking innovative solutions to shape our future. 
Our ongoing research in procedures, technology, and equipment will 
ensure our patients and warfighters always benefit from the latest 
medical technologies and clinical advancements.
    Air Force Medical Service vascular surgeons, Lieutenant Colonels 
Todd Rasmussen and William ``Darrin'' Clouse, have completed 17 
research papers since 2005 and edited the vascular surgery handbook. On 
January 10, 2009 a U.S. Marine sustained bilateral posterior knee 
dislocations with subsequent loss of blood flow to his lower legs 
following an improvised explosive device attack in the Helmand 
Province. Casualty evacuation delivered the Marine to our British 
partners at Camp Bastion, a level II surgical unit within an hour. At 
Bastion, British surgeons applied knowledge gained from combat casualty 
care research and restored blood flow to both legs using temporary 
vascular shunts. Medical evacuation then delivered the casualty to the 
455th Expeditionary Medical Group at Bagram. Upon arrival, our surgeons 
at Bagram performed definitive vascular reconstruction and protected 
the fragile soft tissue with negative pressure wound therapy. The 
Marine is currently recovering at the National Military Medical Center 
in Bethesda and is expected to have functional limbs.
    In another example, a 21-year-old Airman underwent a rare 
pancreatic autotransplantation surgery at Walter Reed Army Medical 
Center (WRAMC) to salvage his body's ability to produce insulin. The 
airman was shot in the back three times by an insurgent at a remote 
outpost in Afghanistan. The patient underwent two procedures in 
Afghanistan to stop the bleeding, was flown to Germany, then to WRAMC. 
Army surgeons consulted with University of Miami's Miller School of 
Medicine researchers on transplantation experiments. The surgeons 
decided to attempt a rare autotransplantation surgery to save the 
remaining pancreas cells. WRAMC Surgeons removed his remaining pancreas 
cells and flew them over 1,000 miles to the University of Miami Miller 
School of Medicine. The University of Miami team worked through the 
night to isolate and preserve the islet cells. The cells were flown 
back to WRAMC the next day and successfully implanted in the patient. 
The surgery was a miraculous success, as the cells are producing 
insulin.
    These two cases best illustrate the outcome of our collaborations, 
culture of research, international teamwork, innovation, and 
excellence.

Shaping the Future Today Through Partnerships and Training
    Under a new partnership with the University of Illinois at Chicago, 
we are researching directed energy force protection, which focuses on 
detection, diagnosis and treatment of directed energy devices. We are 
exploring the discovery of biomarkers related to laser eye injuries, 
development of films for laser eye protection and the development of a 
``tricorder'' prototype capable of laser detection and biomarker 
assessment. Additional efforts focus on the use and safety of laser 
scalpels and the development of a hand-held battery operated laser tool 
to treat wounds on the battlefield.
    We continue our 7-year partnership with the University of 
Pittsburgh Medical Center to develop Type II diabetes prevention and 
treatment programs for rural and Air Force communities. Successful 
program efforts in the San Antonio area include the establishment of a 
Diabetes Center of Excellence, ``Diabetes Day'' outreach specialty 
care, and efforts to establish a National Diabetes Model for diabetic 
care.
    Another partnership, with the University of Maryland Medical Center 
and the Center for the Sustainment of Trauma and Readiness Skills (C-
STARS) in Baltimore is developing advanced training for Air Force 
trauma teams. The project goal is to develop a multi-patient trauma 
simulation capability using high fidelity trauma simulators to 
challenge trauma teams in rapid assessment, task management, and 
critical skills necessary for the survival of our wounded warriors. A 
debriefing model is being developed to assist with after action reviews 
for trauma team members.
    Radio frequency technology is contributing to medical process 
improvements at Keesler AFB, MS. Currently, Keesler AFB is analyzing 
the use of automatic identification and data capture (AIDC) in AFMS 
business processes. The AIDC evaluation focuses on four main areas: 
patient tracking, medication administration, specimen tracking, and 
asset management. Further system evaluation and data collection is 
ongoing in 2010 with an expansion of AIDC use in tracking automated 
data processing equipment.

                               CONCLUSION

    As a unique health system, we are committed to success across the 
spectrum of military operations through rapid deployability and 
patient-centered care. We are partnering for better outcomes and 
increasing clinical capacity. We are strengthening our education and 
training platforms through partnerships and scanning the environment 
for new research and development opportunities to keep Air Force 
medicine on the cutting edge.
    We will enhance our facilities and the quality of healthcare to 
ensure health and wellness of all entrusted to our care. We do all this 
with a focus on patient safety and sound fiscal stewardship. We could 
not achieve our goals of better readiness, better health, better care 
and reduced cost without your support, and so again, I thank you.
    In closing, I share a quote from our Air Force Chief of Staff, Gen. 
Norton A. Schwartz, who said, ``I see evidence every day the Medical 
Service is `All In,' faithfully executing its mission in the heat of 
the fight, in direct support of the warfighter, and of families back 
home as well.'' I know you would agree that ``All in'' is the right 
place to be.

                   CRITICAL WARFIGHTING-SKILL BONUSES

    Chairman Inouye. I have many questions here. I'd like to 
submit most of them. But, I have a few.
    This morning, I received a call from a constituent, who 
said, ``I just saw an ad that provides a bonus of $350,000 to 
anyone volunteering to serve as a doctor.'' I have no idea what 
service or where the ad was, but, General, do you have any idea 
what this is all about?

                           RECRUITING BONUSES

    General Schoomaker. No, sir, but I'll be happy to look into 
it further. We have a variety of bonus programs to bring 
medical professionals of a variety of sources--physicians----
    Chairman Inouye. What is the bonus for, say, a surgeon?
    General Schoomaker. Sir, I'll have to look into the----
    Chairman Inouye. Oh.
    General Schoomaker [continuing]. Specifics of it. It's 
dependent upon whether we're looking at loan repayment from 
earlier training or multiyear signing bonuses by specialty. 
It's pretty much shared across the three services. Maybe--I'm 
sorry, I don't have the authority to do this--but maybe one of 
my colleagues would be able to answer.
    Admiral Robinson. Senator Inouye, Mr. Chairman, I think the 
critical warfighting-skill bonuses are in the, on the order of 
about $275,000 over a 4-year period. And I may not have all of 
the numbers right. And then, there are a variety of lesser 
bonuses that fit into place. So, there's variable incentive 
pay, there's board-certified pay. There is a list of them, and 
they're utilized in general surgery, orthopaedic surgery. And 
the things that are most critical that we are seeing now are 
mental health specialists, so psychiatrists will also benefit.
    There's another level of board--or of bonus pay for 
clinical psychologists, for social workers, and also for mental 
health nurse specialists. It's much less, but there are 
incentive bonuses that are being utilized. All three services 
are utilizing--we do it a little differently, but the amounts 
are approximately the same.
    So, I do not know anything about a $350,000 bonus. But, 
again, we can look into that.
    [The information follows:]

    No, there is not currently a $350,000 bonus for ``anyone 
volunteering to serve as a doctor.'' Navy currently offers a 
Critical Wartime Skills Accession Bonus (CWSAB) for specific 
physician and dental specialties. The accession bonus depends 
on the specialty being accessed. The bonuses range from 
$220,000 to $400,000. The Navy currently authorizes CWSAB to 
General Surgery, Orthopedic Surgery, Urology, Family Medicine, 
Emergency Medicine, Psychiatry, Pulmonology, Diagnostic 
Radiology, Anesthesiology, Preventive Medicine, Oral and 
Maxillofacial Surgeons, and Comprehensive Dentists.

    Chairman Inouye. I thank you very much.
    General----
    General Green. Senator, if I may add----
    Chairman Inouye. Yes.
    General Green. I'm sorry, sir.
    Under current authorities for the multiyear retention 
bonuses can go as high as $100,000 a year. Although I am not 
familiar with the ad that you bring to our attention; however, 
I will say that, as our personnel communities look at accession 
bonuses, one of the tools they have used is to build an 
accession bonus that basically gives a lump-sum payment, but 
then, they don't necessarily receive that particular multiyear 
retention pay. So, accession bonuses could go up, technically, 
by the authorities we have, as high as $400,000, but then they 
would not receive that same pay while they were on Active Duty. 
If that helps you, sir.
    Chairman Inouye. Oh, thank you.

                  REHABILITATION FOR WOUNDED WARRIORS

    General Schoomaker, on warriors in transition, is that a 
rehab program? Because I had the good fortune to be assigned to 
Percy Jones General Hospital during World War II, and there 
they had a 10-month program that included everything from how 
to use your prosthetic appliance, driving, carpentry, 
electrical work, plumbing, musical instruments, sports, sex, 
the whole works--dining. And I felt, when I left the hospital, 
prepared for the world. Do we have any sort of rehab program 
for our men and women?
    General Schoomaker. Yes, sir. I mean, the simple answer is, 
``absolutely.'' In fact, I think, in prior conversations you 
and I have had, you shared with me the experience that you had. 
And I'm--I, frankly, have taken that on the road, frequently, 
to talk about rediscovering lessons from prior wars, what we 
had in World War II through the convalescent hospital that you 
recovered in at Battle Creek, our Valley Forge Convalescent 
Hospital during the Vietnam era. These were lessons, quite 
frankly, that, in the late 1970s and 1980s and 1990s, we 
forgot. And as we move toward a more strict definition, much 
like the civilian sector, of inpatient and outpatient medicine, 
this war and the injuries, both in battle and not, and the 
illnesses associated with it, have taught us the need to 
rediscover and to redesign intermediate rehabilitation.
    And this transition process that we have, that--most 
recently, my deputy commander--excuse me--my Assistant Surgeon 
General for Warrior Care and Transition, and the Commander of 
our Warrior Transition Command, Brigadier General Gary Cheek, a 
career artilleryman, has worked on--in association and 
collaboration with our colleagues in the Navy, the Marine 
Corps, and the Air Force, has developed a comprehensive 
transition plan--it's automated now across our 29 warrior 
transition units--and nine State-based, community-based warrior 
transition units. And it includes all of the things that you 
describe, from initial healing to longer-term recovery and 
rehabilitation, and includes the family, and is tailored to the 
individual. It has vocational elements to it, educational 
elements, and always wraps in there the family and the 
soldier's interest in either returning to duty or going out 
into productive citizenship. On average, right now, about 50 
percent of our warriors in transition actually return to duty, 
which is, I think, a substantial reinvestment of our people 
back into uniform.
    You know, I think, sir, that we have returned to duty over 
140 amputees, as an example of this, and we've sent about 40 of 
them into combat, 3 or 4 of whom have gone back into combat as 
amputees, having lost their limb not in combat, but in training 
accidents or in motor vehicle accidents. And so, we see this as 
a terrific success and a rediscovery and a recharging of the 
whole effort to transition these soldiers successfully.
    Chairman Inouye. Is this a standard program for all men and 
women in transition, or is it up to the hospital?

              WALTER REED NATIONAL MILITARY MEDICAL CENTER

    General Schoomaker. No, sir. There are criteria to get them 
into the program. We currently have approximately 9,000 
soldiers in them across these units I described; about 7,000 of 
them are within our hospitals and on campuses in our 
installations; about 2,000 are out in nine different States in 
these community-based organizations. We have some fairly good 
criteria to get them into the program, but, once into the 
program, the emphasis is in transition. It's a--an aspirational 
model that focuses on building abilities and rechanneling or 
redirecting their efforts and their interests if their former 
service and their former roles cannot be re-realized again. And 
it's in very close association with the Veterans Administration 
and other civilian rehabilitation efforts.
    Chairman Inouye. Thank you.
    Admiral Robinson, I'd like to ask a few questions relating 
to Walter Reed National Military Medical Center. The 
subcommittee has just a vague idea of what the additional 
budget will look like. We have no idea precisely as to how much 
military construction will be involved, when will it commence, 
and how much operation/maintenance will cost, how much new 
equipment. Can you give us some idea?
    Admiral Robinson. Yes, sir. I can't give you the complete 
answer that you're looking for, but I can give you a Navy 
answer, of sorts.
    The complete answer has to be contained in the JTF CAPMED 
comprehensive master plan for the facility. And then, when that 
occurs, we can have, I think, an understanding of what 
requirements will be necessary for the facilities--whatever 
increased additional cost there will be for facilities at the 
Walter Reed National Military Medical Center.
    As I sit today, there is a very--I call, a nonrobust number 
of about, perhaps, $750 or $800 million that is being projected 
to be needed in order to finish that construction, but I think 
that we'll really need to wait, because that's not a very good 
requirements-based analysis, as I sit now.
    So, I think the first answer is the research--or, the 
comprehensive master plan.
    The second portion is, in terms of the building that is 
occurring now, the Base Realignment and Closure Commission 
(BRAC) has funded us completely for new construction, and 
that's been fine, and that's worked well. BRAC, as you know, 
did not fund any renovation. And the problems that have 
occurred have been that we're building a wonderful and state-
of-the-art facility, but we're attaching it to a 1982 
constructed building. It's a very good building, it's a very 
fine building; but it's 2010, so it's a building from another 
era. The renovation that is going to occur was not part of the 
BRAC funding, so Navy has taken that up, and we are working 
hard and will fund the renovation.
    Sequencing it and getting it all done is the major element 
now, because we don't think that we will be able to get all of 
the renovation done by the opening date of September 2011 at 
the Walter Reed National Military Medical Center. We do not 
feel that that will decrease the timeline on the opening of the 
new medical center, but we do think that there will be more 
work to be done on the renovation side of the building.
    And the third thing is, there are many definitions that are 
now running around regarding what makes the proper facilities 
commitment and what makes the proper ``world-class''--which is 
the word I'm getting to--there are many definitions of what 
that could be, and I'm not sure exactly what that means.
    In terms of quality of care, in terms of satisfaction with 
care, in terms of ability to give care comprehensively, we 
already feel that we are at a world-class level. If ``world-
class'' is defined from a facilities point of view, that means 
square footage of operating rooms or square footage of single-
family or single-patient rooms, then there will be more work 
that has to be done.
    I think that that definition of ``world-class'' needs to be 
placed in a very careful place, because ``world-class'' at the 
National Naval Medical Center or Walter Reed National Military 
Medical Center will automatically be translated to ``world-
class'' in the military health system for Army, for Air Force, 
for Navy, and that will be CONUS and OCONUS facilities. So, I 
think that how we define ``world-class'' can't be defined just 
for one facility, it's going to need to be defined for the MHS. 
Keeping that in mind as we do this, I think, is important.
    Chairman Inouye. In terms of dollars, how much is involved?
    Admiral Robinson. Sir, at this point, the buildings--and, 
forgive me, I don't do this on a daily basis, but I think we're 
at the $1.5 billion level, in terms of facilities, but I think 
that the addition that will be needed is truly unclear at this 
moment. The additional funding that we--that is being talked 
about by the JTF CAPMED is in the $800 million range, but I 
don't think that that is a number that--I don't think that is 
the end number, and I don't think--I don't know the analysis 
behind that number. So, unfortunately, I'm not able to give you 
a very good answer regarding that.
    Chairman Inouye. May I request that, for the record, a 
detailed response be made?
    Admiral Robinson. Yes, sir, we'll do that.
    Chairman Inouye. Thank you.
    Admiral Robinson. You're welcome.
    [The information follows:]

    To carry out the 2005 BRAC law, JTF CAPMED was established 
to oversee the realignment of Walter Reed Army Medical Center 
to the new Walter Reed National Military Medical Center in 
Bethesda and Fort Belvoir Community Hospital. JTF CAPMED 
reports to the Secretary of Defense through the Deputy 
Secretary of Defense. Due to the alignment of JTF CAPMED as an 
independent DOD entity, Navy Medicine does not direct JTF 
CAPMED on construction or other priorities, nor are we planning 
for future operation and maintenance requirements, since that 
by definition belongs to JTF CAPMED. These emerging priorities 
and requirements are driven by many things, all of which are 
outside Navy Medicine's budget process. As part of our mission 
to ensure that our Wounded Warriors receive the care they need 
and deserve, Navy Medicine is in regular communication with JTF 
CAPMED and continues to provide support as necessary. Because 
of this regular communication Navy Medicine is aware of the 
unique challenges facing JTF CAPMED, to include the projected 
increase of financial requirements. However, specific details 
of these challenges or the financial requirements cannot be 
defined or defended by Navy Medicine.

    Chairman Inouye. And now, General Green, on the matter of 
recruiting and retaining, we have noted that, for example, in 
medical schools today, about one-half of the graduates are 
women, but, on an average throughout the services--in the 
Medical Corps, I think it's 72 percent men and 28 percent 
women. And it's the same thing in the Dental Corps; it's about 
75-25. Is a special effort being made to recruit women, or is 
that part of culture?
    General Green. Sir, we have looked at many avenues to try 
and increase our attractiveness to women graduating from 
medical school. Many times, it comes up to, as they look at 
life choices and raising a family, concerns over time away from 
that family, et cetera, play into this. And so, one of the 
things that we've been looking at is whether we could do 
something with the Reserves, which would allow people to come 
on Active Duty, basically pay back a portion of their 
commitment, and, as some life-changing event occurred, could 
there be a way to let them go into a Reserve commitment for a 
period of time, and then come back to us on Active Duty? These 
things have many implications regarding how a career is managed 
and whether or not they can be competitive with others, to make 
certain that we do not limit them in any way in their career 
planning.
    And so, we have done some research, actually gone out and 
talked with medical schools, looked at reasons why we have not 
been attractive. And, for the most part, it is not that our 
scholarships are not attractive to these folks, it's not that 
we don't have very successful scholarship programs, it has to 
do with concerns over lifestyle and the ability to adjust to 
things like childbirth, marriage, and changes in their own 
personal situation.
    And so, we'll continue to very actively try and attract 
those folks. We realize that more than 50 percent of medical 
school graduates now are women, and we very much want to bring 
them in; we simply have not yet found a way to make ourselves 
attractive and change those percentages that you have quoted to 
us, sir.
    Chairman Inouye. How would you rate our retention and 
recruiting? Excellent? Good? Fair?
    General Green. We have taken a different approach in the 
Air Force. As you know, we did not have a great deal of success 
in bringing in fully qualified, and so, we decided to move 
dollars from our recruiting into scholarship programs, and have 
significantly increased the scholarships that we are offering.
    We have done very well. We have three areas that we are 
having troubles right now; in particular, it's with 
psychologists, oral surgeons, and pharmacists. And so, we are 
hoping to offer some more scholarships in those lines.
    When we go after people who are interested in pursuing 
education, we find that we have always been able to fill nearly 
100 percent. We had one year where we were at 98 percent. 
Whereas, when we went after fully qualified, we frequently were 
not able to get even one-half of what we were trying to 
achieve.
    With our nurses this year, with the changes we've made in 
recruiting, we have seen a decrease in our ability to bring 
nurses in. Whereas, the other two services, in their 
recruiting, have brought in, I believe, very close to 100 
percent of their nurses that they need, this year we were only 
able to bring in about 81 percent.
    Now, our nurse manning statistics are good. We're sitting 
at about 90 percent. And our efforts have shifted again to try 
and use the enlisted to nursing, and we're going to be bringing 
in about 50 enlisted members per year, which we think will fill 
the gap.
    I will let General Siniscalchi talk a little bit as to some 
of the things that we're also doing to establish relationships 
with the nursing schools to show the benefits of an Air Force 
career.
    I don't think that we're falling behind, in terms of our 
changes in how we approach recruiting, but some of the efforts, 
in terms of the scholarships and things, have long tails. As 
you know, to graduate a physician--I'll use a family 
physician--4 years of medical school and 3 years of residency. 
And so, from the time they take the scholarship to the time we 
see them coming out is about 7 years. And so, we are very 
interested in maintaining our ability to bring in fully 
qualified. We are leveraging the special pays and authorities 
that you have given us, to make certain that we can bring in 
people who are interested in an Air Force career.
    Chairman Inouye. Thank you.
    General Schoomaker and Admiral Robinson, for the record, 
will you submit a paper on recruiting and retention?
    Admiral Robinson. Yes, sir.
    General Schoomaker. Absolutely, sir.
    [The information follows:]

    The Army Medical Department is experiencing shortages in certain 
specialties and in certain locations. However, despite the persistent 
deployment tempo, the national shortage of many healthcare disciplines, 
and the compensation gap between military and civilian providers, the 
Army is doing well recruiting and retaining healthcare providers. 
Recruiting and retention authorities and bonuses are working, but we 
need to maintain constant vigilance.
    The most difficult skill sets to recruit and retain are fully 
qualified physicians with surgical or primary care specialties, 
dentists (general and specialty), behavioral health professionals, and 
nurse anesthetists. According to the U.S. Army Recruiting Command 
(USAREC), one of the greatest challenges in the recruitment of health 
professionals is simply a lack of awareness of military medicine in 
general and Army Medicine in particular. In an attempt to alleviate 
this challenge, USAREC is adopting a strategy of increased marketing of 
the benefits of Army Medicine.
    Mission success within the active force continues to rely on 
recruitment into our student programs. The world-class training 
programs offered by the Army Medical Department are critical to 
recruiting and retaining providers. Graduates of Army medical training 
programs enjoy a first-time board pass rate well above the national 
average.
    The Critical Skills Accession Bonus granted by Congress has been 
fundamental in turning around recruitment into the Health Professions 
Scholarship Program. In fiscal year 2009, we were able to recruit 103 
percent of mission for dental students, 103 percent of Veterinary Corps 
recruiting missions, and 93 percent for medical students. These are 
significant increases from previous fiscal years and will be the 
building blocks for the future force.
    The Active Duty Health Professions Loan Repayment program has been 
very successful with 256 officers participating and receiving up to 
$44,000 annually. The average continuation rate of healthcare personnel 
(the percentage of personnel who, at their first opportunity to leave 
service, choose to remain) has averaged 92.5 percent over the last 5 
years, peaking at 93.7 percent in 2009. Health Professions Special Pays 
are a key element in the retention of health professions. The new 
Consolidated Special Authority authorized by Congress provides 
increased flexibility for which we are grateful. We must continue to 
make full use of the recruiting and retention authorities and bonuses 
provided by Congress if we are to maintain strong recruiting and 
retention. Our experience over the last decade has proven that 
incentives, bonuses, and special pays work.
    Recruiting for Navy Medical Department active duty is good to very 
good. Navy Medicine recruiting efforts have been successful the past 
few years in making overall goal for all Corps in fiscal year 2008 and 
fiscal year 2009. Active Duty recruiting is projected to meet or exceed 
fiscal year 2010 goals with fiscal year 2010 recruiting performance 
outpacing the fiscal year 2009 effort. There continues to be difficulty 
in directly accessing wartime specialties and medical specialties that 
are highly compensated in the civilian sector.
    Retention for Navy Medical Department active duty is fair to good. 
Retention has stabilized over the past years due to increased retention 
bonuses. The overall loss rate for the officer corps was approximately 
9 percent. The following provides a short synopsis of each of the 
Corps' issues.
Medical Corps
    We continue to experience difficulty in recruiting mental health 
providers, possibly due to the increased demand in the civilian sector.
    Recruiting and retaining general surgeons, preventive medicine, 
occupational medicine, family medicine, and psychiatrists will remain a 
challenge over the next 5 years. Wartime demand, perceived inequities 
in pay comparability between military and civilian providers, and 
limited student pipelines are contributing factors.
Dental Corps
    Dental Corps has difficulty directly accessing and retaining oral 
surgeons and general dentists because of the pay gap between military 
and civilian compensation. A general dentist pay package offering 
significant compensation increases is currently routing through DOD. 
Additionally, the DOD Health Professions Incentive Working Group will 
be recommending a $20,000 per year increase in incentive special pay 
for oral surgeons in fiscal year 2011.
Medical Service Corps
    High operational commitments are affecting retention for physician 
assistants, clinical psychologists and social workers. The new 
accession and retention bonuses recently approved should have a 
positive impact on these specialties.
    Recruiting for clinical psychologists, podiatrists, and pharmacists 
is difficult because of the perceived inequities in pay comparability 
between military and civilian providers.
Nurse Corps
    High operational commitments are affecting retention in all of 
Navy's nurse practitioner specialties.
    Current initiatives in place to retain these critically manned/high 
OPTEMPO communities include RN Incentive Special Pay, Health 
Professional Loan Repayment Program, and a progressive Duty Under 
Instruction (DUINS) program for which officers are eligible after the 
first permanent duty station.
Hospital Corps
    The Hospital Corps has been very successful at both recruiting and 
retaining corpsman.

    General Schoomaker. If I could just make one comment----
    Chairman Inouye. Sure.
    General Schoomaker [continuing]. From the earlier 
discussion about the recruiting bonuses.

                     RECRUITING CIVILIAN PROVIDERS

    Army medicine is 60 percent civilian. I--for people who 
might be listening or reading this account, I'd very much like 
to encourage people who are looking for a career as a civilian 
in the medical services of the uniformed services, to come and 
look at us, to include women who might be looking at--we're 
experimenting and looking at the potential for job-sharing 
around a single position, split between, you know, multiple 
civilian physicians, psychologists, psychiatrists, and the 
like.
    Chairman Inouye. Thank you.
    Senator Cochran.
    Senator Cochran. Mr. Chairman, thank you.
    General Green, I was noticing a newspaper report discussing 
a medical group at Keesler Air Force Base, in Biloxi, 
Mississippi, assembling to provide emergency medical service in 
Chile for the victims of the earthquake there. And the numbers 
of people who are being treated by this special unit that's 
flown from our State is in the neighborhood of 3,000 to 5,000 
people, and making available care from the Medical Support 
Squadron that was based in Biloxi, Mississippi.
    Have you had any recent report? This is a 2- or 3-day-old 
report from a newspaper at--the Biloxi Sun Herald in 
Mississippi.
    General Green. Sir, that team went to Wilford Hall. They 
aggregated with their equipment in San Antonio, and left, I 
believe, late yesterday, are expected to arrive in Chile today. 
They will be working very closely with the Chileans, in terms 
of trying to decompress healthcare issues that arise whenever 
the healthcare infrastructure has been damaged. We built our 
EMEDS-25, which is the unit that's gone down there, based on 
the number of patients that they can actually see. That 
particular unit that has gone to Chile is an EMEDS-25. I 
believe it's just over 65 medical folks, and another 20 to 30 
support people, that basically help with water and electricity 
and making sure the hospital has all of its needs met.
    The intent is for them to augment the Chilean system. We'll 
work hand-in-hand with the Chilean doctors. And they will 
probably, I would guess--before the end of their deployment, 
probably see in the neighborhood of between 3,000 and 10,000 
patients.
    We maintain a robust supply channel to get that to them. 
And you may wonder, How do you see so many patients with so 
few? And the answer is that, when you're working hand-in-hand 
with a host nation a lot is possible. As long as you have a 
good logistics chain and the ability to move patients back into 
the host-nation hospital, we find that we have tremendous 
capabilities. And these have been used both here in the States 
and overseas.
    Keesler did a superb job of mobilizing their people in less 
than 24 hours from the time they were notified. And a very 
excited group from Mississippi have gone to do this important 
work for our country.
    Senator Cochran. Well, we appreciate that. And it's very 
impressive to contemplate the amount of work and effort that 
went into this, mobilizing the people, getting everything 
organized and--it's not just a drive to the neighborhood; it's 
a long way to Chile. And it's really remarkable, I think. And 
you're to be congratulated, I think, as a service; and the Air 
Force personnel who are at Keesler, and those who are 
volunteering to make this trip, really deserve our highest 
praise and commendation.
    General Green. Thank you, sir, I'll pass that to Brigadier 
General Dan Wyman, our Commander down there.
    Senator Cochran. Well, thank you.
    I wonder, just as a general proposition, the extent to 
which our services are able to recruit and retain qualified 
medical personnel to provide healthcare services. When I was in 
the Navy, we had one medical doctor aboard our ship, a heavy 
cruiser. And I was impressed, though, by the corpsmen, who 
really make up the bulk of the people who do the work and 
provide healthcare services at sea like that, when you're a 
long way from anywhere. They really do a marvelous job, 
sometimes with emergencies. I have to admit, I wasn't in a 
military conflict when I was in the Navy. Some of the ports we 
visited might have thought we were in a military conflict, 
but----
    Anyway, what is your assessment right now of our ability to 
retain and train competent people to do these very important 
jobs?
    General Schoomaker. Is that directed to me, sir?
    Senator Cochran. Yes, sir.
    General Schoomaker. To the Army?
    Senator Cochran. Right.

                         VALUE OF COMBAT MEDICS

    General Schoomaker. First of all, let me just make a 
comment, that I'm really pleased that you recognize. A lot of 
people don't recognize the central role that our enlisted 
medics play in this. The second largest military occupational 
specialist--the only larger population is that of infantrymen, 
11 Bravos--is the combat medic, the 68 Whiskey. In fact, 
yesterday, we held a ceremony down in San Antonio, where my 
headquarters is, with--attended by five of my predecessors, 
Surgeons General, including now--former Secretary Jim Peake, 
who was the Surgeon General of the Army before that, and who 
conceived of the need to better train our medics.
    We now have the 68 Whiskey program--very highly trained 
medics. And, frankly, much of what my colleagues and I have 
talked about, in terms of success on the battlefield, is owed 
to our medics. Whether they're Navy corpsmen, who are serving 
with marines, or our Air Force medics, these kids are just 
amazing human beings who have--who are truly heroic.
    So, I appreciate that you recognized that, and the role 
that they play.

                   RECRUITING AND RETAINING OFFICERS

    As far as recruiting and retaining other officer-level 
specialties, we're doing quite well, sir. We had--especially in 
the Nurse Corps and the Medical Corps, the physicians and 
nurses--some difficult years in the past, but last year, 
physician recruitment, through our Health Profession 
Scholarship Program, which is one of the centerpieces of that 
program, of bringing in kids interested in going to medical 
schools under scholarships from the military, has been very 
successful. That program is absolutely essential to us. It's--
in the Army, it's well funded, both for the Active as well as 
the Reserve component of it. And we're seeing the products of 
it.
    Our graduate health education, and specifically physician 
graduate education programs, and our nurse graduate programs, I 
think are essential for retention of those high quality people. 
If we didn't have those programs, frankly, I don't think we 
would be doing as well as we do, because we recruit 
successfully through the scholarship programs or loan repayment 
programs, but we retain them through offering to them some of 
the very best training programs for physicians and nurses that 
exists anywhere in the country.
    Senator Cochran. Admiral Robinson, I didn't mean to 
overlook your opportunity of serving the Navy in the position 
you do. We appreciate your service. And I--what is your 
reaction to that same question?
    Admiral Robinson. Senator Cochran, thanks very much.
    First of all, the corpsmen are the backbone of Navy 
medicine. And you noted that--one doctor on your ship, but 
there were more--there were probably several corpsmen. Today, 
in our submarine force and surface force, independent-duty 
corpsmen very often are department heads for the medical 
departments. So, we actually count on these men and women to 
give first-rate medical care at sea to a large number of our 
forces. And they are qualified to do that, and they do a good 
job, and have been doing that for the last 50 years. So, it's 
not a new program; it's something that we've had in place, and 
we need to continue.
    The 8,404 corpsmen, who are corpsmen with the Marine Corps, 
do an outstanding job, both from integrating with the marines, 
but also from taking care of marines and people in harm's way. 
And, unfortunately, the largest number of casualties and 
mortalities that we have in Navy medicine over the course of 
the last many years actually is a result of the death of 8,404 
corpsmen, my corpsmen who are with the Marine Corps.
    So, the point is that the sacrifice and the bravery and the 
quality of the care that the men and women who are corpsmen and 
who are enlisted medics give is a testimony to the mortality/
morbidity rates coming out of theater, out of the battlefield, 
and also testimony to en route care, to the surgical care, to 
the care that's received at Landstuhl, and the care that's 
received here. So, it's a continuum of care that starts with 
that combat medic, with that corpsman on the battlefield, 
that's able to reach out and actually do an effective job.
    And recruitment and retention--Navy medicine, I think I 
almost will parallel completely what General Schoomaker said. 
We've had some poor years, but recently we have had good 
recruiting and retention numbers on the Active component side 
of our physicians. We are down in family practice, general 
surgery, in terms of critical specialties that we need more of, 
and also psychiatry, mental health, but we are doing a great 
job, and I feel very happy that the Health Profession 
Scholarship Program and several of our other programs are back 
up and are actually producing quite well.
    On the Reserve side, there are some challenges that we're 
having, and I think that the challenges--we've looked at this, 
and I think the challenges in the medical recruiting portion 
may be related to how we changed the recruiting several years; 
instead of having an Active component and a Reserve component 
recruiter, we put the recruiters together. And I think that, at 
that point, as soon as the Active component member was 
obtained, as it were, I don't know if the emphasis was put on 
the Reserve component. We separated that out again, and we're 
going to look at this very hard, but I think we're going to see 
an uptick in the Reserve component recruiting that's occurring.
    That's something that's on my radar screen, but right now, 
recruitment and retention in medical is all right--and I don't 
want to overplay this--we're looking hard, but it's okay, and 
it's better than it's been in the last several years.
    Senator Cochran. Great. Thank you very much.
    Mr. Chairman.
    Chairman Inouye. Thank you.
    Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman.
    This hearing really does come at a critical time. We're in 
the seventh year in Iraq, and are increasing our operations in 
Afghanistan. And the Department of Defense continues to see our 
returning members come home with both visible and invisible 
wounds of war.
    I know that you've all made a lot of progress, but we know 
our job's not finished. We need to make sure that all of our 
members and their families have access to healthcare at all 
times, and we can't forget to--our wounded warriors, our 
reservists, National Guard and Active Duty servicemembers, as 
they transition back to civilian life, and make sure that we're 
meeting all their needs.
    To that end, I wanted to ask you specifically about the 
National Guard and Reserves. They've been called on a number of 
times to support us, and they're coming home to some real 
hardships, with the economy that is very difficult for all of 
us, but particularly for them. Some of them come home to no 
jobs when they're released from Active Duty, and healthcare 
becomes an issue for them, as well.
    In some cases, the returning National Guard and Reserve 
soldiers have to live off limited savings or their drill pay to 
support their families. And, you know, that contributes to 
greater mental health stress for them. So, I'm very worried 
about how we're dealing with this right now.
    And I wanted to ask all of you what kind of efforts are 
currently underway to improve access to mental healthcare 
during the dwell period for our National Guard and Reserve.
    Open it up to any of you who'd like to comment.

                MENTAL HEALTHCARE FOR RESERVE COMPONENT

    General Schoomaker. First of all, ma'am, we share with you 
the concern about the strain on the Active--the Army National 
Guard and the Reserves. This period of transformation for the 
Army, as you know, has been a transition from the reliance on 
our Reserves as a strategic reserve poised to be mobilized in 
the event of a strategic threat to the Nation on a large scale, 
to one of an operational reserve, where they are very much 
involved in continuous operations and mobilization and 
deployment.
    Our first goal, across the board, in terms of health, 
dental, mental, and physical care, is at separation and 
demobilization, to fully explore what problems--and, in the 
case of dental health, to restore dental health; in the case of 
behavioral health problems, to comprehensively evaluate how the 
soldier is doing. And, I think, in the National Guard and 
Reserves, we still have a way to go with that.
    Our Vice Chief of Staff of the Army, General Chiarelli, 
last year, recognized that access to healthcare for the 
National Guard and Reserve, who tend to live in sites remote 
from our installations and in the heartland, often in rural 
areas, does not have the access to care, even under TRICARE, 
that we would like. And we have a--he chartered, through Army 
medicine, a task force, co-chaired by Major General Rich Stone, 
in the Army Reserves, and Major General Deborah Wheeling, in 
the National Guard, to bring together leaders in TRICARE, 
leaders in the managed-care support contracts across the 
country, and for all--from all the State's Guards and others, 
to identify our problems in getting access to care, and to 
improve that. And that's a work in progress, ma'am, but we 
share your concerns.
    Senator Murray. Well, particularly now. These Guard and 
Reserve members are coming home; many of them are living at or 
below the poverty line, including their drill pay, and they 
just--they don't have a job and they don't have health 
insurance. I know we take care of them prior to deployment. I 
think it's 6 months prior to deployment, they get healthcare. 
But, they come home, and they don't have anything during dwell 
time. You're going to call them up again, you know, in a year 
or two, and that becomes both a recruitment issue for you, but 
it's also a real hardship on their families. And what are we 
doing to look at that?
    General Schoomaker. I think the first thing that we've been 
working on with you all is an extended benefit through TRICARE 
Reserve Select and other forms of TRICARE coverage, to reduce 
the benefit--excuse me--reduce the premium load on National 
Guard and reservists----
    Senator Murray. During dwell time.
    General Schoomaker. Yes, ma'am--so that they can get access 
to care. There's no question that----
    Senator Murray. So, is it an issue of budget or is it an 
issue of policy? What is it that----
    General Schoomaker. I think it's a combination of things. 
It's focus from Commanders. We've got Reserve component 
National Guard and Reserve commanders now focusing more on 
their soldiers' comprehensive health benefits when they're in 
dwell, and putting emphasis on that. It's choices you've 
outlined, yourself, ma'am, that when a soldier has a limited 
budget, and part of that is even for a modest premium for a 
TRICARE benefit, they often choose not to do that. And, 
frankly, as you know, young people often kind of take risk that 
they're not going to run into health problems, and so, they 
forego health benefits, for that reason. And I think, more and 
more, we're emphasizing the importance and the need for them to 
retain their medical and dental readiness, even in dwell.

                      NATIONAL GUARD AND RESERVES

    Senator Murray. Well, I think it's a policy that we need to 
look at and really focus on. We're a long ways into the war in 
Iraq, and, with a lot of returning soldiers, we know that's 
going to go on for some time, particularly in Afghanistan, and 
I'm very concerned about that, so I hope we can explore that.
    Does anybody else have a comment on that issue?
    Admiral.
    Admiral Robinson. Senator Murray, I think that the TRICARE 
Reserve Select is part of the answer. And that benefit, if I'm 
not mistaken, has been extended to the Reserve forces, because, 
certainly, the beneficiary numbers in the TRICARE system have 
increased, and I think part of that increase is that.
    The second thing is that--and this is only for 180 days--
it's only for 6 months, but the Active Duty, Reserve members 
that are coming off of Active Duty can still be covered, and 
their families can be covered with TRICARE for that 180-day 
period.
    So, marrying those two with the Reserve Select program and 
the 180 days can be of some benefit, in terms of getting the 
care that they need.
    In terms of the mental health coverage, on the Navy side 
the psychological--the Reserve Psychological Outreach Program 
and the Reserve Psychological Outreach Teams, which consists of 
about 24 to 25 social workers, are doing a good job of going to 
the Navy Operational Reserve Centers--the NOSCs are what 
they're called--and they have actually been reaching out to 
just under about 20,000 to 25,000 people. They have seen 1,700 
people and referred people to mental health coverage. It's a 
small part, but it's the increased focus on getting out into 
the heartland areas, the areas away from the medical centers, 
and also taking care of----
    Senator Murray. Yup.
    Admiral Robinson [continuing]. Those people, who aren't 
seen regularly.
    Senator Murray. Right. But, we've been talking about this 
for a long time, so I'm frustrated that we're not doing better 
than we are today.
    Admiral Robinson. We are doing better, but we're not doing 
all that we need to do. I would frame it in, in that direction.
    Senator Murray. And I agree. I think that's fair. But, 
we're--we still have a big problem out there.
    Admiral Robinson. Yes, ma'am, we do.
    Senator Murray. General.
    General Green. I think all the services share in their 
medical continuation, in terms of any problems that are 
identified from their deployments. We also all have the same 
survey systems that are applied, regardless--Active Duty, 
Reserve, or Guard--with the post-deployment surveys and the 
PDHRAs at about 6 months. We're looking for any problems that 
may have developed in the interim.
    The medical continuation is one of those things where any 
problem that looks like it's associated with deployment, that 
they need to remain on Active Duty, we try and get that 
resolved by extending their orders and keeping them there. And 
the TRICARE Reserve Select is available to them for 6 months 
post.
    We also have programs that haven't been mentioned here such 
as the Yellow Ribbon Program----
    Senator Murray. Right.
    General Green [continuing]. That are designed to try and 
help people find services and to ensure that they're getting 
some assistance. We're looking--the Army, in--particularly, is 
looking at some telemental-health, in terms of how we can also 
be of assistance that way. And all the services are looking at 
these things because we see some of the gaps that you see, and 
are trying to close those gaps as best we can.
    Senator Murray. Okay. General Schoomaker, I wanted to ask 
you about the issue of suicides.
    In January of this year, the Army released information that 
there were 160 suicides of Active Duty soldiers in 2009, 140 in 
2008. For Reserve soldiers, you reported 78 suicides; 2009, 57. 
That increase in military suicides is really disturbing to me. 
And I think we need to be doing everything we can to make sure 
that we identify and mitigate the issues that are leading up to 
these unfortunate incidences. I wanted to ask you, What 
measures or programs has the Department of Defense instituted 
to mitigate future suicides? And what are we doing out there?

                           SUICIDE PREVENTION

    General Schoomaker. Ma'am, I think all the services, but 
certainly the Army, shares with you the concern that we've had 
about suicides. We've seen an increase, over the last 5 or 6 
years, from a suicide rate within the Army that roughly was 
one-half of the benchmark, you know, age- and gender-adjusted 
statistics in the civilian sector, to one that now has risen to 
be almost in parallel with. It's hard to tell, in the civilian 
sector, because the civilian-sector numbers that are released 
by the Centers for Disease Control are 2 years after the fact, 
so we won't see 2009 statistics until 2011. But, this is a--
this is an issue which the highest levels of the Army have 
taken responsibility for. The Vice Chief of Staff of the Army 
has chartered a task force. For the past year, they've looked 
very, very carefully at all factors across----
    Senator Murray. Is this the National Institutes of Health 
study?
    General Schoomaker. No, ma'am, that's actually an 
additional piece of this. The STARRS program--the acronym for 
which I just blocked--but, the STARRS program is a $50 million, 
5-year program that the Secretary of the Army chartered last 
year--with the National Institutes of Health, with University 
of Michigan, with Johns Hopkins--looking very carefully at all 
of the factors--what's been described as a Framingham Study 
that was done in Framingham, Massachusetts, beginning in the 
1940s, looking at the risk factors for heart disease, and has 
changed our whole approach, nationally, to public health 
measures around heart disease. The same methodology is now 
being applied to suicide and suicide prevention.
    But, within the Army itself, we're very actively looking at 
all of the factors that go into this rising suicide rate. There 
is no one single factor we can put our finger on. Roughly one-
third of our suicides occur in people who have never deployed 
at all. Roughly one-third occur in soldiers who are downrange 
and deployed. And one-third are in those that have deployed 
once or twice within the last several years.
    And the one transcendent factor that we seem to have, if 
there's any one that's associated with it, is fractured 
relationships of some sort, either a broken marriage, a 
girlfriend/boyfriend, even a relationship that might have been 
forged with the Army itself, as a very tight association a 
soldier made may develop, and then maybe does something that 
gets him administratively punished or, you know, nonjudicial 
punishment, and they go out and kill themselves. And so, we're 
looking at all of those related factors--alcohol and drug abuse 
that may be associated with it--because this is an impulsive 
act, frequently lubricated by alcohol or drugs, and we are, as 
an Army, very, very focused on how we can improve it.
    At the Department level, there's a task force that has been 
chartered by the Secretary. In fact, Major General Phil Volpe, 
one of my physicians, is a co-chair of that task force, right 
now is looking at DOD-wide programs and how we can, in a 
unified way, take efforts to prevent suicide and better 
understand it.
    Senator Murray. Okay. Well, I would like to work with all 
of you and, you know, have a--get as much information as 
possible. If we need to be doing more, in terms of support 
services, outreach, whatever, I think we really need to focus 
on that issue.

                        MENTAL HEALTH AWARENESS

    General Schoomaker. Yes, ma'am, we welcome it.
    Senator Murray. Air Force or Navy, either one of you want 
to comment on what your services are doing to promote mental 
health awareness or--are either of you doing studies, long 
term, on this?
    Admiral Robinson. Studies, I cannot answer. I can tell you 
that, in terms of the awareness and in terms of trying to do 
education and training, trying to make sure that we make this 
an imperative and a leadership imperative for all of our 
Commanders, making sure that we decrease the stigma of getting 
mental healthcare, which has been quite pervasive and is really 
a deterrent to people who need to get care, and also to the 
establishment in our operational stress programs, both in 
combat, but also--I'm talking--not in combat, now; I'm talking 
about operational stress--in noncombat situations, and also our 
caregivers' operational stress programs, because they often are 
under a great deal of stress--making sure that we have primary 
care members--and a great deal of the mental healthcare that is 
given to individuals, around the country, but certainly in the 
services, is given by family practitioners and primary health 
providers, and making sure that they have training and that 
they understand what is going on.
    The dependent--the Deployment Health Clinics, the 17 that 
we have in the Navy, about one-third of the people that are 
coming in are coming in for mental health issues. And the nice 
thing is, no one knows why you're going into that clinic, but 
we have embedded psychiatrists, psychologists, and primary care 
members in that clinic, so you can be referred immediately and 
talk to someone, and get the care that you need.
    I think, also, one additional thing, and that is the ACT 
Program, that we take to the deckplates, as we say; and that 
is, each man and woman, each person, each shipmate, can do the 
ACT. The ``Ask,'' ``Are you thinking about harming yourself?'' 
The ``C'' is the ``Care,'' the care to say, ``I think you need 
some help. I think you need to see a chaplain. I think you need 
to go someplace.'' And then, the ``T'' part is the ``Treat,'' 
and that is to actually make sure that people get to that 
level.
    The continuum of care that we try to give indicates that 
everyone--every person in the Navy, civilian and Active Duty, 
in war and out of war--is responsible for their shipmate and is 
responsible--we're responsible for one another.
    Senator Murray. General Green.
    General Green. The Air Force, since 1997, has had a very 
successful Suicide Prevention Program, basically focused on 11 
suicide prevention initiatives, most of that focused on very 
close focus by leadership, in terms of getting our wingman 
program out and making certain that everyone understands that 
this is not acceptable. With those 11 suicide prevention 
initiatives, we were actually able to decrease our rate below 
10, for probably 5 to 7 years--10 per 100,000. Over the last 3 
years, we have seen slight increases back to about our 1997 
rate. We are also trying to reinvigorate our program. Actually, 
we work very closely together across the services to do that.
    We do have one study that the Air Force has funded, 
different than the others, because we were very interested, in 
particular, with civilian suicides, because of some events that 
have been happening that have made the news out at Hill Air 
Force Base. And so, we had the RAND Corporation look at some of 
our initiatives out there to try and create a first-sergeant 
equivalent, people who could be there and be kind of initial 
capability to help civilians find assistance in an area that 
did not have all the mental health support that it needed. And 
then, we've also put, in our occupational clinics out there, a 
mental health social worker to try and assist with some of 
that.
    We did also identify that we have about three times the 
rate of the rest of the Air Force in two career fields, in 
security forces and in intel career fields. We are taking a 
very targeted approach with those career fields to try and do 
face-to-face interventions with much smaller groups, using some 
of our video vignettes, similar to that used in our computer-
based training. We are also mandating those front-line 
supervisors will receive specific suicide training.
    Because our program's been in place since 1997, it is in 
our PME schools, it is in our basic training schools. And so, I 
think we'll continue to have success. Our rates are probably 
about--not quite one-half of what the other services are. But, 
we believe our programs are still valid, and we're just 
emphasizing and trying to focus them where we see problems.
    Senator Murray. Okay. I really appreciate all of your focus 
and attention on this. I think it's extremely important.
    And I know I'm out of time, Mr. Chairman, and you've been 
generous.
    I do want to submit some questions for the record.
    One, in particular, that I want to hear back from all of 
you on is what we're doing for children of servicemembers 
today. We have a lot of families out there who have sacrificed 
a heck of a lot in a very tough economic climate, and I know 
who bears the brunt often is the kids of those families, and 
I'd like to hear back from each one of you what you are doing 
uniquely with our families and what we, as Congress, ought to 
be doing, or can be doing, to better support the children of 
the members of our services.

                    SUPPORTING FAMILIES AND CHILDREN

    General Schoomaker. Yes, ma'am. We would love the--to 
participate in that. As you know, one of the centers of this is 
in your State, at Madigan Army Medical Center. It's one of our 
centers for outreach for children.
    Ma'am, if I might, real quickly, append the record just to 
say, before I get hate mail from my colleagues at Uniformed 
Services University of the Health Sciences, one of the pivotal 
players in this landmark study on suicide, the 5-year, $50 
million study with the National Institutes of Mental Health is 
the Uniformed Services University of Health Sciences, Dr. Bob 
Ursano, who is really heading up this project.
    Senator Murray. Okay. Look forward to hearing much from 
that.
    Admiral.
    Admiral Robinson. Senator Murray, for your children--and 
this isn't a complete answer, but a short one, because it 
actually came from this hearing, 2 years ago, but the FOCUS 
Program--Families Over Coming Under Stress--which was 
originally started with Navy in very small groups of mainly 
Special Ops families who had had such an intense OPTEMPO. And 
we have now seen some really excellent results with that 
program, in terms of marriage, counseling. I can't say that all 
the marriages are successful, but there's been a reduced rate 
of divorce, there's been a reduced rate of children involved in 
drugs and in other acting-out behaviors. It's a program that's 
focused on spouse and children, and it's been very successful. 
And it's being incorporated, now, into not only Navy, but also 
Army and Air Force.
    Senator Murray. I'd like to get a briefing on that, if you 
could tell me what you're doing and how it's working----
    Admiral Robinson. Certainly.
    Senator Murray [continuing]. And what some of your 
statistics are. That would be great.
    Admiral Robinson. I'll be happy to do that.
    [The information follows:]
Project FOCUS (Families Over Coming Under Stress) Outcome Metrics
    FOCUS has demonstrated that a family-centered targeted prevention 
program is feasible and effective for military families. Utilizing 
national and local partnerships, community outreach, and flexible and 
family friendly skills-based approach, FOCUS has successfully initiated 
a resiliency training program in collaboration with the military 
community. FOCUS has demonstrated that a strength-based approach to 
building child and family resiliency skills is well received by service 
members and their family members reflected in high satisfaction 
ratings. Notably, program participation has resulted in significant 
increases in family and child positive coping and significant 
reductions in parent and child distress over time, suggesting longer-
term benefits for military family wellness. Standardization in program 
implementation provides the foundation for FOCUS program implementation 
and sustainability to support larger scale dissemination.
Current Service Metrics
    Total all FOCUS Services to date at all sites: 92,000.
  --Navy: 40,000 (services began March 2008).
  --Marine Corps: 50,000 (services began March 2008).
  --Army: 2,000 (services began November 2009).
  --Air Force: 600 (services began November 2009).
    Specific outcomes of program interventions as measured by validated 
and standard metrics used in psychological health surveys are:
  --Pre- and post-intervention levels of overall psychosocial 
        functioning of program participants (both adults and children), 
        suggest a significant improvement. The statistical level of 
        significance is p < .001 level.
  --Pre- and post-intervention levels of general emotional stress 
        suggest a significant reduction in depression, anxiety, and 
        somatic complaints on the part of adult care givers. The 
        statistical level of significance is p < .01.
  --Change scores on 6 dimensions of family functioning were found to 
        be highly significant at the p < .0001 level of statistical 
        significance. This suggests a marked level of improvement 
        across areas such as behavior control, problem solving, 
        communication, affective involvement and responsiveness, and 
        general level of family functioning.
    Project FOCUS surveyed both parents and child participants and 
found a high level of overall satisfaction with FOCUS services. The 
average of all respondents on levels of satisfaction is reported below. 
A rating of 7 was the highest possible rating: 6.54 for ``program was 
very helpful''; 6.59 for consumers being ``very satisfied''; and 6.73 
for consumers who would ``recommended the program to others''.
    In summary, since Project FOCUS has been in operation, ongoing and 
multiple assessments of program effectiveness have repeatedly shown 
that the program is worthy of being viewed as a model program for 
military families.

    Senator Murray. Very good.
    Admiral Robinson. Thank you.
    Senator Murray. Thank you very much.
    Thank you.
    Chairman Inouye. Thank you.
    General Schoomaker, Admiral Robinson, and General Green, I 
thank you very much.
    Chairman Inouye. And we'll now listen to the second panel, 
a very important one.
    I'd like to welcome back Major General Patricia Horoho, 
Chief of the U.S. Army Nurse's Corps; and Major General 
Kimberly Siniscalchi, Assistant Air Force Surgeon General for 
Nursing Services; and I'd also like to extend a special welcome 
and congratulations to the newly appointed Director of the Navy 
Nurse Corps, Rear Admiral Karen Flaherty.
    I'd like to also extend my congratulations to General 
Horoho for being selected to serve as U.S. Army Deputy Surgeon 
General and also as the Nurse Corps Chief.
    As all of you know, I did have the privilege of serving in 
the Army, and spent about 20 months in various hospitals. And 
at that time, I saw the doctor about once a week, and the 
nurses 24 hours, 7 days a week. And, as a result, I looked upon 
them as special angels, in my case. They helped prepare me to 
get back into life.
    Today, you have patients with problems that did not exist 
in World War II. For example, in my regiment, with all the 
casualties, there wasn't a single survivor of double 
amputation, no survivor of brain injuries. But, these are 
becoming commonplace now, because--for example, in my case, it 
took 9 hours to evacuate me by stretcher. Today, if it were in 
Afghanistan or Iraq, I'd be evacuated in about 30 minutes by 
helicopter. And so, the survival rate is extremely high.
    And added to this, you have cell phones, daily telephone 
calls between husbands and wives, and CNN telling you what's 
happening out there.
    And so, the stress is not only limited to soldiers, airmen, 
and marines, but also the family.
    Do you think that nurses are adequately prepared and 
trained to serve men and women with problems that didn't exist 
during my time?
    General Horoho.
    General Horoho. Thank you, Mr. Chairman.

                          PREPARED STATEMENTS

    Chairman Inouye. Your statements have been made part of the 
record, so----
    General Horoho. I'm sorry, sir?
    Chairman Inouye. Your full statements are part of the 
record now.
    General Horoho. Okay.
    [The statements follow:]

         Prepared Statement of Major General Patricia D. Horoho

    Mr. Chairman and distinguished members of the committee, it is an 
honor and a great privilege to speak before you today on behalf of the 
nearly 40,000 Active component, Reserve component and National Guard 
officers, non-commissioned officers, enlisted and civilians that 
represent Army Nursing. It has been your continued tremendous support 
that has enabled Army Nursing, in support of Army Medicine, to provide 
the highest quality care for those who are entrusted to our care.
    Last year I promised you an update on the Army Nurse Corps Campaign 
Plan that we began in October 2008. It became evident that our efforts 
to transform Army Nursing mirrored the desire of national nursing 
organizations and their leaders to improve nursing practice in support 
of the healthcare reform initiative. Today I will share with you some 
of Army Nursing's accomplishments that are leading national nursing 
initiatives as well as some of the challenges that we will face in the 
years ahead.

                  LEADER DEVELOPMENT: BUILD OUR BENCH

    The first priority for Army Nursing is to develop full spectrum 
Army nurse leaders. Considering our Nation's continuous engagement in 
overseas contingency operations and the complex clinical challenges our 
nurse officers face both home and abroad, I challenged my senior 
leaders to develop training platforms that will prepare our nurses to 
succeed in any contingency-based operation around the world.
    Identifying the need for a clinical transition program for new 
graduate Army Nurses, the Army Medical Command (MEDCOM) formally 
fielded the BG (R) Anna Mae Hayes Clinical Transition Program (CTP), 
named in honor of our 13th Corps Chief, across nine medical centers 
beginning in October 2008. During fiscal year 2009, 364 new graduate 
Army Nurses completed this program. Throughout the year, the program 
was standardized to decrease the variance among the nine program sites. 
Thus far in fiscal year 2010, over 270 nurses have graduated from the 
program. Their enthusiastic endorsement of the program usually ends 
with the question ``when can I deploy?''
    Our nurses take great pride in wearing the cloth of our nation. 
After graduating from the Officer Basic Leader Course, the new nurse 
officer enters the Leader Academy via the CTP. This program is based on 
the Army leader development strategy that articulates the 
characteristics we desire in our Army leaders as they progress through 
their careers. The CTP is a 25.5 week program designed to bridge the 
baccalaureate education and professional practice of the New Graduate 
Army Nurse (NGAN). It consists of three formal phases (orientation, 
preceptorship, and clinical immersion) developed to foster critical 
thinking, communication, and deployment skills. Incorporated into the 
phases are a 5-hour monthly didactic seminar, journal club, and 
research review with a focus on leadership, professional role 
development, and improvement of patient outcomes. The CTP is congruent 
with the National College of State Boards of Nursing's intent to 
require residency programs for new nurses.
    Initial review of survey data collected during fiscal year 2009 
reveals NGAN positive responses to the following domains of new 
graduate nurse satisfaction: intent to stay, confidence levels in 
individual practice, and enthusiasm for the practice of nursing. The 
responses of the NGANs were similar to the published survey results 
from civilian clinical nurse transition programs. With the key elements 
of this program standardized, outcome variables related to risk 
management (such as medication errors, patient falls, and failure to 
rescue) can now be evaluated in fiscal year 2010.
    The first course that we realigned in support of the Campaign Plan 
was the Head Nurse Course. It has been renamed the Clinical OIC and 
NCOIC Clinical Leader Development Course. The renaming is a result of 
acknowledgement of the critical relationship that exists between the 
Clinical Nurse, OIC (Officer in Charge) and their clinical right arm--
the NCOIC (Non-Commissioned Officer in Charge). As an integrated 
training platform, this course has had very positive results. It 
provides our mid-level managers the opportunity to learn the critical 
skills needed for working as a team, and to master those skills in a 
simulated environment. This allows participants the opportunity to hone 
tactics and to learn techniques and procedures and decision-making 
skills that are used in the clinical environment. The training received 
in this course promotes cognitive competency and teamwork, and metrics 
are being developed to examine the program's impact on patient 
outcomes. Twelve clinical NCOICs from across Army Medicine attended the 
Head Nurse Leader Development Course as a pilot test October 2009. Due 
to the success of this pilot test, full attendance of Clinical NCOICs 
at this course is in the approval process. Both the CTP and the 
clinical leader development course are designed to prepare clinical 
leaders to be experts at navigating the complexities of care delivery 
in any environment.
    Through the past year we have leveraged the experience and 
expertise of our clinical Sergeants Major, as the senior enlisted 
advisors and subject matter experts on NCO and enlisted issues. They 
are our primary advisors on policies and regulatory guidance. Their 
voice and ideals have brought us a ``results-based leadership'' that 
has allowed us to excel in our imperatives and adopt a ``new 
paradigm,'' or view of the world. These NCOs could not accomplish their 
mission without the hard work and dedication of the men and women of 
the Army Medical Department (AMEDD) Enlisted Corps. It's through their 
unrelenting compassion to save and heal, despite hardships and dangers 
to life and limb that makes them ``angels on the battlefield.''
    We are committed to the growth and development of our NCOs and 
Soldiers. Therefore, starting in fiscal year 2011 we will fund two 
senior NCOs to obtain their Masters in Healthcare Administration which 
will ensure a continuous capability to meet the needs of the 21st 
Century. In addition, we are developing an Intensive Care Unit course 
for our Licensed Practical Nurses (LPN); this additional capability 
will allow commanders the flexibility to use LPNs for transport of 
critical patients, improve patient outcomes, and expand practice 
opportunities.
    Finally, the Leader Academy facilitates enhanced career-long 
development of adaptive full spectrum Army Nurse Corps leaders through 
the level of Regional Nurse Executive (RNE). We adopted the American 
Organization of Nurse Executive competencies that include skills such 
as healthcare economics, and healthcare policy management as well as 
abilities in outcomes measurement and change management in order to 
ensure the RNEs have the knowledge, skills and behaviors to help manage 
the regions system of health. We leveraged George Mason University's 
``Nursing Administrative Leadership Academy'' into our own leader 
academy as a training platform for our RNEs. We are sending three of 
our RNEs to the program this summer. We are also selectively using 
AMEDD courses such as the Interagency Federal Executive and the 
Executive Skills Course to hone and refine the RNE's abilities as 
influencers of the delivery of health. We believe the Army Nursing 
Leader Academy is setting the standard nationally for how nurse leaders 
are prepared to have an active and influential voice in healthcare, 
AMEDD, and national nursing policy.

                      WARRIOR CARE: BACK TO BASICS

    Our second strategic imperative is to standardize nursing care 
delivery systems in order to perfect nursing care at the bedside. We 
created a Patient and Family centered System of Nursing Care (SOC) that 
has as its cornerstone standardized nursing practice. This SOC will not 
only enable the Surgeon General's intent to improve and standardize 
care from the point of injury through evaluation and inpatient 
treatment and then return to duty, but will also enable, for the first 
time, comprehensive measurement and subsequent improvement of nurse-
sensitive patient outcomes.
    We piloted elements of this SOC at Blanchfield Army Community 
Hospital, Fort Campbell, Kentucky, in January 2009. After 6 months of 
monitoring we identified notable improvements in care such that nurse 
sensitive errors declined, while compliance with quality initiatives 
increased. During the 6 month pilot period, we found a 44 percent 
decrease in nursing medication errors and a 100 percent decrease in 
risk management events. Additionally, patient pain reassessment 
improved from 90 percent to 99 percent and reporting of critical 
laboratory values improved from 92 percent to 100 percent. We realized 
several ``quick wins'' such as the marked improvement in how nursing 
staff communicate with patients and physicians. Unexpectedly, we noted 
improvement in nurse retention metrics including a 24 percent increase 
in nurses' opinions that they are rewarded for a job well done, and a 
23 percent increase in nurses' opinions that nurses are seen as 
important leaders in their organizations. Overall, nurses reported that 
they believed that they were being heard, and their opinions valued. 
One nurse at Blanchfield said ``Now I feel like I have a voice in the 
organization.''
    Using the data from the Blanchfield pilot, we fully conceptualized 
the SOC as a three-sided pyramid with one side delineating clinical 
practice elements, another professional practice elements, and another 
business practice elements. The pyramid is anchored by the Army nursing 
triad; Army nurses, NCOs, and enlisted and civilians comprise its base. 
Next month, select elements of care are being implemented at three 
medical centers: Walter Reed Army Medical Center, Washington, DC; 
Brooke Army Medical Center, Fort Sam Houston, Texas; and Madigan Army 
Medical Center, Fort Lewis, Washington. For one element of the 
professional practice side of the pyramid, we are implementing an Army 
nursing creed--it is our nursing ethos and codifies who we are as 
nurses by articulating what we believe in and value as nurses; it is 
the heart of nursing practice. It includes Army values and the American 
Nurses Association Standards of Practice that allow us to define a 
standard level of nursing care common to all nurses and a standard 
level of behavior in the professional role.
    In April, at the same three hospitals, we are implementing nursing 
peer review that aligns a business strategy with clinical practice. 
Peer review is a best clinical business practice that enables us to 
retain the very best nurses who provide quality care as measured 
against our professional standards of practice. Peer review is a talent 
management tool that provides real time, constructive feedback to 
clinicians to assist with their professional growth which leads to good 
patient outcomes.
    In May, we will implement the Army Nurse Corps Practice Council 
along with unit-specific governance councils to support the clinical 
practice side of the pyramid. Governance councils will facilitate 
decentralized joint decisionmaking by nursing leaders and staff nurses 
at the frontline of care--the patient/nurse interface. These unit 
councils will collaborate with the Army Nurse Corps Practice Council to 
identify best practices relative to nursing tactics, techniques, and 
process, and then codify these practices for standard use across Army 
Nursing. Army Nursing identified two best practices that were 
incorporated into the SOC. At Tripler Army Medical Center (TAMC), 
nurses modified environmental and staff behavior factors to tailor 
inpatient care to provide ``Healing Hours.'' The restorative importance 
of sleep is well documented, but hospitalized patients report many 
factors including noise, pain anxiety, light, and interruptions by 
hospital staff as sleep disruptors. To validate the most common sleep 
disruptors, TAMC nurses requested input from 227 patients over a 6 week 
period and received 135 responses. 71 percent of patients reported 
averaging less than 4 hours of sleep a night during their 
hospitalization. 62 percent reported their sleep being interrupted by a 
nurse or provider. With the information gathered, TAMC initiated the 
Healing Hours concept. Healing Hours are individualized based on 
diagnosis and requirement for hands-on care. The overall purpose of 
Healing Hours is to promote rest through consolidation of patient care 
activities. Ancillary services aligned their services to support this 
initiative. Pharmacy adjusted routine medication times to coincide with 
established rest hours. Routine laboratory service rounds do not begin 
before 0600 hours. Signs are posted on each patient's door to remind 
all staff of requested Healing Hours. Patients are provided information 
during pre-admission activities to encourage them to bring comfort 
items from home; i.e. earplugs, earphones, and eye masks.
    At Walter Reed Army Medical Center, senior nursing leadership 
examined hourly nursing rounds as a measure to improve patient and 
staff outcomes. A total of 11 intensive, medical, surgical, and same 
day surgery units participated in the project, where we simultaneously 
measured outcomes such as patient satisfaction, staff satisfaction, 
falls, medication errors, and call light use. We compared pre and post 
intervention efficacy of hourly nursing rounds and found that within 4 
months of the implementation of hourly rounds, patient outcomes, such 
as the use of call lights and patient falls decreased while patient 
satisfaction increased.
    In order to ensure implementation of innovative ways to deliver 
care to the inpatient, outpatient, and deployed environment, we are 
also moving forward with implementing team nursing, comprised of RN, 
LPN, and medics. This aspect of the SOC aligns with The Surgeon 
General's (TSG) ``Come Home to Army Medicine'' campaign. This community 
based primary care will bring healthcare closer to home, standardize 
business practices, and develop the model for patient centered medical 
home.
    As we begin implementation of the SOC, our nurse researchers have 
begun the transformation of a geographically disparate one to three 
person research cells into the Offices of Nursing Science and Clinical 
Inquiry (NSCI). The NSCI will combine the resources of Research Ph.D. 
Scientists, Nurse Methods Analysts, Clinical Nurse Specialists, and the 
new DNP (Doctorate of Nursing Practice) with a robust mission that will 
provide decision support, evidence-based practice, and research. These 
NSCIs at each regional medical center will promote a shared vision 
across Army nursing using shared and capitalizing on shared resources 
and infrastructure. This change will shift emphasis in focus to 
capitalize on integration of evidence-based research into practice, 
improve warrior care, enable leader development and maximize human 
capital while addressing Army nursing priorities. This fundamental 
shift will transform Army nursing from an expert based practice to 
system based care and will provide the impetus to move toward a culture 
and workforce with the ability to develop research agendas and 
translate evidence into practice at the bedside. Currently the Army 
Nurse Corps has an inventory of 33 ANC Research Scientists and two 
civilian nurse scientists with doctoral degrees. Twenty-one of these 
are actively working in research assignments.
    In 2008, we initiated a comprehensive review of all Army nurse 
business and clinical processes and associated training and education. 
The gap analysis revealed a requirement for more advanced degree 
experienced nurses at patients' bedsides to influence nursing care; 
specifically, to direct nursing care within a systems-based care 
delivery model that decreased nursing care variance across the Army 
Medical Department in order to measure and improve patient outcomes. To 
that end, we expanded our review to examine the new Doctor of Nursing 
Practice (DNP) role as a modality for closing the gap. After this 
review was completed, we recognized the value of placing select DNP's 
within our NSCIs and the ANC is in the process of making this 
infrastructure change. This will provide clinical leadership, create a 
partnership with nurse Ph.D.'s and Nurse Method Analysts, and 
facilitate practical application of evidence-based research at the 
patient bedside to ensure evidence-based nursing care.
    According to the American Nursing Association (ANA), one of the 
most significant shifts in health policy is represented in a measure to 
expand the involvement and authority of advance practice nurses. Army 
Nursing is also working closely with national nursing organizations 
such as the American Academy of Colleges of Nursing (AACN) in leading 
national efforts to conceptualize a value-add role for DNPs as well as 
the new innovative clinical nurse leader role.
    The Army nursing SOC will require new capabilities while allowing 
us to better leverage current nursing capabilities. For example, 
nursing case management is increasingly being recognized as an 
essential component of healthcare delivery. Case managers provide added 
value to the multidisciplinary healthcare team. Case managers in 
Warrior Transition Units (WTUs) are providing care to over 9,000 
Soldiers and have facilitated the transfer of over 8,500 Soldiers back 
to duty or on to become productive Veterans. Warrior satisfaction with 
case management services has remained at or above 92 percent throughout 
the year.
    The Army Nurse Case Management Course was fielded in December 2008. 
This course was designed to better prepare case managers in their role, 
facilitate the successful completion of national certification, and 
standardize case management services across WTUs, to ensure case 
managers are effectively trained to perform their mission. Over 300 
nurse case managers participated in this web-based program that 
utilizes adult learning principles that enhance the Army NCM's 
understanding of case management theory. Students learn about best 
practices across military and civilian settings, thus gaining knowledge 
of principles and tools utilized in case management.
    Army nursing case management is improving care in primary care 
settings as well as in our WTUs. Nurses across the country espouse 
success stories where case management has had a positive impact on 
patient care. In Alaska, NCMs were working with a 28 year old infantry 
Soldier undergoing the Medical Evaluation Board process for moderate 
Post-Traumatic Stress Disorder (PTSD). During one of their sessions 
they talked about his mother who died at age 34 with colon cancer. 
Because the case managers had developed a good rapport with the 
Soldier, he felt comfortable mentioning that he had some rectal 
bleeding. He was immediately evaluated, determined to have metastatic 
colon cancer, and underwent a colectomy. The operation saved his life. 
Subsequently, he was able to medically retire as a healthy, productive 
veteran.
    The strategic end state of this SOC is optimized nursing care 
delivery systems that wrap capability around AMEDD goals and priorities 
to achieve the best patient outcomes possible. This capability and 
functional structure is designed to leverage proliferation of evidence-
based care and best practices to support TSG's strategic objectives.

             EVIDENCE-BASED PRACTICE: OPTIMIZE PERFORMANCE

    Our third strategic imperative is to optimize Army Nursing 
performance using evidence-based management and evidence-based clinical 
practice. Evidence-based clinical practice aims to merge best practices 
from both clinical care and business practices to produce optimal 
outcomes. These goals are achieved through scientific analysis, data 
management, and system redesign to support the everyday performance of 
all our nurses. For example, the Workload Management System for Nursing 
(WMSN) is a tool that ANC has been using for accurately measuring 
patient acuity in order to establish manpower requirements in our 
inpatient care settings. This past year, we initiated the most dramatic 
update to our WMSN since 1985. Led by talented Army Nurses, the WMSN 
Refresh and Optimization project will enable us to upgrade our WMSN 
operating system, integrate and migrate all previously separate 
servers, update the clinical classification and acuity measures, and 
develop a software interface for real time reporting tools. This 
milestone business process improvement will afford our nursing 
leadership the necessary data to support current and future resourcing 
decisions.
    Another example is the Clinical Information System (CIS) that was 
developed with input from our clinical and nursing informatics experts 
that has played a major role in modernizing our electronic health 
record. This past year included tremendous expansion of the CIS 
inpatient health record throughout the MEDCOM. The CIS is designed to 
help nurses and other healthcare personnel collect, record, store and 
access patient data, as well as data from medical instrumentation and 
physiologic monitors from a centralized computer system. The impact of 
a standardized inpatient nursing documentation system cannot be 
minimized as it not only provides standardized documentation of the 
patient's history, but allows, through its requirement to enter data 
fields, standardization of how nurses practice.
    Another evidence-based initiative is our collaboration with the 
Veteran's Health Administration (VHA) on Clinical Terminology 
Standardization that has resulted in the development of over 2,236 
standardized clinical terms. The development of Systematized 
Nomenclature of Medicine--Clinical Terms and Logical Observation 
Identifiers Names and Codes will allow for intra-operable standardized 
clinical vocabulary to assist both the providers, and the clinical 
researchers. Future collaboration will allow for a seamless process to 
add, review, and map new terminology and integrate this into DOD 
inpatient documentation systems.
    Given the magnitude of investment and the substantial military 
healthcare renovation and construction projects in the National Capital 
Region (NCR), it is important to examine the relationship between 
environmental evidence-based design (EBD) features and patient and 
staff outcomes. COL Petra Goodman, an Army Nurse (AN), has collaborated 
with investigators from numerous agencies, to include our sister 
services, military treatment facilities in the NCR and the DOD Patient 
Safety Center, to develop research protocols in EBD principles and 
their specific outcomes, including falls, work-related injuries, and 
hospital acquired infections. There series of studies will provide 
critical baseline information for future research in EBD.
    Implementing 2005 BRAC Law, Army Nurses have been involved from 
``Day One'' in creating the new 1.23 million square foot Fort Belvoir 
Community Hospital ensuring that the project delivers on its mission to 
create a World Class Military Health Care facility. DeWitt Army 
Community Hospital (DACH) nurses, both uniformed and civilian, have 
provided critical input in the design, development, and implementation 
phases of this project which includes numerous EBD features such as 
single bed rooms with family zones, maximized use of natural light, 
healing gardens and positive distractions, increased HEPA filtration, 
ceiling mounted patient lifts, walled rather than cubicle spaces, and 
the use of reduced noise sources and sound absorbing materials. MAJ 
LaShanda Cobbs, AN, serving as Transition Director for the hospital 
project until July 2009, provided key leadership in coordinating design 
concept of operations workgroups, guiding utilization of EBD 
principles, and developing manning determinations for this state-of-
the-art inpatient and ambulatory care center. Looking to the future, 
DACH nurses will continue to play pivotal roles in implementing 
integrated bedside IT solutions, the Vocera hands-free nurse call 
system, creating patient controlled environments utilizing Smart Room 
Technology, and myriad other operational solutions to maximize EBD 
features to minimize hospital acquired infections and increase patient 
safety.
    Never before have we relied so heavily on nursing research to 
infuse nursing practice with evidence-based science. In February 2009, 
the Triservice Nursing Research Program (TSNRP) invited nurse 
scientists from all services to meet in order to determine new 
priorities for TSNRP. Not surprisingly, Force Health Protection was 
recognized as the number one priority. Deployment research is designed 
to ask critical questions that cannot be answered other than on the 
battlefield providing medical care for our service members. Army nurses 
have led the way with deployment research relative to their strong 
presence in field environments. There have been 34 nursing led 
protocols, 27 of those are from ANC researchers and one joint Army/Air 
Force protocol. A breakdown of these protocols includes a total of 20 
protocols on warrior care, including five on Soldier Health, three on 
Trauma care, and one on Behavioral Health and a total of 14 protocols 
to study the impact of compassion fatigue and stress on nursing and 
healthcare professionals. Post Traumatic Stress Disorder (PTSD) is a 
focal point for many of the studies. COL Kathy Gaylord at the Army's 
Institute of Surgical Research is conducting three studies to evaluate 
alternative therapies for treatment of PTSD or PTSD symptoms in burn 
patients. ``Gradual Virtual Reality exposure therapy and D-Cycloserine 
(a learning enhancer pill) treatment for combat-related PTSD'' is a 
pilot study to determine the effectiveness of virtual reality therapy 
for service members who have sustained a burn injury requiring multiple 
dressing changes as a distraction to reduce their pain during these 
dressing changes. ``Cranial Electrotherapy Stimulation (CES) on PTSD 
Symptoms in Burned Outpatients'' is a double-blind randomized control 
research study is to determine if CES given to service members who have 
sustained a burn injury and meet PTSD criteria will be effective to 
reduce their PTSD symptoms and other deployment-related symptoms. ANC 
research scientists also continue to collaborate with the other DOD 
agencies, the Department of Veterans Affairs, and universities in 
support of the congressionally funded studies for research. In the 
Pacific region, Army nurses established a clinical-academic research 
partnership between Pacific Regional Medical Command (PRMC) and the 
University of Hawaii. This first formal academic-clinical nursing 
research partnership between Tripler Army Medical Center and the 
University of Hawaii creates a joint vision for the future of nursing 
and healthcare. This partnership provides the resources and structure 
that will allow Pacific Regional Medical Command (PRMC)-based nurses 
and University of Hawaii (UH)-based nurses to ask and answer the 
clinically relevant military healthcare questions.
    Army Nurses, like MAJ Rebecca Terwilliger, are leading the way with 
an innovative best clinical practice pilot to improve nursing care. She 
won a $17,532 grant from the March of Dimes to establish a Centering 
Pregnancy Program for antepartum patients. Participants enroll into a 
stable group that begins meeting at 16 weeks followed by monthly 
meetings until 32 weeks, then every other week for the remainder of the 
pregnancy. The group meets for 2 hours each session and is led by a 
certified nurse midwife. Benefits of the program include the 
development of a socialization and support network system while 
providing 2 hours of education on topics related to pregnancy, 
childbirth and newborn care. Evidence has shown that the program 
increases patient satisfaction, increases continuity with a provider 
and decreases preterm birth rate; for those that deliver prematurely, 
delivery occurs in gestation and the newborn is at a higher birth 
weight.
    Research is also supporting evidence-based business practices. For 
example, we used data to evaluate our accession portals and make timely 
changes on how we recruit, retain, and incentivize nursing personnel to 
remain a part of our nursing team. The Army Nurse Corps was very 
successful in recruiting and retaining Army Nurses in 2009. Research, 
like that being done by LTC Breckenridge-Sproat, AN, titled ``Factors 
Associated with Retention of Army, Air Force, and Navy Nurses'' will 
survey Active Duty Army, Navy and Air Force nurses to explore factors 
influencing decisions to maintain their active duty status. In the 
history of military nursing research, there has never been a retention 
survey using a validated instrument conducted across all three 
services. Considering the changing market for registered nurses in the 
United States and the complex factors that influence decisions to 
remain on active duty, it is important to obtain data to support 
appropriate strategies to retain military nurses in the Army, Navy and 
Air Force. The results of this multi-service study will provide the 
Corps Chiefs from the Army, Navy, and Air Force with a better 
understanding of factors impacting nurses' intent to stay in the 
military. The findings should allow administrators to capitalize on 
specific factors that positively influence nurses to stay in the 
military and implement changes to ameliorate factors that are 
influencing nurses to leave the military.
    Research is also helping us develop new recruiting strategies, 
called precision recruiting, whereby we are recruiting experienced 
medical-surgical and specialty trained nurses. This strategy will 
provide us with a balanced force of new nurse graduates with more 
experienced clinical nurses. Leveraging data allowed us to determine 
the need for precision recruiting, i.e., targeted recruiting of 
critical low densities. As a result, we increased our recruitment of 
Nurse Anesthetists, Behavioral Health Nurse Practitioners, Family 
Health Nurse Practitioners, and critical skills such as Emergency Room 
and Critical Care trained nursing personnel. These skills are 
especially in high demand with our nation's continued involvement in 
overseas contingency operations. Working closely with Accessions 
Command, we are formulating a recruitment strategy that ensures a 
consistent pipeline of ROTC, Army Enlisted Commissioning Program 
(AECP), and Federal Nurse Commissioning Program graduates, balanced 
with direct accessions of experienced nursing personnel.
    Evidence-based processes also allow us to look at who, when, and 
where we have the greatest attrition and how attrition is impacting the 
care we provide for our beneficiaries. Incentives, such as Incentive 
Special Pay, critical skills bonuses, and hiring bonuses have not only 
allowed us to conduct precision hiring of civilian nurses, but also 
allowed us to compete with the recruitment market for experienced and 
well qualified nursing personnel. I want to thank the committee for 
supporting these initiatives in the past and look forward to your 
continuing support in the future. In addition we raised and then 
codified minimum standards for entry into the AECP based on the quality 
of the nurses this program produces. In the past we have had as high as 
14 percent non-completions in the AECP. Data analysis revealed an 
antiquated admission criteria resulting in candidates who were not 
adequately prepared to sustain the rigors of the Bachelor's of Science 
program. The change in admission standards has vastly improved the 
quality of candidates in the program and will ultimately impact the 
quality of care we will provide to our warriors and their families.

                   HUMAN CAPITAL: PORTFOLIO OF TALENT

    People are our organizations' most valuable asset and remain one of 
my top priorities. Success toward our strategic initiatives has been 
possible only because of the commitment and extraordinary work by the 
triad of nursing; Active and Reserve component officers, non-
commissioned officers, and civilians. Our efforts over the past year in 
both recruitment and retention of active duty and civilian nurses have 
positively impacted Army Nursing. Investing in human capital requires a 
strategic approach to managing the recruited and retained talent so 
patient outcomes are optimized throughout the organization. 
Subsequently, our fourth imperative is optimizing human capital talent 
through talent management and succession management planning. One of 
the ways we are managing talent is by leveraging nursing capability in 
new ways. A great example of this is the ``curbside nursing'' concept 
that clinical nurse midwives implemented at Fort Campbell, KY. In 2009, 
it became strategically imperative that some type of new Soldiers' 
health initiative for women's gynecological intervention and engagement 
was needed to address the backlog of gynecologic appointments. Several 
Certified Nurse Midwives (CNM) services have actively engaged in 
leaving the confines of the hospitals and entered what normally has 
been recognized as a Soldier's clinic. This medical model approach to 
women's wellness has received laudatory comments noted in Army Provider 
Level Satisfaction Survey reports across several installations.
    To support TSG's strategic priority of implementing a comprehensive 
behavioral health system of care, BG Steve Jones, Commander, Pacific 
Regional Medical Command, and I worked together to implement a program 
to assess the effectiveness of connecting behavioral health resources 
with soldiers in a virtual encounter. Nursing resources were engaged in 
validation of the assessment tool as well as serving as a force 
multiplier through the integration of NCM and 68X, Mental Health 
Technicians, in the virtual program. Partnered with behavioral health 
(BH) providers, NCM screen for ``at risk'' Soldiers face-to-face and 
virtually with the intent to provide access to BH in remote or isolated 
locations. Many Soldiers returning from deployment do not need the 
complex services of the Warrior Transition Unit (WTU), but they do have 
significant concerns that could impact successful reintegration with 
families and non-combat environments. Coordinating care and support 
through the NCM, Soldiers and families are guided to financial, 
emotional, and physical care to support reintegration. The NCM effort 
in this Comprehensive Behavioral Health System, led by Amy Earle, RN, 
mitigates stressors to the Soldier and family by connecting them to 
services within the community.
    At Europe Regional Medical Command, the Maternal Child Nursing 
section uses a Perinatal Clinical Nurse Specialist to track high risk 
patients, which resulted in significantly increasing the number of 
infants that were immunized against Hepatitis-B at birth or prior to 
discharge as recommended by the Centers for Disease Control. In 2009, 
LTC Sherri Franklin, Chief of Nurse Midwifery, started a new midwifery 
program with 3 active duty CNMs at Fort Benning, Georgia. Due to the 
increased demand for low risk obstetrical care and the size of the post 
increasing, this planned service will be stabilized at Benning. Planned 
for 2011, an additional 6 new CNM graduates from accredited mastered 
prepared programs across the United States will be welcomed as new 
clinicians.
    This year, for the first time in our history, two of the deployed 
Combat Support Hospitals will be commanded by Army Nurse Corps 
officers. In 2009, 333 active duty Army Nurses were deployed in support 
of Operation Iraqi Freedom and Operation Enduring Freedom. This 
represented a total of 70,589 deployed man days. In 2009, the 6 month 
(180 days) PROFIS deployment policy was successfully implemented, 
considerably reducing the adverse affects of long deployments on our 
nursing personnel. Through the expert coordination of our nursing 
leaders, nursing staff were rotated at 6 month intervals with no 
adverse impacts in patient care. However, our low density nurse 
specialists, to include nurse anesthetists, nurse practitioners, 
critical care, perioperative and emergency nursing are still 
experiencing frequent deployments with some nurses completing their 
second and third deployments. We are conducting an in-depth force 
structure analysis to determine our objective force structure for the 
future years.
    Our Budgeted End Strength is projected to increase from 3,515 in 
fiscal year 2010 to 3,580 in fiscal year 2011. In addition, 80 Army 
Nurse Corps officer authorizations are projected as a part of the Grow 
the Army strategy. We are modeling for the optimal number of critical 
care nurses, emergency room nurses and behavioral health nurses needed 
to ensure sufficient staffing in our CONUS based medical treatment 
facilities and to continue the theater support that has supported the 
93 percent survival rate of our service members injured in our combat 
theaters. We recognized that many of our specialty nurses transition to 
advanced practice roles as nurse anesthetists or nurse practitioners 
but their ``loss'' from the specialty role was not included in our 
previous models. Using innovative analytical processes we have 
identified shortfalls in our training requirements that, when 
corrected, will increase the available strength of these critical low 
density nurse specialists. With increased numbers, the adverse impact 
of frequent repeat deployments will be mitigated. The Army Nurse Corps 
has always been committed to advanced education as an essential element 
of quality healthcare. As we face the continuing behavioral health 
challenges, we are increasing our number of nurses selected for 
behavioral health nurse practitioner programs. Of note, only the 
Psychiatrist and the Behavioral Health Nurse Practitioner has 
prescriptive authority as Behavioral Health providers. We have 
recognized that this level of Behavioral Health providers is critical 
in both garrison and deployed settings to facilitate optimal behavioral 
healthcare. This year, we will select 5 nurses for attendance in the 
Psychiatric/Mental health NP program at Uniformed Services University 
(USU) to start in 2011. In addition, as we transition our advanced 
practice nurse roles to the future DNP, we will be sending one nurse 
for a DNP program as a Psychiatric/Mental Health NP.
    We rely on the USU Graduate School of Nursing as the strongest 
educational platform to develop critical talent to provide nursing 
capability across Army Medicine. A good example of how USU is helping 
us build new nursing capabilities is the perioperative nursing program. 
COL (R) Wanzer and LCDR Conrardy, USU nursing faculty, developed a 
perioperative CNS program marketing brochure and designed a marketing 
poster for presentation at the 11th Annual Tri-Service Perioperative 
Symposium in Chicago in March 2009, and along with her fellow 
researchers Cole Hawker and D. Moultrie, were awarded the 2009 
Association of Perioperative Registered Nurses National Research 
Excellence Award for their research titled: ``Factors Associated with 
Multidrug Resistant (MDR) Acinetobacter Transmission Occurring in 
Traumatic War Injuries''. COL (R) Wanzer was also invited to address 
Congress during hearings on healthcare reform and presented ``The Role 
of Clinical Nurse Specialist in Health Care Delivery: Today and in the 
Future.'' The Psychiatric Mental Health-Nurse Practitioner (PMH-NP) 
Program was evaluated for its academic content, testing, and overall 
effectiveness. Changes have been made to the course structure in order 
to ensure students integrate and apply their knowledge in context of 
the goals of the program. In addition the Graduate School has signed 
eleven new memorandums of understandings with new clinical sites. In 
October 2008, USU chartered a task force to examine implementation of a 
DNP curriculum to be in line with the American Association of Colleges 
of Nursing decision to move the current level of preparation necessary 
for advanced practice nursing from the master's to doctoral level by 
the year 2015. The results of 8 months of study revealed that USU 
should take the steps necessary to implement a USU DNP program. This 
further expands USU's strength as an education platform for Army 
Nursing so that we can apply a practical application of evidence-based 
research at the patient bedside to ensure evidence-based nursing care.
    Over 60 percent of our organization is our civilian workforce, so 
our retention efforts continue to be focused on this group. We continue 
to have unprecedented success in our civilian nurse loan repayment 
program, with over 41 percent of total Army student loan repayments 
going to nurses. For fiscal year 2010, 314 applicants were selected to 
participate in the nurse loan repayment program, the largest number 
since the program started in 2006. We also recognize that our talented 
civilian healthcare professionals have unique issues and challenges. To 
provide support to our civilian nurse workforce, the Civilian Nurse 
Task Force was chartered in March 2009 to provide a forum for specific 
discussion on issues related to recruitment, retention, and career 
progression. This group's hard work resulted in the adoption of a 
civilian RN career pathway that remains in a working phase today. From 
this task force, a Nurse Consortium was established, in November 2009, 
and each medical treatment facility has a civilian nurse 
representative. This consortium works on key issues affecting 
satisfaction of the civilian nurse workforce. Current working issues 
include improving the relationship between civilian and military 
nurses, recruitment of civilian new graduate nurses, and civilian 
nurses in senior leadership positions in medical treatment facilities. 
Our first step to leverage civilian nurse talent at the senior 
executive level was the selection of Dr. Patricia Wilhem as a member of 
the Army Nurse Corps Executive Board of Directors. In addition, the 
``Civilian Connection'' link was established on our new, innovative ANC 
website and is used to post links and information pertaining to 
civilian nurses. It facilitates a sharing of information not only 
between civilian nurses but also between civilian and military nurses 
to enhance professional relationships.
    Finally we continue to leverage our retired ANC officers to serve 
as nurse role models, mentors and subject matter experts and 
ambassadors for the ANC. COL (R) Jeri Graham, president of the Army 
Nurse Corps Association (ANCA) in partnership with the ANC conducted 
the pilot Veteran's Resiliency Program in May 2009. There were sixteen 
participants with eleven active component combat veteran nurses and 
five Vietnam veteran nurses. The program was designed to address the 
issues that returning warrior nurses have after deployment that impact 
retention. The program was received favorably and with many positive 
comments to sustain the program in the future.

                               CONCLUSION

    There has been great momentum since I introduced the Army Nurse 
Corps Campaign Plan to you last year. Our success has been the result 
of compassion, commitment, and dedication from all members of the triad 
of nursing. They have inspired me with their pride, enthusiasm, and 
openness to change. We continue to experience amazing progress in each 
of our strategic imperatives and we are ensuring that the ANC remains 
relevant and a force multiplier for Army Medicine.
    I continue to envision an Army Nurse Corps in 2012 that will leave 
its mark on military nursing and will be a leader of nursing practice 
reform at the national level. The implementation of the standardized 
Patient & Family Centered System of Care is revolutionizing nursing 
care in the ANC and ensures that we optimize patient outcomes at every 
point of care delivery, both home and abroad. It reminds us that our 
priorities remain the patients and their families. Our common purpose 
is to support and maintain a system of health. In order to achieve this 
common purpose, we will let nothing hinder those who wear the cloth of 
our Nation or those who took an oath to forever save, protect, care, 
and heal.
                                 ______
                                 
          Prepared Statement of Rear Admiral Karen A. Flaherty

                              INTRODUCTION

    Good Morning. Chairman Inouye, Senator Cochran and distinguished 
members of the subcommittee, I am Rear Admiral Karen Flaherty, the 22nd 
Director of the Navy Nurse Corps. Thank you for the opportunity to 
speak to you today. I also want to express my sincere thanks and 
appreciation for the hard work and dedication of Rear Admiral Christine 
Bruzek-Kohler, the 21st Director of the Navy Nurse Corps during this 
past year.
    In his 2009-2010 Chairman, Joint Chiefs of Staff Guidance, Admiral 
Mullen declared the ``Health of the Force'' as one of his three 
strategic initiatives, stating, ``Our core responsibility is to win 
wars while caring for our people and their families. They are the heart 
and soul of our formations, our fleets, and our air expeditionary 
wings, and our incredible fighting spirit. As a Nation, we have a 
solemn obligation to fully support, across the spectrum of need, our 
service men and women, standing and fallen, and their families.''
    Today, I will highlight the accomplishments and opportunities 
facing the Navy Nurse Corps in 2010 as we care for the Health of the 
Force. The total Navy Nurse Corps, comprised of Active, Reserve and 
Federal Civilian nurses, number more than 5,500 strong. Working 
together, we are clinicians and advocates for our patients, we are 
mentors and leaders for our colleagues, and we are the face of caring 
and compassion to those affected by armed conflict and natural 
disasters. My strategy as Director has been focused in three areas: 
People, Practice and Leadership. It is within these three areas that I 
would like to highlight our successes and address our current and 
future efforts.

                               OUR PEOPLE

Recruitment
    Today's Navy Nurse Corps Active Component (AC) is manned at 91.2 
percent with 2,837 nurses currently serving around the world. We have 
already achieved Navy Nursing's Active Component recruiting goal for 
2010, for the fourth consecutive year. Reserve Component (RC) 
recruiting is currently at 16.4 percent of the fiscal year 2010 mission 
and requires our continued focus. I attribute our recruiting successes 
to the continued funding support for our accession programs, the local 
recruiting activities of Navy Recruiters and Navy Nurses, and the 
continued positive public perception of Service to our Country.
    The top three direct accession programs that are favorably 
impacting our recruiting efforts include the Nurse Accession Bonus 
(NAB), the Health Professions Loan Repayment Program (HPLRP), and the 
Nurse Candidate Program (NCP). The NAB continues to offer a $20,000 
sign-on bonus for a 3-year commitment and $30,000 for a 4-year 
commitment; the HPLRP repays student loans up to $40,000 for a 2-year 
consecutive obligated service, and NCP, tailored for students who need 
financial assistance while attending school, provides a $10,000 sign-on 
bonus and $1,000 monthly stipend.
    In 2008, Navy Medicine created a recruiting team aimed at 
increasing the visibility and focus on Navy Nursing recruiting 
initiatives. This effort provides a Navy Nursing presence at local and 
national professional nursing conferences and collegiate recruiting 
events. In collaboration with the Navy Medicine Office of Diversity, 
our Nurse Corps Recruitment Liaison Officer coordinates with local 
Military Treatment Facilities (MTFs) to have diverse Navy personnel 
attend national conferences and recruiting, increasing Navy's 
visibility among minority populations. This has allowed us to broaden 
our reach, and participate in and recruit across a broad range of 
national nursing conferences. Further, recognizing that America's youth 
contemplate career choices at a young age, Navy Nurses travel to local 
community schools and serve as guest speakers and ambassadors for our 
Corps, the Navy and the nursing profession.
    Leveraging current technology, the Nurse Corps Recruitment Liaison 
Officer uses a combination of social networking media tools, including 
Facebook and Twitter, and online discussion forums (e.g., BLOGs), to 
reach students at colleges and high schools, encouraging them to 
consider a career in Navy nursing. Through these media tools, students 
ask candid questions and can obtain instant feedback in a mode of 
communication with which they are comfortable. Additionally, students 
provide feedback of what is and is not working in the recruiting 
process. Using this information, we have implemented process 
improvement strategies to correct any gaps in the recruiting process. 
One improvement we are implementing in 2010 is an early mentorship 
program for those entering the Navy Nurse Corps through one of our 
accession programs. Junior nurses will serve as mentors to guide new 
accessions from school to their first duty station, providing 
information on pay, travel, duty stations and transition to ``Navy 
Life.'' We know that the first impression of the Navy and the Navy 
Nurse Corps are an important part of subsequent career decisions.
    Today, the Reserve Component is 83.6 percent manned with 1,112 
nurses in inventory. Last year, the Navy Nurse Corps Reserve Component 
(RC) met 87 percent of their recruiting goal. Over 48 percent of the 
accessions were Navy Veterans (NAVETS--nurses coming to the RC from 
active duty) with the remainder joining the Navy Reserve as direct 
accessions. Success in recruiting NAVETS is related to the initiation 
of an affiliation bonus of $10,000 and a policy that guarantees these 
individuals a 2-year deferment from deployment. Additionally, the 
establishment of the Career Transition Office (CTO) at Navy Personnel 
Command has been very successful in identifying those members desiring 
to move from the active component to the reserve component. The CTO, 
working in concert with the Reserve Affairs Officer (RAO) and 
Centralized Credentialing and Privileging Department (CCPD), 
implemented practices that facilitate a smooth transition with regards 
to billet assignment, pay and establishment of credentials.
    Our reserve recruiting goal for fiscal year 2010 is 165 nurses. A 
recruiting initiative targeting direct accessions will offer entry 
grade credit for advanced education and work experience among the 
critical wartime specialties of Certified Registered Nurse Anesthetists 
(CRNAs), psychiatric/mental health, emergency room, and perioperative 
nursing. These initiatives will be expanded to include medical-surgical 
nurses and critical care nurses as well.

Retention
    Retaining Navy Nurses is one of my top priorities. We remain 
committed to providing a Total Force of Navy Nurses, balanced in terms 
of seniority, experience, and skills, to provide the very best care to 
Sailors, Marines and their families. Key efforts have positively 
impacted retention, including the Registered Nurse Incentive Specialty 
Pay, a targeted bonus program for undermanned clinical nursing 
specialties and highly deployed Nurse Practitioners. Our nurses are 
enriched by being able to practice in both deployed and garrison care 
settings.
    It is our responsibility as Nurse Corps leaders to fully understand 
all retention issues. We commissioned the Center for Naval Analyses 
(CNA) in 2009 to conduct a survey and hold focus groups to help us 
understand the factors that influence career satisfaction and 
dissatisfaction in the Nurse Corps. We have found that support for 
families, childcare availability, healthcare, and other benefits such 
as the Post 9/11 GI Bill play an important role in nurse retention.
    Navy Nurses told us they wanted a clinical career ladder. Junior 
nurses felt they had to leave clinical nursing in order to advance in 
their careers. They also told us that deployments were fulfilling and 
had a positive affect on retention. The factors affecting retention are 
described more as a ``pull'' away from the military versus a ``push'' 
out of the military.
    To increase promotion opportunities for senior level positions, we 
converted a portion of vacant Lieutenant billets to Captain and Ensign 
billets. These actions also improved the alignment of billets with the 
number of junior officers being accessed each year. This right-sizing 
is also occurring for the Reserve Component led by Rear Admiral Cindy 
Dullea, my Reserve Component Deputy Director. The RC is challenged with 
personnel gaps in the junior ranks and a larger senior officer force. 
These initiatives will ensure we maintain an appropriate balance of 
highly-skilled experienced nurses with promotion opportunities.
    My goal for this year is to increase retention by 50 percent in the 
AC for those with less than 10 years of service, and to retain the 
appropriate numbers in each officer rank in the RC. To achieve this 
goal, we are increasing communication and mentoring across all ranks, 
developing a clinical leadership model, and creating a user-friendly 
job-assignments process focused on clinical specialty development. Most 
importantly, I have asked each Nurse Corps officer to be part of this 
strategy; people stay in organizations because of the positive 
influence of their peers and immediate supervisors.

                              OUR PRACTICE

Clinical Excellence
    Clinical Excellence is one of the main tenets of the Nurse Corps 
Clinical Leadership Model. Our strategy prepares every nurse to 
practice safe, competent care in any clinical setting, whether in a 
hospital or clinic, onboard ship or in forward deployed settings. 
Clinical Excellence is an expectation of the patients we care for and 
is an integral part of the interdisciplinary healthcare team of Navy 
Medicine. In 2009, we developed and implemented standardized 
orientation and nursing competencies across all of our nursing 
specialties. This creates portability, efficiency and consistency of 
care across all environments. Our goal is to deploy an electronic 
standardized procedure manual in 2010 for all facilities to have real 
time access to state-of-the-art updates to clinical care.
    Over the past several years, the Nurse Corps identified eight 
critical wartime specialties, and developed our manning, training and 
bonus structures to incentivize nurses to practice within these 
specialties. Additionally, each Nursing Specialty has an assigned 
Specialty Leader, a Clinical Subject Matter Expert who understands the 
nursing practice within each community. These Specialty Leaders are key 
in the sourcing process for deployment missions, and have been 
empowered to implement improvement strategies for their specialty 
communities.
    Understanding deployments and the type of care needed by our 
patients is essential when developing our nurses. For example, the 
critical care patient in Afghanistan may be required to stay on the 
ground longer given the environmental challenges impacting medical 
airlift evacuation. Our staff needs to understand this and add to their 
portfolio of skills in both acute and chronic critical care nursing 
competencies. To accomplish this goal, our Specialty Leaders worked 
with Senior Nurse Leaders at MTFs to create partnerships with local 
civilian hospitals and military nurses cross-train in local Emergency 
Departments and Intensive Care Units (ICUs). All Navy Nurses deploying 
in a critical care role cross-train in an ICU and attend the Essentials 
of Critical Care Orientation Course, the industry standard for critical 
care orientation. We are also piloting a ``closed-loop'' detailing 
process where nurses who desire to practice in the critical care 
specialty for their careers, have the ability to be transferred to 
hospitals that provide critical care nursing. Our goal is to keep these 
highly-trained critical care nurses working in critical care.
    To support the behavioral health needs of our Warriors and their 
families, the Nurse Corps has increased its inventory of psychiatric/
mental health clinical nurse specialists and nurse practitioners. This 
growth will support the projected growth of the Marine Corps, Blue in 
Support of Green (BISOG) and the increase in the number of Operational 
Stress Control and Readiness (OSCAR) teams. We have successfully 
employed Psychiatric-Mental Health Clinical Nurse Specialists and 
Mental Health Nurse Practitioners to meet the operational demands of 
the Psychiatric-Mental health caseload. Looking ahead, we will align 
our core privileging with our civilian counterparts, deploy mental 
health nursing assets where needed, and increase the education pipeline 
to meet this requirement.
    Senior Nurses empower their staffs to innovate in hospital, clinic 
and operational settings, ensuring a culture of clinical excellence is 
infused at all levels. An example of these innovations is a job sharing 
initiative in USNH Guam, where two nurses can gain leadership 
experience, while continuing to excel as clinicians. A Family Nurse 
Practitioner in Okinawa, created efficiencies, eliminated patient visit 
backlogs, and increased family satisfaction while maintaining family-
centered care. He established a Fast-Track clinic that resulted in a 25 
percent decrease in non-urgent care provided by the Emergency 
Department. Through Clinical Excellence in Practice, our nurses gain 
the confidence and competencies to ensure that Navy Medicine remains a 
leader in healthcare.
Nursing Education
    I am a fervent supporter of graduate nursing education, research 
and professional growth of my officers, and am committed to the 
sustainment and growth of the Tri-Service Nursing Research Program 
(TSNRP). Each year, approximately 73 officers are selected for Duty 
Under Instruction, the Nurse Corps' graduate education program. 
Additionally, nurses are selected to participate in the Johnson and 
Johnson Wharton Fellow's Program in Management at the University of 
Pennsylvania, and several Navy-sponsored leadership courses. Clinical 
specialization matched with leadership experience is key to developing 
the clinical leader.
    The American Association of Colleges of Nursing made the decision 
to move the current level of preparation necessary for advanced nursing 
practice from the master's degree to the doctorate-level by 2015 based 
upon shifting patient demographics, health needs, and changing health 
system expectations. The Navy Nurse Corps supports a phased approach 
toward adopting the Doctorate of Nursing Practice (DNP) as the 
recommended terminal degree for Advanced Practice Nurses, and will 
utilize a combination of short- and long-term action steps to 
incorporate the DNP degree option as part of its education strategy. 
Using existing funding, three nurses will graduate with a DNP in 2012 
and the DNP degree will be incorporated into the Nurse Corps Training 
Plan. As we make the transition to a greater number of DNPs, we will 
conduct careful reviews of future education funding requirements.
    To expand this clinical leadership model to Federal Civilian 
Registered Nurses, we launched the Navy Graduate Program for Federal 
Civilian Registered Nurses, the first of its kind in the Uniformed 
Services, and funded five competitively selected Federal civilian 
registered nurses to pursue their Master of Science in Nursing degrees. 
These selected candidates agreed to work a compressed work schedule 
during the time they are in graduate school and incur a 2-year 
continued service agreement. This program has been fully funded in 
2010, and we are currently receiving applications to select our next 
class of candidates for Fall 2010. We expect that this new program will 
retain our current civilian nurses, incentivize new nurses to consider 
entry into Federal service, sustain Military Treatment Facilities with 
subject matter experts when military nurses are deployed, and offer new 
educational growth for our civilian colleagues.
    Every military nurse joins the Service with a Baccalaureate degree 
or higher, thus our Nurse Corps education strategy is focused on 
Graduate Nursing Education. I thank you for your support of this 
critical strategy.

Nursing Research
    Navy Nurse Researchers assigned to Medical Centers educate nurses, 
physician residents, faculty, and staff about research design, 
implementation and evaluation. They facilitate the research process 
though collaboration with the Nursing Research team, Clinical 
Investigations and local, national and international academic 
institutions. More than 15 formal studies are in progress to promote 
the health and wellness of our Warriors and their families. 
Additionally, several evidence-based practice projects underway 
synthesize research literature to create individual evidence-based 
nursing practice guidelines and ensure practice effectiveness. The 
``Back-to-Basics Bundle of Care Project'' at Naval Medical Center San 
Diego and the ``Electronic Ticket-to-Ride, a Standardized Hand-off 
Program'' at National Naval Medical Center are just two examples of 
research projects that will increase patient safety and satisfaction, 
increase efficiency, decrease healthcare costs, and promote positive 
health outcomes during inpatient stays.
    Navy Nurses are accomplished authors, presenters and leaders not 
only in the field of Nursing, but also in healthcare and medicine. Many 
have contributed to military, national and international forums as 
keynote speakers and subject matter experts. Captains Linnea Axman, NC, 
USN and Patricia Kelley, NC, USN were members of the planning committee 
for the 2009 Botswana Conference. This conference, co-sponsored by Navy 
Medicine and Uniformed Services University, identified opportunities 
for the development of collaborative international research proposals 
and advancement of the concepts of integrity in research. Commander 
Michele Kane, NC, USN was the first Nurse Corps officer to provide the 
keynote address at the 2009 World Congress on Military Medicine. The 
research conducted by these outstanding nurses is a testament to their 
expertise, scholarship and commitment to advancing scientific knowledge 
in the field of medicine.
    Among the many nationally recognized award winners for Navy Nurses, 
Lieutenant Colleen Mahon, NC, USN was recognized as the National 
Association of Women's Health Obstetric and Neonatal Nursing's Navy 
Nurse of the Year, and Commander John Maye, NC, USN was selected as the 
American Academy of Nurse Anesthetists' Researcher of the Year.

Outreach and Partnerships
    Navy Nurses, at our MTFs in the United States and abroad, 
passionately support the professional development of America's future 
nursing workforce by serving as preceptors, teachers and mentors for 
local colleges and universities, as well as entire health systems. 
During Continuing Promise 2009, Navy Nurse Corps officers from the USNS 
Comfort served as subject matter experts providing training in Advanced 
Cardiac Life Support, Basic Life Support, IV insertion, basic first 
aid, trauma care, EKG interpretation and basic nutrition to 35,000 host 
nation medical personnel. Although a U.S. Navy mission, Nurses worked 
with partners from the Active Component, Reserve Component, Army, Air 
Force, U.S. Public Health Service, and over 90 nurse volunteers from 
Project Hope, the Church of Latter Day Saints, and Operation Smile. 
Additionally, over 40 military nurses from Canada, El Salvador, 
Netherlands, and France worked side-by-side with us in providing care 
to over 100,000 patients. Today, the USNS Comfort is deployed staffed 
by caring colleagues providing humanitarian assistance to the people of 
Haiti.
    Navy Nurses deployed to Afghanistan in embedded training teams are 
teaching culturally and linguistically appropriate public health 
measures. In response to news of H1N1 outbreaks throughout the world, 
nurses prepared emergency response plans and training for the local 
Forward Operating Base (FOB) and Regional Hospital in eastern 
Afghanistan, well in advance of cases appearing in-theater, and 
deployed critical counterinsurgency tactics by performing village 
medical outreaches to the local community members in eastern 
Afghanistan. These missions improved relationships, increased trust and 
fostered cooperation with U.S. and coalition forces among the local 
population.

                             OUR LEADERSHIP

    I believe that leadership at all organizational levels is 
responsible for ensuring the personnel under their charge are healthy 
and productive. This is echoed by Admiral Mullen, ``As leaders, we must 
ensure that all receive the care, counseling, training and financial 
support to become self-sufficient and lead productive and fulfilling 
lives'' (CJCS Guidance, December 2009). My nursing leaders have 
developed and are implementing an interactive career planning guide 
useful for mentoring seniors and subordinates at every stage of their 
careers. This mentoring tool asks pointed self-assessment questions to 
the officer and the nurse leader to assist both in making the best 
professional career decisions balanced with professional and personal 
goals. It guides the nurse leader in assessing the strengths and needs 
of the officer and balancing them with organizational goals. Blending 
our officers' clinical excellence, operational experience and 
leadership develops the highest caliber leaders for Navy Medicine today 
and in the future. Each nurse is a leader, whether caring for a 
population of patients, leading a Command, or being the Nursing voice 
for our Fleet or our Marines. Each day, we have an opportunity to 
impact the health and well-being of others.
    A key role of a leader is to know their people and help them 
develop the resiliency to be able to handle stressors and life events. 
Navy Medicine's Operational Stress Control and Care for the Caregiver 
programs have a direct impact on the health and well-being of the 
force, deployment readiness and retention. By developing and providing 
education and training opportunities throughout the service member's 
career, Operational Stress Control builds resilience and increases 
effective responses to stress and stress-related injuries and 
illnesses. We know that caring for service members and their families 
and experiencing the trauma and stress that they experience can impact 
our medical staff. Strengthening the resilience of our Navy Nurses will 
assure they are better equipped to meet the day-to-day challenges of 
both naval service and their profession.

                            CLOSING REMARKS

    Thank you for providing me this opportunity to share with you the 
remarkable accomplishments of the Navy's Nurse Corps and our continuing 
efforts to meet Navy Medicine's mission. On behalf of the outstanding 
men and women of the Navy Nurse Corps, and their families who 
faithfully support them, I want to extent my sincere appreciation for 
your unwavering support.
                                 ______
                                 
      Prepared Statement of Major General Kimberly A. Siniscalchi

    The Total Nursing Force (TNF) is comprised of our officer and 
enlisted nursing personnel including the Active Duty (AD), Air National 
Guard (ANG), and Air Force Reserve Command (AFRC) components. It is a 
pleasure to lead and serve alongside my senior advisors, Brigadier 
General Catherine Lutz of the ANG and Colonel Anne Manly of the AFRC. 
Together, we command a total force team delivering evidence-based, 
patient-centered care and support to meet Global Operations. Our 
nursing service personnel confront the challenges of increasing 
commitments and deployments with distinction and professionalism. They 
support the top priorities of the Secretary and the Chief of Staff of 
the Air Force to: (1) Continue to Strengthen 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 & Space Inventories, Organizations & Training, 
and (5) Recapture Acquisition Excellence. This testimony will reflect 
how Air Force Nurses, lead, partner, and care every time and 
everywhere.

                         EXPEDITIONARY NURSING

    Operational capability, the foundation and moral fiber of Air Force 
nursing, is instrumental in driving remarkable achievements. Air Force 
nurses and medical technicians at Craig Joint Theater Hospital (CJTH) 
at Bagram Airfield, Afghanistan provided outstanding nursing care for 
the highest number of casualties in OEF. CJTH is the only total U.S. 
staffed Level III military treatment facility in Afghanistan, and 
offers the most advanced medical capability in the country. CJTH nurses 
functioned as preceptors for nine Afghan nurses embedded as part of an 
Afghan Trauma Mentorship program. The Afghan nurses worked side-by-side 
with Air Force nurses and medical technicians, gaining valuable 
clinical experience, which they are excited to share with their co-
workers to create positive change for the Afghan healthcare system for 
years to come.
    The summer and fall of 2009 at CJTH is summarized through excerpts 
written by Dr. Zeriold, the ``trauma czar'', of his time in 
Afghanistan. ``A conflict that had become known as `The Forgotten War' 
was suddenly remembered as we entered the Afghan theater. We found a 
hospital and system in existence for several years that had seen a 
moderate number of patients. We brought only ourselves; it was a team 
from all over the United States from all branches of the military. No 
extra equipment, no new technology, no more medications, gear, or 
personnel. We were the standard deployment team for this theater. 
However, the pattern of this war changed. Over the next 6 months, we 
took care of more than 1,000 trauma admissions and countless medical 
admissions. The acuity was very high, and injuries were horrendous. A 
new pattern of war trauma had emerged for this hospital, a pattern that 
rivals and even surpasses a 500 bed, university based, Level I trauma 
center. We safely returned to the states 550 injured U.S. service 
members. We returned them to their families, children, and spouses. We 
changed the devastated lives of 450 Afghan nationals and won their 
hearts. I will never forget the bonds we formed with so many. And the 
kids--my God, I will never forget the kids; reaching out their little 
hands, with a smile, at the time of discharge as if to say thank you, 
`I'll be okay, and can I go home now?' As a result of your dedication 
and work, this hospital and this team set the theater standard, and 
broke theater records for caseload, admissions, transfers, and 
outcomes. We transformed this time, mid to late 2009, into an era never 
to be forgotten.''
    CJTH also functions as the primary theater Aeromedical Evacuation 
(AE) hub, for out of country casualty transport. The Contingency 
Aeromedical Staging Facility at Bagram facilitated an average of 500 
patient movements per month, starting July 2009. ``They are the `Angels 
of the Battlefield'--medics dedicated to transporting wounded U.S. and 
coalition service members, as well as locals, to the medical care they 
need. It's our job to take care of these wounded warriors,'' said Maj. 
Dawn Rice, an Air Force Reserve flight nurse and medical crew director 
assigned to the 451st Aeromedical Evacuation Squadron (AES). ``We take 
great pride in getting people the top-notch care they deserve. Our 
country and our military will do whatever it takes to get people to the 
appropriate medical facilities. We want people to know this,'' she 
added. ``Hopefully, it will give them some comfort when they are 
outside the wire fighting the enemy.''
    Air evacuation is a detailed process with the aircrew acting as the 
most visible link in the chain. The process typically begins at a local 
level. ``The primary mission at smaller field hospitals is simply 
stabilizing the patient,'' said Chief Master Sergeant John Trujillo, 
451st AES superintendent. ``Once the patient is stabilized and can be 
moved to another more capable hospital, then it's our job to get them 
there.''
    While caring for wounded service members is the crew's primary 
mission, they provide the same level of dedication to all. The squadron 
recently flew a 9 year-old Afghan girl and her 13 year-old brother from 
a major hospital at Bagram Airfield to a base in Southern Afghanistan. 
She had been at the hospital at Bagram for 2 months recovering from 
injuries received during a mortar attack on her village. Prior to the 
United States stepping in, her brother had been tasked with her care, 
replacing bandages on her legs and overseeing her well-being. As she 
was brought aboard the aircraft for her flight, nurses from Bagram said 
their tearful goodbyes while crewmembers gave the children gifts and 
treats, bringing out their smiles. Looking at the children, the Major 
spoke about this moment and how it transcended geographical borders and 
political differences. It was truly a moment of human compassion. The 
care being given was not just between Americans and Afghans, or adults 
and children, but between human beings taking care of each other. 
``This is why we do what we do,'' said Major Rice softly. ``These are 
the moments we live for,'' she added with a smile.
    Nursing Services are integral to the support of global and home 
base operations. Day after day, we take the best care of our Nation's 
heroes at home and abroad. AE continues to be one of the greatest 
successes in the war on terror, and is the vital link to saving lives. 
Another example of our AE teams' heroic efforts occurred when a skilled 
team of medical personnel worked tirelessly to keep a badly burned 23-
year old civilian alive. Having already died and been brought back to 
life by a shot of adrenalin and cardiopulmonary resuscitation, he was 
carried by litter onto a C-17 medical evacuation flight from Balad, 
Iraq to Germany. Lieutenant Colonel Belinda Warren tucked a blanket 
around the patient and inserted numerous tubes to provide vital fluids 
to his body. ``You have to make sure the burn victims don't get cold, 
replace all the fluids leaking from their burns, and make sure they 
don't go into hypothermia or get their blood clotting factors out of 
whack,'' she said. As an Air Force Reserve Critical Care Air Transport 
Team (CCATT) nurse, her goal was to make the patient as comfortable as 
possible. On a return flight to Germany later that month, she learned 
that he had about a 20 percent chance of survival, a higher rate than 
usual, and is doing better than expected, given the severity of his 
injuries.
    These critical missions sustain world-class care across the 
continuum, ensuring our warriors are able to return to the fight with 
continued healthcare and family support. Since overseas contingency 
operations began in 2001, over 70,000 patients have been aeromedically 
evacuated. Year 2009 proved to be a robust one for patient movement. We 
moved 21,500 patients globally including over 9,000 from the war fronts 
in Iraq and Afghanistan. Men and women of the 32 Total Force 
Aeromedical Evacuation (AE) Squadrons were augmented by CCATTs 
delivering hands-on care in the air. These units are currently staffed 
at approximately 90 percent, but as the troops in the Area of 
Responsibility (AOR) increase, additional crews will be needed and are 
being built to support them.
    One of our challenges in developing new AE crews is the training 
pipeline. It currently takes approximately 6 to 9 months to train each 
new crewmember. The initial phase of this training takes place at our 
School of Aerospace Medicine and is standardized for the Total Force. 
Once the didactic portion of AE is completed, flight nurses and 
technicians return to their units. The time required for nurses and 
technicians to be qualified on an aircraft can take an additional 2 to 
6 months. The Total Force is pursuing a single standardized Flight 
Training Unit (FTU) similar to that being used by our pilots. This FTU 
will standardize the upgrade training process across the Total Force by 
creating a single level of qualification and will, most importantly, 
shorten the pipeline to approximately four weeks, creating parity among 
all AE crews.
    Captain Jac Solghan and his Aeromedical Evacuation Liaison Team's 
(AELT) actions provide a great example of what individuals and teams 
bring to the fight when put to the test. Within 12 hours of landing at 
Bastion Joint Operating Base, an improvised explosive device (IED) 
explosion/multi-collision incident injured 5 Afghan National Army 
personnel and 12 local nationals. After their initial medical 
assessments and treatments, Capt. Solghan's AELT responded by providing 
Afghan patient movement requests for rotary wing airlift. Within 40 
minutes, the patients were ready for transport to Kandahar Air Base.
    Additionally, Capt. Solghan and his team successfully coordinated 
with the United Kingdom (UK) Aeromedical Evacuation Control Center 
(AECC) for the transport of a UK solider that suffered a blast injury 
that left him with only one functioning lung. Capitalizing on the 
capabilities of the USAF Lung Team stationed at Ramstein Air Base, 
Germany, and the technology of a Nova artificial lung, this UK service 
member was transported in the U.S. Aeromedical Evacuation System to 
Germany for critical treatment, and then finally to the Birmingham 
Military Hospital, UK, where he is now doing well. This success story 
demonstrated a multinational effort of over 1,000 aircrew, ground, and 
medical personnel.
    Capt. Solghan and his team significantly improved the Afghan 
patient movement system, integrating United States airlift capability 
with International Security Assistance Force and Afghan hospital 
networks. They executed the first-ever United States airlift transport 
of an Afghan patient to an Afghan hospital and enabled eight new 
casualty transport routes, increasing inpatient turnover by 70 percent 
and influencing new joint theater policy. They also initiated joint 
operations with the Afghan National Army Air Corps, enabling more than 
43 patient evacuations with indigenous air assets thus fostering 
national military airlift capability.
    Major Louis Gallo, another Air Force nurse, elevated the level of 
care delivered to our wounded warriors, by leading the first 
Contingency Aeromedical Staging Facility at Bagram Air Base, 
Afghanistan. His team set up tents to stage patients as they waited for 
flights to Germany. He coordinated the procurement of essential 
communication equipment and support services needed to sustain 
operations. Knowing that injured patients needed more than medical 
care, he contacted the United Service Organization, whose volunteers 
set up a morale tent within days with supportive and recreational 
services to aid those awaiting transportation.

                              HUMANITARIAN

    As a result of the devastating earthquake in Haiti on January 12, 
2010, the Special Operations Surgical Teams and Special Operations 
Critical Care Evacuation Teams, assigned to the 1st Special Operations 
Wing, Hurlburt Field, Florida, deployed with the initial response 
aircraft and were the first military medical teams on the ground. The 
intense training and combat experience gained in Operation Iraqi 
Freedom (OIF) and Operation Enduring Freedom (OEF) prepared the teams 
for extremely difficult conditions. They worked around the clock to 
provide emergency life-saving care to countless American citizens and 
Haitian Nationals. The teams established treatment areas at the Port-
au-Prince Airport and the American Embassy. The Critical Care Nurses 
provided casualty evacuation of patients both in and out of country as 
well as pre- and post-operative intensive care unit management. The 
Nurse Anesthetists assisted in lifesaving surgeries including several 
amputations, and augmented the ICU.
    Our Air Force Nurse Corps mission is ``we lead, we partner, we 
care.'' These words have never been more relevant as when the nurses 
and medical technicians of Joint Base McGuire-Dix-Lakehurst repatriated 
our fellow Americans who survived the horrific earthquake in Haiti. 
``Over a 4 day period, around the clock, plane after plane, those three 
words, `lead, partner, and care,' defined every aspect of the mission 
we found ourselves involved in,'' stated Major Robert Groves, Deputy 
Chief Nurse and Education and Training Flight Commander. He summarized 
his team's experiences using the Air Force Nurse Corps mission as a 
backdrop:
  --We lead.--Every shift had an assigned Nurse Corps officer and 
        Senior Non-Commissioned Officer, an Aerospace Medicine Services 
        Technician, to organize healthcare, mentor colleagues who had 
        never participated in such an operation, and, of course, to 
        provide care to earthquake survivors. Among the major tasks 
        were organizing the treatment areas in the evacuation 
        operations center, inventorying and obtaining supplies, meeting 
        planes, triaging patients, and assisting with patient transport 
        to higher echelons of care.
  --We partner.--When operational tasks did not involve direct care, 
        one could find nurses and technicians supporting the endeavors 
        of our other Air Force colleagues. We allowed survivors to 
        share their experiences, played soccer with children in the 
        fitness center gym, assisted them to find appropriate clothing 
        at the donation center, helped them pack new suitcases for 
        their trip to families, and provided the use of personal cell 
        phones to call loved ones to let them know they were okay. For 
        some, these were the first words heard from loved ones in the 
        four days following the earthquake.
  --We care.--Direct patient care came easily and naturally to our 
        nurses and aeromedical technicians. But, it was more than that. 
        From the beginning of operations it was decided that no 
        survivor would be alone while on the ground in our area. While 
        few evacuees required transfer to higher echelons of care, when 
        they did, there was a member of our team assigned to accompany 
        them throughout the process. Many evacuees had not navigated 
        the American healthcare system. To prevent them from being 
        overwhelmed and lost in an unfamiliar system, one of our team 
        remained with them until they boarded flights to their 
        families. Sometimes it involved overnight stays at local 
        hospitals so they had a familiar, encouraging face during their 
        treatment. In the end, we processed 579 evacuees, with 70 
        needing more extensive medical care and six requiring transport 
        to community medical partners. But, the knowledge, skills and 
        cooperation with each other and our Joint Base mission partners 
        will be a long-lasting experience and will carry fond memories 
        of our military service long into the future. These four days 
        are what our readiness training had adequately prepared us to 
        do. This is what our service is all about.

                        RECRUITING AND RETENTION

    A robust recruiting program is essential to keep the Nurse Corps 
healthy and ready to meet the complex challenges in healthcare and 
national security. While we have executed incentive programs to address 
the nursing shortage, shortfalls continue to be an enormous challenge. 
Today's nursing shortage is expected to deepen as nursing faculty ages. 
The capacity for nursing schools to educate sufficient numbers of 
registered nurses (RN) to meet the future demand is stressed, largely 
due to the limited number of nursing faculty. On July 2, 2009, the U.S. 
Bureau of Labor Statistics reported the healthcare sector of the 
economy is continuing to grow, despite the recession, with more nursing 
jobs expected to be created in the next decade than in any other single 
profession. RNs will be in high demand to fill the majority of these 
positions, as they are the largest component of the healthcare 
workforce. The BLS projects that nearly 600,000 new RN jobs will be 
created by 2018. Quality of life and career opportunities, coupled with 
bonuses, special pays, and other incentives, are critical recruiting 
tools for Air Force Nursing.
    Recruiting fully qualified nurses continues to be one of our 
largest challenges and our historical and present statistics tell us 
this will be an issue for years to come. In fiscal year 2009, we 
accessed 284 nurses against our total accession goal of 350 (81 
percent), down 12 percent from what I reported the previous year. 
National competition to access nurses will continue as many 
professional employment opportunities exist.
    Our Nurse Enlisted Commissioning Program continues to be a superb 
resource as we continue to grow our own from our valuable enlisted 
medics. In fiscal year 2009, of 69 applicants, 40 qualified candidates 
were selected. In fiscal year 2010, we will meet our steady state goal 
of 50 quotas per year. The graduates from this program are commissioned 
as Second Lieutenants and will continue to be valuable assets.
    As we strive to meet our recruiting goals, NC retention remains 
challenging. In fiscal year 2009, 267 (almost 10 percent) nurses 
separated or retired from the Air Force, with 73 percent having 20 
years or less time in service and 58 percent being Lieutenants and 
Captains. With an Incentive Special Pay (ISP) budget increase of $3.3 
million compared to last year, our NC ISP is currently in its second 
year of execution. Seventy-eight percent of our nurses exercised single 
or multi-year contracts. This year's focus was to increase retention by 
recognizing advanced academic preparation, certification and 
experience. In addition, we expanded the number of nurses eligible for 
ISP by adding additional Air Force Specialty Codes and clinical 
settings. While the ISP was not a retention bonus out right, we look 
forward to seeing a positive impact on retention as a result of this 
initiative.
    A number of societal, scientific, and professional developments 
have stimulated a major paradigm change in graduate nursing education. 
One major impetus for this change was the American Association of 
Colleges of Nursing's (AACN) decision in 2004 to endorse the Position 
Statement on the Doctorate in Nursing Practice (DNP). This decision 
moves the current level of preparation necessary for advanced nursing 
practice from the master's degree to the doctorate-level by the year 
2015. The U.S. Air Force Surgeon General fully supports AACN's 
decision, and in response, the Air Force Nurse Corps has researched 
current practice issues within the Nurse Corps and has developed an 
implementation proposal for achieving the AACN goals by 2015. 
Currently, all Air Force Nurse Practitioners are trained through a 
master's degree program. The Air Force NC recommends a phased 
implementation approach to meet the AACN intent. Starting in calendar 
year 2010, the Air Force Nurse Corps proposes a small pool of Nurse 
Corps candidates to be selected to attend Doctor of Nursing Practice 
(DNP) programs and by 2015, all students entering the nurse 
practitioner (NP) career path will graduate with a DNP. In addition, by 
2015, all new Air Force NP candidates accessed through the Health 
Professions Scholarship Program (HPSP) will be prepared at the 
doctorate level. Recruitment of fully qualified NPs has been a 
challenge and will likely become more difficult with the increased 
educational requirements. The Nurse Corps must pursue additional 
incentives to entice DNPs to enter the Air Force.

                          OPERATIONAL CURRENCY

    Education and training is the foundation of the Nurse Corps 
competencies and one of our priorities is to ensure currency platforms 
meet emerging clinical and operational requirements. The Nurse 
Transition Program (NTP) continues to be one of our many successes with 
10 military and two civilian locations. We graduated 158 NTP nurses in 
fiscal year 2009. Last year; I reported a civilian partnership with the 
Scottsdale Healthcare System, in Scottsdale, Arizona was on the 
horizon. I was honored to deliver the commencement address for the 
second class in December, where we graduated 15 students. We have 
partnered with an outstanding Magnet status organization and our new 
Air Force nurses are getting unprecedented clinical opportunities. At 
just 6 months, the Scottsdale program is already proving to be a 
cornerstone in the success of a strong military partnership between 
Scottsdale Healthcare and Luke Air Force Base, Arizona, located 35 
miles east of Scottsdale. From October to December, nurses trained on 
inpatient units at two Magnet-recognized facilities where they gained 
hands-on clinical experience and competence in direct patient care 
under the supervision of nurse preceptors. Their training was further 
enriched with rotations in peri-operative services, wound care, 
infusion services, laboratory, pediatrics and the Maricopa County burn 
unit. The privilege of training in Magnet-recognized facilities is an 
experience that will prepare our nurses to meet the demands in our 
stateside facilities as well as in deployed settings around the globe. 
I am proud of the exceptional work the course supervisors, Majors 
Deedra Zabokrtsky and Nancy Johnson, have achieved in such a short 
period of time. The Scottsdale program will begin a steady state of 20 
to 25 nurses per class in 2010, making it the largest nurse transition-
training site.
    The 882nd Training Group at Sheppard Air Force Base, Texas, is 
instrumental in establishing the largest joint armed services medical 
education and training center that the world has ever seen. To date, 
the 882 Training Group spent more than 11,000 hours working side by 
side with their Army and Navy counterparts to consolidate 15 military 
enlisted medical technical training courses. These collaborative 
efforts have allowed the three services to incorporate best practices 
and build state-of-the-art training platforms that will prepare the 
next generation of medics for the military's diverse missions. The 882 
Training Group began transitioning key and essential personnel in the 
fourth quarter of fiscal year 2009 and will continue staging instructor 
staff and equipment to the Medical Education and Training Campus (METC) 
at Fort Sam Houston in San Antonio through the last quarter of fiscal 
year 2011 when all courses are projected to be operational. The first 
METC Senior Enlisted Advisor is Chief Master Sergeant Kevin Lambing, an 
Air Force Senior Aerospace Medical Technician.
    Our enlisted medical technicians, led by Chief Master Sergeant 
Joseph Potts, are vital to the achievements of the TNF. One of many 
outstanding Airmen is Staff Sergeant Christopher Brown, a medical 
technician deployed from the 88th Medical Group for 192 days to Kabul, 
Afghanistan, where he was assigned to Joint Task Force Phoenix VII. 
SSgt. Brown received a Meritorious Service Medal in recognition of his 
superior performance as a medical technician while supporting 
humanitarian missions, conducting medical evacuations, training 
Afghanistan medics, participating in military convoys, and setting up 
an Afghanistan medical clinic. He was the sole medic for a 12-person 
police mentoring team traveling to various remote areas surrounding 
Kabul to train Afghan police. Assigned to the Afghan Evaluation 
Transition Team, he was given 14 Afghan medics to train and prepare to 
treat patients at a bare base. He participated in the longest convoy in 
OEF history to move the Afghan Kadack to the bare base in western 
Afghanistan. SSgt. Brown is a fine example of the many committed Airmen 
who continue to make our Air Force proud.
    In an effort to increase advanced life support capability at bases, 
we have trained several of our Aerospace Medical Service Technicians to 
the National Registry of Emergency Medical Technician-Paramedic level. 
The inaugural class launched last fall graduated 19 students. This 
initiative helps reduce the number of contract services in our 
emergency response platforms by growing our own paramedics from our 
enlisted force. This will also provide a marketable career path outside 
the military when these individuals retire. We are expecting an annual 
growth rate of 50 per year with the vision of providing relief for a 
stressed career field.
    Another force multiplier is our Independent Duty Medical 
Technicians (IDMT). We continue to see a steady increase in our IDMTs 
as we balance the end strength of our medical technicians. They play an 
integral role within our Air Force Medical Service as our physician 
extenders. They are designed to function in a small footprint providing 
patient care, as well as fourteen other ancillary support functions. 
The continued efforts to recruit IDMTs have garnered our highest 
``true'' volunteer candidates equaling 24 in the past 10 years. The 
remainder of our IDMT candidates are gained through the Noncommissioned 
Officer Retraining Program designed to right size undermanned career 
fields across the Air Force. Additionally, continuation of the 
selective reenlistment bonus has aided the recruitment and retention of 
these valuable assets. Information technology has further enhanced our 
IDMTs' capabilities. We supply each IDMT with a hand-held Hewlett-
Packard iPAQ that is fully loaded with reference materials, thereby 
increasing access to the most up-to-date medical information without 
adversely affecting space and weight limitations of their medical bags.

                           SKILLS SUSTAINMENT

    For nearly a decade, the Air Force Medical Service has partnered 
with high volume civilian trauma centers to prepare doctors, nurses, 
and technicians to care for combat casualties. Maintaining readiness to 
care for the complex traumatic injuries seen in war is challenging as 
most military treatment facilities care for lower acuity patients. To 
bridge this gap, three Centers for Sustainment of Trauma and Readiness 
Skills (C-STARS) platforms were established at the R Adams Cowley Shock 
Trauma Center in Baltimore, at University Hospital Cincinnati, and at 
Saint Louis University Hospital. C-STARS Baltimore has a surgical and 
emergency care focus. C-STARS Cincinnati is designed specifically for 
the clinical sustainment of Critical Care Air Transport Teams. C-STARS 
St. Louis serves a range of medical and surgical specialties. In 2009, 
817 doctors, nurses, and technicians completed vital training at one of 
these three centers. Since inception, these partnerships have enabled 
4,336 Total Force medical Airmen to maintain clinical currency. During 
their 2 to 3 week tours, participants complete 90 to 100 percent of 
required readiness skills through hands-on patient care, supplemented 
by didactics, cadaver labs, training with patient simulations, and 
field exercises.
    In addition to the immersion experience obtained at C-STARS, a 
complementary initiative was started in 2009 called STARS-P, the 
Sustainment of Trauma and Resuscitation Skills Program. Personnel 
assigned to designated STARS-P military treatment facilities at Wright-
Patterson AFB, Ohio; Luke AFB, Arizona; Nellis AFB, Nevada; Travis AFB, 
California; and Wilford Hall Medical Center, Texas, rotate through 
local civilian Level I trauma centers as part of their normal duty 
time. For example, medical personnel assigned to Luke AFB, routinely 
rotate to nearby Scottsdale Healthcare. As a new initiative, we 
continue to define processes that best match the needs of the military 
treatment facility and the host civilian institution; however, STARS-P 
holds great promise as another approach to honing war-readiness skills. 
These partnerships with civilian medical facilities have proven to be 
invaluable to maintaining a high state of readiness to deliver quality 
care to our Soldiers, Sailors, Airmen, Marines, their families and 
coalition partners.
    Another valuable skills sustainment program is the Critical Care/
Emergency Nursing (CC/EN) Fellowship. The three fellowship sites, 
Wilford Hall Medical Center, San Antonio, Texas, St. Louis Hospital, 
St. Louis, Missouri, and the National Naval Medical Center, Bethesda, 
Maryland, continue to produce superbly trained nurse clinicians. Many 
graduates have already employed their new skills at deployed locations 
in Afghanistan or Iraq, and several stationed at the 59th Medical Wing 
have returned to one or both AORs for more than one tour. Forty-three 
percent of the San Antonio Military Medical Center graduates have 
obtained advanced certification as Critical Care Registered Nurses. As 
of March 2009, 99 of 313 critical care nurses are Critical Care 
Registered Nurses. Graduates of these benchmark programs are phenomenal 
and often light years ahead of their peers. Nurse leaders repeatedly 
report from the deployed environment that our graduates are the best, 
``Put into any situation and they simply shine.'' They have developed 
critical thinking skills that often exceed those of more experienced 
critical care nurses.
    We received updates from two of our June 2009 graduates, Captain 
Matthew Howard and Captain Lindsay Erickson, both currently serving at 
Bagram Air Base, Afghanistan. Their comments clearly highlight their 
enhanced level of clinical and critical thinking skills. Capt Howard 
stated, ``I in-serviced the staff on ventriculostomies the very first 
shift I worked. We set a record last month for the most traumas since 
the war started here, and if we keep going, we will exceed it this 
month. More importantly, the survival rate is up 3 percent and at a 
record high.''
    Capt Erickson stated, ``By the end of my second week, a mass 
casualty situation arose. The unit was full with 16 patients. We moved 
three non-vented patients to the ward, and quickly acquired six new 
trauma/burn patients. I started the day with a three-patient assignment 
and ended up taking one of the new traumas on top of that. It was 
challenging but I felt very well prepared and took the assignment on 
without hesitation. No doubt my Critical Care fellowship training 
prepared me well. One of the burn patients required bladder pressure 
monitoring. Many of the nurses here aren't too familiar with this, so I 
volunteered to teach.''
    The CC/EN Fellowships have set the standard. Our graduates provide 
the highest quality care, both stateside and in the deployed 
environment, positively impacting lives on a daily basis. In the area 
of responsibility, the impact is palpable with a sustained 95 percent 
survival rate for OIF, and 96 percent survival rate for OEF.

                        ORGANIZATIONAL STRUCTURE

    The Air Force Medical Operations Agency (AFMOA) in San Antonio, 
Texas is a single support agency that stood up in September 2008 under 
the command of Brigadier General Mark A. Ediger. Nearly 18 months 
later, AFMOA has progressed as a robust centralized reach-out, reach-
back clinical support hub, collaborating with the major commands to 
standardize business practices across the Air Force Medical Service in 
pursuit of ``Excellent Healthcare, Clinical Currency.'' To that end, 
the AFMOA Surgeon General Nursing Directorate, comprised of three 
divisions and led by Colonel Leslie Claravall, has concentrated efforts 
toward developing currency platforms to sustain clinical skills for 
deployed operations. For example, the Provision of Nursing Care 
Division, led by Colonel Doug Howard, participated in an ``Emergency 
Department Analysis and Process Improvement Project'' in November 2009 
and is partnering with emergency services leadership of nine military 
treatment facilities to employ efficient evidence-based processes. 
Ultimately, the goal is to increase throughput leading to enhanced 
patient safety and satisfaction, while providing more experience and 
opportunity for medics to sustain clinical currency. Other clinical 
arenas, to include inpatient care and specialty care clinics, will be 
targeted in the same manner.
    Additionally, AFMOA Surgeon General Nursing is contributing to 
efficient healthcare and clinical currency by building tools to enhance 
mentoring and information sharing. To illustrate, the Education and 
Training Division, led by Colonel Lilly Chrisman, was key in 
facilitating ``Mosby on line'' as an Air Force Medical Service 
enterprise-wide reference tool. Modernizing access to the most current 
edition of a sound clinical reference allows our medics to obtain 
guidance anytime from any computer, while saving countless dollars by 
averting the distribution of new hard copies to replace outdated ones 
across the Air Force Medical Service
    AFMOA Nursing Service Resourcing Division, led by Colonel Robert 
Hontz, was the last division to stand up this summer. This division 
analyzed nurse resources across the major commands making 
recommendations to support Air Force initiatives such as the Medical 
Home Model for patient-centered care, a new Special Needs Coordination 
Cell to improve continuity of care for special needs family members, 
and the plus up of mental health nurses to support increasing 
deployment demands on a stressed career field. The Mental Health Nurse 
(46P3) and the Mental Health Nurse Practitioner (46Y3P) Air Force 
Specialty Code (AFSC) is currently staffed at 77 percent for 46P3 and 
100 percent for the 46Y3P. The high mobility tempo of this specialty 
makes it difficult to retain these critically manned mental health 
nurses. Currently, there are 30 psychiatric nurses in deployment unit 
type codes increasing to 40 in fiscal year 2010 to meet the career 
field's rigorous mobility requirements. The entire Air Force Medical 
Service mental healthcareer field is in the Band ``D'' Battle Rhythm 
which requires a 1:2 deployment: dwell time. Seven to eight psychiatric 
nurses are deployed worldwide in support of OIF and OEF each cycle.
    The Air Force Medical Service is taking steps to alleviate the 
stressors on the mental health nursing career field, and plans are 
under way to build a formal training program at the David Grant Medical 
Center at Travis AFB, California. This course will train clinical 
nurses to become mental health nurses. Additionally, we are pursuing an 
increase in mental health nurse and mental health nurse practitioner 
authorizations. Our goal is to place 10 additional mental health nurses 
in our bedded military treatment facilities to augment the staff caring 
for our wounded warriors and other beneficiaries. The advanced clinical 
capability of our mental health nurse practitioners has been lauded by 
patients as well as other provider staff. The Air Force Medical Service 
has ``grown our own'' through the Air Force Institute of Technology 
program, with 14 of our 15 nurse practitioners having come from our 
mental health nurse career field.

                                RESEARCH

    Air Force nurse researchers are integral to the joint research 
conducted in the U.S. Central Command area of responsibility. The Joint 
Combat Casualty Care Research Team (JC2RT) consists of six Army and 
three Air Force members with the mission of fostering and facilitating 
medical research, performance improvement, and evidence-based practice 
initiatives for the United States Central Command Joint Operations 
Area: Multi-National Corps--Iraq Theater, U.S. Forces Afghanistan, and 
Kuwait. In March 2009, the Department of Defense medical research 
program was initiated in Afghanistan under the direction of Colonel 
Elizabeth Bridges, an Air Force Reserve Ph.D. prepared nurse. 
Simultaneously, Lieutenant Colonel Teresa Ryan, also an Air Force 
Reserve Ph.D. prepared nurse from Keesler AFB, Mississippi was the 
senior Deployed Combat Casualty Research Team (DC2RT) researcher at 
Balad, Iraq.
    Colonel Bridges laid the groundwork for the arrival of a team of 
six researchers (physicians, nurses, a nutritionist, and a 
physiologist) who arrived in September to Bagram. Currently, Major 
Candy Wilson, a Ph.D. prepared nurse, from the 59th Clinical Research 
Squadron at Lackland AFB, Texas is at Bagram. In August 2009, the JC2RT 
Headquarters office moved from Ibn Sina, Iraq to Bagram, Afghanistan. 
In October 2009, Lieutenant Colonel Kevin Bohan from the Graduate 
School of Nursing, Uniformed Services University of the Health Sciences 
along with SGT Andrew Coggins, a Army laboratory services NCO, 
established an office in Kandahar to expand the research program. The 
nurse researchers assigned to the DC2RT identified the following major 
areas for research: mild traumatic brain injury, management of complex 
orthopedic trauma, pain management across the continuum of care, and 
integration of information from the Level II medical facilities and the 
en-route phase of care, both medical evacuation and aeromedical 
evacuation.
    The teams provide guidance and review for all research conducted in 
Afghanistan, Iraq and Kuwait. The Ph.D. prepared nurses provide 
leadership and guidance on scientific merit, design and methodology of 
research. Each team member is involved in collecting data for a variety 
of research protocols focusing on combat casualty care. Over 150 
research studies have been conducted or are being planned as a result 
of the JC2RT's efforts. More than 20,000 subjects have been enrolled in 
research studies. Areas of research conducted by the U.S. military in 
Afghanistan and Iraq have led to advancements in combat casualty 
medical care and therapies to include tourniquet application, combat 
gauze, life saving interventions, en-route care, resuscitation, blood 
product administration, burns, wound care, post traumatic stress 
disorder (PTSD), traumatic brain injury, and infectious diseases.
    Colonel Bridges, as the first research nurse in Bagram, 
Afghanistan, from April to August 2009, received Tri-Service Nursing 
Research Program (TSNRP) funding for a functional hemo-dynamic study in 
Afghanistan. Since 2006, 34 nursing research protocols have been 
approved with U.S. Air Force nurse researchers being principal 
investigators in five of those studies. The overall nursing research 
themes include warrior care, healthcare delivery, trauma, behavioral 
health, and nursing/healthcare professional issues. Nursing principal 
investigators have investigated pain management, functional hemo-
dynamics, and StO2 monitor for occult hypo-perfusion, carbon monoxide 
exposure, women's health, sleep disturbances in soldiers, oral care in 
the critically ill, retention, recruitment, PTSD, burnout, compassion 
fatigue, and moral distress in nursing personnel. To date, three Air 
Force led nursing research protocols are in the final stages of 
approval by the institutional review board, which researchers by law 
must submit their research proposal to receive approval before 
beginning a research study.
    As a member of the Joint Combat Casualty Research Team, Major 
Wilson augmented the Combined Joint Special Operation Forces to provide 
healthcare for local men, women, children and the Afghanistan National 
Army. During visits to the villages, Maj. Wilson, a nurse practitioner, 
along with other healthcare professionals, provided medical care for 
over 10,000 patients during a 6-day period. The rugged and austere 
healthcare delivery conditions required medical diagnoses to be made 
based on patient presentation, without the aid of laboratory or 
radiology analyses. In addition to the direct benefits of the care 
provided, valuable and actionable intelligence was gathered on these 
missions that resulted in improved situational awareness by U.S. forces 
and directly resulted in saving lives of service members.
    The TSNRP Executive Director position transitioned to Colonel Marla 
DeJong in 2009, the second Air Force nurse researcher to hold this 
position. The TSNRP is the only program with the primary mission of 
funding military unique and military relevant nursing research. Colonel 
DeJong is responsible for facilitating tri-service nursing research to 
optimize the health of military members and their beneficiaries. The 
goal of military nursing research is to produce knowledge that further 
enhances clinical practice, the delivery of healthcare, nursing 
education, and nursing management. Since its inception in 1992, the 
TSNRP has funded more than 300 military nursing research studies and 
several evidenced-based practice projects. Ultimately, application of 
this new knowledge improves the quality and delivery of nursing 
practice, promotes the best possible outcomes for patients and 
families, and informs healthcare policy decisionmakers. With the 
support of TSNRP funding, the pocket guide, Battlefield and Disaster 
Nursing Pocket Guide, which I shared during last year's testimony, has 
been distributed to 15,000 Air Force military nurses and medics to 
augment readiness preparation.
    During 2009, military nurse leaders, researchers, and stakeholders 
of the TSNRP revised the mission and research priorities to ensure the 
funding clearly reflects the mission and research vision of military 
nurses. The current TSNRP research priorities are (1) force health 
protection, (2) nursing competencies and practice, and (3) leadership, 
ethics, and mentoring. The TSNRP sponsors Grant Writing Workshops for 
novice and experienced researchers to learn how to design studies and 
write high-quality applications that will be competitive for funding. 
Annually, the TSNRP conducts a Post-Award Management Workshop to inform 
grant recipients of Federal, Department of Defense, and TSNRP 
management policies and guidance on grant execution.
    Results from TSNRP-funded research impacts nursing clinical 
practice in deployment resilience, retention, methods to reduce 
ventilator-associated pneumonia, health disparities, and women's health 
during deployments. For example, Major Jennifer Hatzfeld who defended 
her dissertation in 2009, ``Assessing Health Disparities in the Air 
Force'' documented the prevalence of health disparities according to 
race or ethnicity for chronic diseases such as hypertension, high 
cholesterol, and diabetes among adult Active Duty Air Force members; 
however, she found no evidence of disparities in the treatment outcomes 
of patients with these conditions, indicating patients received 
appropriate medical care.
    Numerous mission-relevant studies are in progress. Colonel Bridges' 
study is designed to evaluate new methods of monitoring patients after 
hemorrhage on the battlefield. Colonel Penny Pierce, a retired Air 
Force nurse reservist, and her colleagues have systematically collected 
comprehensive survey data from deploying troops beginning with the 
Persian Gulf War and continuing through OEF and OIF. The initial 
studies focused primarily on military women due to the sociopolitical 
concerns raised by deployment of large numbers of women, reservists, 
and mothers of dependent children. Later studies included men and women 
from the Air Force and Army, enabling researchers to compare findings 
by gender, military service, and deployed locations. Data collection 
pertained to physical, mental, and gender-specific health issues. 
Junior enlisted women and families experiencing economic hardships were 
particularly vulnerable to work-family conflict. Further, individuals 
with work-family conflict were at high risk to develop post-traumatic 
stress disorder. Stressors such as family conflict and organizational 
issues influenced the physical and mental health of military members 
and impacted retention. Importantly, these stressors are potentially 
modifiable. Work is underway to identify interventions that will 
benefit individuals, families, and the uniformed services.
    TSNRP-funded researchers continue to disseminate the results of 
their studies through peer-reviewed publications and numerous 
presentations at nursing and medical conferences. The TSNRP co-
sponsored the Karen A. Rieder Nursing Research Poster Session at the 
115th annual meeting of the Association of Military Surgeons of the 
United States. Air Force nurses presented 29 of the 90 posters which 
summarized the results of recent studies, evidence-based practice 
projects, and process improvement activities. Colonel Bridges, for 
example, recommended interventions to prevent complications during en-
route care of casualties transported by Critical Care Air Transport 
Team during OEF and OIF.
    In addition to her duties as TSNRP program director, Colonel DeJong 
is assigned to the DOD Blast Injury Research Program Coordinating 
Office. She organized and hosted an international, state-of-the-science 
meeting on blast-related mild traumatic brain injury. The meeting 
resulted in a thorough assessment of knowledge about TBI and identified 
the gaps necessary to shape future research. Colonel DeJong also co-
chaired the Joint Program Committee for Battle Injury Prevention 
Research and helped execute the $247 million Battle Casualty and 
Psychological Health Research Program.
    Colonel Karen Weis, another one of our Ph.D.-prepared nurses, co-
authored Psychosocial Adaptation to Pregnancy: Seven Dimensions of 
Maternal Role Development. Colonel Weis also authored a nurse-physician 
communication assessment tool used in several military treatment 
facilities, as well as the Methodist health system in Houston, Texas. 
The instrument assesses perceived barriers to physician-nurse 
communication enabling focused attention for improved staffing 
effectiveness.
    Colonel John Murray just completed a chapter entitled, ``The U.S. 
military health system: Meeting healthcare needs in wartime and 
peacetime'', to be included in Policy & Politics in Nursing and Health 
Care. As the Director of Education, Training & Research, Joint Task 
Force, National Capital Region--Medical, he developed Joint-level DOD 
Assurance and Issuing authority for research within the National 
Capital Region. Colonel Murray is a member of the Department of 
Veterans Affairs (VA) National Research Advisory Council and the VA 
workgroup for Research on Educational Interventions for Health 
Professionals.
    Lieutenant Colonels Patricia Bradshaw and Karen O'Connell, and 
Majors Susan Dukes, Brenda Morgan, and Antoinette Shin are near 
completion of their Ph.D. program. These nurses will be deliberately 
placed as the Nurse Corps builds research specific locations or 
``cells''.
    We recently developed a nursing research fellowship and the first 
candidate will begin this spring. This 1-year pre-doctoral research 
fellowship will focus on clinical and operational sustainment 
platforms. The intent of this program is for the fellow to develop a 
foundation in nursing research and ultimately pursue a Ph.D.
    The desire for evidence-based nursing care is at the forefront of 
the nursing staff at the 59th Medical Wing, Wilford Hall Medical 
Center, San Antonio, Texas. Newly hired nurses are oriented to the 
benefits of nursing research and evidence-based practice during nursing 
orientation. The deliberate promotion of nursing research has resulted 
in three nurses developing protocols for funding from TSNRP.
    Nursing staff from the 88th Medical Group, Wright-Patterson AFB, 
Ohio, have submitted three research grants this year and are 
participating in two nursing studies. Major Bonnie Stiffler, the 
primary investigator for the study, ``Barriers to Screening Mammography 
for Medical Treatment Facility Enrolled Beneficiaries,'' is conducting 
telephone interviews to identify barriers to obtaining provider 
recommended mammography. The goal is to identify barriers to care and 
then develop methods to minimize or eliminate the barriers. Colonel 
Robie Hughes is the primary investigator for a funded multi-site study 
titled, ``Air Force Nurse Transition Program Student Quantitative 
Medical Simulation Performance''. This study will be the first formal 
study conducted at the nine Nurse Transition Program sites during a 
simulated medical scenario evaluating nurse performance from this 
established 11-week training program.

                       STRATEGIES FOR THE FUTURE

    I am proud to report that we have created a Master's Degree in 
Flight Nursing with an Adult Clinical Nurse Specialist focus and 
concentration in Disaster Preparedness. This program, the first of its 
kind in the country, was designed and ready for students in just 3 
months. We partnered with Wright State University-Miami Valley College 
of Nursing, Dayton, Ohio and the Health and National Center for Medical 
Readiness Tactical Laboratory at Calamityville. Graduates from this 
program will gain expertise in Flight Nursing as well as emergency and 
disaster preparedness from military and civilian perspectives. Our 
first candidate will begin in the spring. The unique and diverse 
curriculum will meet Homeland Security Presidential Directive #21 and 
include advanced clinical courses in acute and chronic health issues 
for the adult population with an emphasis in flight and disaster 
nursing. The Flight Nursing component will address symptom management 
and stabilization during air transport. In addition to the classroom 
training, students will be connected with a preceptor in an active 
flight nursing setting with both fixed and rotary aircraft at the 
375th, Scott AFB, Illinois and Care Flight at Miami Valley Hospital, 
Dayton, Ohio. Students will be exposed to tragic scenarios to 
illustrate the impact disasters place on the health and safety of 
individuals and families. A former 54-acre cement plant in Ohio is 
being developed into an all-hazards disaster and training facility. 
This site will be incorporated into joint civilian and military 
training programs to provide a realistic venue to simulate natural and 
man-made disasters. Upon completion of this rigorous program, graduates 
will be eligible to take the Adult Health CNS and American Nurse 
Credentialing Center certification exams.
    The Graduate School of Nursing at the Uniformed Services University 
Health Sciences (USUHS) continues to provide cutting-edge academic 
programs to prepare nurses with military unique clinical and research 
skills in support of delivery of patient care during peace, war, 
disaster, and other contingencies. As they move toward their vision of 
being a nationally recognized academic leader, while on the forefront 
of a nurse and nurse educator shortage, the Graduate School of Nursing 
was asked to collaborate with the Federal Nursing Service Chiefs to 
increase the cadre of baccalaureate-prepared military nurses, through 
creative partnerships with existing schools of nursing. One of 
Uniformed Services University Health Sciences' top initiatives is to 
work with civilian nursing institutions to address the military nursing 
shortage and assist the Department of Defense to identify strategies to 
encourage and incentivize potential applicants to enroll in 
baccalaureate nursing programs. USUHS plans to develop and deploy a 
comprehensive survey to assess the willingness of potential student 
populations to consider accepting an undergraduate nursing education in 
return for a commission as a Nurse Corps officer in the Armed Forces 
with a subsequent service obligation. The targeted populations will 
include students in nursing school programs, qualified applicants who 
are not accepted for admission to nursing school due to space 
limitations, associate-degreed registered nurses, second career nurses, 
and enlisted service members with a desire to be commissioned as a 
nurse corps officer. Data from these surveys will be analyzed to 
identify and quantify perceptions of potential nurse applicants towards 
military service.
    As I reported last year, we developed Master Clinician roles to 
afford our most clinically experienced senior nurses with advanced 
academic preparation to remain at the bedside without sacrificing 
promotion opportunities. We have 20 Colonel positions identified across 
our military treatment facilities and are diligently working to fill 
these authorizations in fiscal year 2010.

                               WAY AHEAD

    Nursing, the essential healthcare profession, is highly valued for 
providing skilled, evidence-based quality care to Airmen and their 
families. We continue to arm our nursing service personnel with the 
necessary skill sets through education, training, and research to meet 
the challenges of operating in the ever changing global environments.
    Nurse recruitment and retention continues to be our focus as we 
develop academic partnerships, sustain our accession programs, reward 
clinical practice through incentive specialty pay, and enhance nursing 
capabilities through advanced academic preparation such as the Masters 
Degree in Flight Nursing and our DNP implementation plan.
    We look forward to the future. By being actively engaged in nursing 
research, we are generating the knowledge necessary to guide Air Force 
and Joint nursing operations. Through the synergy of our AD, ANG, AFRC, 
civilian, and contract forces, coupled with the collaborative 
relationships of our sister Services and civilian partners, we are 
prepared to meet emerging challenges with strength and confidence. Air 
Force Nursing stands ready today to embrace the challenges of tomorrow 
as we lead, partner, and care, every time, everywhere.
    Mister Chairman and distinguished members of the Committee, it is 
my honor to be here with you today representing a dedicated, strong 
Total Nursing Force of nearly 18,000 men and women. We sincerely thank 
you for your tremendous support for Air Force Nursing.

                  CARING FOR WOUNDED, ILL AND INJURED

    General Horoho. Sir, I absolutely believe Army nurses are 
prepared for those types of injuries. But, it has proven a 
challenge. You know, years ago, if you asked whether or not 
Army nursing provided rehabilitative nursing, we didn't. Post-
9/11, absolutely. That's one of our core competencies. And 
we've worked hand in hand--when we talk about Army nursing, we 
talk about our Active component, our Reserve component, our 
National Guard, our medics, and our civilians. All three of 
those are critical to ensuring that we're being able to meet 
the needs of our patients on the battlefield in--both in our 
stateside facilities.
    So, when you talk about whether you have the capabilities, 
every single one of our medics are highly trained, and that's 
where we've got that life-sustaining care that's given at the 
point of injury, and then they're immediately evacuated back 
either for our forward surgical teams or back to our combat 
support hospitals. And then, in 36 hours, those critically 
injured patients will be seen at Landstuhl Regional Medical 
Command, and then further evacuated to our major--our nine 
other major medical centers.
    And so, we've spent the very first year, in 2008, of really 
looking at every single competency needed to be able to support 
an expeditionary force, and then we've spent this past year 
changing the way that we leader-develop, changing our 
competencies, and actually changing how we assign our nurses. 
So, instead of assigning based on authorizations, we actually 
assign based on capabilities, so we know where the needs are, 
what type of capabilities are needed, and then we make those 
assignments across the Army Nurse Corps.
    Chairman Inouye. Admiral.
    Admiral Flaherty. Yes, sir.
    The Navy Nurse Corps has added a number of programs to keep 
our staff well trained. As the war began, we saw new injuries 
and new types of injuries that perhaps we had not cared for 
before.
    We also have a workforce that had been deployed and had 
been at war, and come back with significant skills. So they are 
part of the training pipeline. They are training each other 
about what they saw, what they've been able to care for, and 
what now is needed.
    We've partnered with our civilian organizations to get our 
nurses to some intensive intensive care unit (ICU) care and 
also some emergency medicine care, because we know they--the 
corpsmen on the battlefield--are the ones who are providing 
that wonderful support for that young marine or that young 
sailor or that young soldier.
    So, do we have all the answers? No, sir. Are we well 
prepared and well positioned to go forward with the future of 
what we see in the injuries? Yes, sir. We have training 
dollars, we have people in the pipeline for master's programs, 
and we are doing all that we can to make sure that that's 
shaped appropriately.
    Chairman Inouye. General.
    General Siniscalchi. Senator Inouye, thank you for your 
question.
    Sir, our focus has been on lifelong training, starting from 
novice through expert. Our nurse transition programs provide us 
an opportunity to take nurses, right from their bachelor of 
science degree program, into a transition program that focuses 
on building clinical competency. And as they progress 
throughout the professional continuum, we have very robust 
programs for skill sustainment, for just-in-time training. 
We've partnered with our sister services on developing critical 
care, trauma, and emergency room fellowships. It's a 12-year--
or, a 12-month fellowship that prepares our critical-care 
nurses to go into intensive-care settings in the deployed--in 
deployed operations, and have the advanced skills that they 
need to take care of our wounded who have traumatic injuries.
    We're focusing on mental health specialties. We are in the 
process of developing a Mental Health Training Program, at 
Travis Air Force Base in California, which will help us to grow 
our own. As we recognize the increased need for behavioral 
health, we can take our clinical nurses and put them through 
this educational program, at Travis, which will help to grow 
mental-health nurses. USUHS has developed a Mental Health Nurse 
Practitioner Program, and they have a unique focus in preparing 
mental-health nurse practitioners with the skill set they need 
to meet the challenges with our wounded warriors and their 
families.
    Our critical care educational programs, our Nurse 
Anesthetist Program, our nurse practitioner programs, are very, 
very robust, and our focus has been on developing partnerships 
with civilian universities and with USUHS so that, throughout 
the continuum, we can allow our nurses--afford our nurses the 
opportunity for advanced clinical preparation and training. I 
had testified last year that we had started a new role for 
master clinicians, and this role allows us to grow clinical 
experts with advanced experience and advanced academic 
preparation, and allow them to continue to compete for 
promotion and function at the bedside as true clinical leaders 
and clinical experts.
    We realize the increased challenges our flight nurses face 
with critical-care--movement of critical-care patients. And so, 
we've recently partnered with Wright State University, in 
Dayton, Ohio, to establish the first of its kind master's 
program in flight nursing, with a focus on adult health 
clinical specialists and homeland defense and disaster 
preparedness. And we are proud to say that our first student 
begins this fall.
    Chairman Inouye. Thank you very much.
    All of you heard Senator Murray set forth a few numbers. 
The suicide rate among service personnel is the highest in 28 
years--about 35 percent higher than the general population of 
the United States. And, surprisingly, over one-third have never 
been deployed. It was assumed that they were afraid of combat, 
but over one-third, never been deployed.
    As I pointed out, nurses spend more time with their 
patients than doctors because of the nature of their work, but 
do you believe that our program to attack this problem is 
adequate? Suicides.

                           SUICIDE PREVENTION

    General Horoho. Yes, Mr. Chairman.
    One of the things that, when we've looked at the 
psychological health in suicide prevention is, we really looked 
at it through the lenses of each member of the team, because 
each healthcare provider and ancillary support provides a 
critical skill set when they're interacting with our patients; 
and not just our patients, but also with their family members.
    We've taken the focus of looking at a holistic, kind of, 
comprehensive view. The Army has been very much engaged, over 
this past year, of looking at a behavioral health system of 
care that looks at taking that capability and, How do we surge 
that across Army medicine, push that into theater by using the 
electronic virtual behavioral health, so that we establish that 
relationship while your warriors are deployed?
    We also have very robust behavioral health and 
psychological support for the family members. One of the 
examples that we're doing right now is with the family members 
of 5-2 that are deployed. In preparation for them redeploying 
back, we have already partnered with TriWest, as well as with 
the local civilian communities and our military health 
providers, to start providing that support with the 
reintegration process now, in dealing with issues now, before 
waiting for those families to reintegrate together.
    So, it's really looking at a comprehensive piece of all of 
our clinical assets, to be able to impact patient outcomes. We 
have a long way to go, but I believe with the partnering that 
we've established with our civilian community leaders in 
healthcare, as well as with our sister services, so that we 
ensure that we are looking at this from a comprehensive 
perspective.
    Chairman Inouye. Admiral.
    Admiral Flaherty. Thank you. As we look at suicides, we 
look at both the Navy and Marine Corps numbers, and Navy 
medicine and Navy nursing are playing a key supporting role to 
our line colleagues. The line runs our program, and we are 
there in a supporting role. And as our Surgeon General talked 
about, often it's relationship--fractured-relationship issues 
that happen either at home or with a girlfriend, a boyfriend, 
et cetera--or partners.
    So, we need to pay attention to that, and we believe the 
core component of our programs really rests on resiliency. And 
how do we build internal resiliency for young men and women 
who, quite honestly, are quite strong, the military families 
are very resilient, but it's the stresses of the deployments 
that often can cause that fracture--so, how do we have our eyes 
on that? How do we care for each other? And it is, as the SG 
talked about, it is that shipmate. And I see you today, and I 
know that you're not the same as you were yesterday; you're not 
as funny as you were yesterday, perhaps. What's going on? That 
should be the first red flag to ask the question, ``How are you 
doing?''
    When people are uncomfortable about asking specific 
intrusive questions, you can ask, ``How are you sleeping?'' 
Because someone's sleep patterns and their sleep behavior often 
is a predictor of stress. So, getting our arms around the 
stress and understanding that.
    I believe we don't need a specialist to have that 
conversation. I believe the Navy nurse has every single skill 
that they need to have those conversations with people to talk 
about how well they're doing. What are their relationships? How 
are they feeling? And that is the backbone of some of the 
programs that we've put in place.
    So, it's resiliency, sir. It's operational stress control. 
For the Navy, we talk about ``staying in the green.'' We travel 
into--we look at a stoplight; green, yellow, orange, and red. 
Red means that I'm fractured and I need, probably, some 
intervention and support. I want to stay in the green; I want 
to be healthy, I want to eat right, I want to feel well, and I 
want to be able to do all the things that matter or are 
important. And we, as Navy support colleagues, try to help 
people stay in the green.
    If you get to the yellow, we can get you back to the green. 
If you get to the orange, we can still get you back to the 
green. We want to keep you there, so that you stay well and 
healthy.
    Chairman Inouye. General.
    General Siniscalchi. Sir, prevention of suicide begins with 
building a strong wingman culture. Resiliency is key to 
prevention of suicide. And in February, our Air Force senior 
leadership supported Lieutenant General Green's plans for 
providing targeted, tiered, resiliency training for our high-
risk groups.
    And as we look at the tiered resiliency training, the focus 
is on instilling resiliency and building that wingman culture 
throughout an entire career. It begins with foundational 
training and it continues throughout a career, focusing on 
groups that are identified as high risk. And as we identify 
groups that are high risk for risk of suicide, then we 
implement face-to-face training, increased interaction from the 
Commander, from the front line supervisor, so that we are doing 
training and instilling resiliency and building that wingman 
culture in building that team.
    Our focus for suicide prevention is on our total force. 
We're looking across our Active Duty, our Guard, our Reserve, 
and our civilian force for suicide prevention.
    Chairman Inouye. To close this hearing, may I call upon the 
nurses, if they so feel, to make their statements.
    General Horoho.
STATEMENT OF MAJOR GENERAL PATRICIA HOROHO, CHIEF, ARMY 
            NURSE CORPS, DEPARTMENT OF THE ARMY
    General Horoho. Mr. Chairman, distinguished members of the 
subcommittee, it is an honor and a great privilege to speak 
before you today on behalf of the nearly 40,000 Active 
component, Reserve component, National Guard officers, 
noncommissioned officers, enlisted, and civilians that are Army 
nursing.
    It has been your continued tremendous support that has 
enabled Army nursing, in support of Army medicine, to provide 
the highest quality of care to those that are entrusted to our 
care.
    Last year, I promised you an update on the Army Nurse Corps 
campaign plan that we began in October 2008. Leader development 
has always been one of the Army Nurse Corps' foundations, but 
as we move the Corps forward, we realize the need to develop a 
strategy to provide overarching, longitudinal training programs 
to ensure that we are building leaders for the future. A major 
initiative is the Leader Academy, a virtual construct designed 
to facilitate and enhance adaptive, full-spectrum Army Nurse 
Corps leaders.
    We also determined that there were nurses that needed a 
standardized clinical transition program to ensure success as 
they move from academics to nursing practice. In October 2008, 
the Army Medical Command formally fielded the Brigadier General 
Retired Anna Mae Hay Clinical Transition Program, named in 
honor of our 13th Corps Chief and the first female officer in 
the Army across nine medical centers. During fiscal year 2009, 
364 new graduate Army nurses completed the program, and so far 
this year over 270 have completed this program.
    The program is designed to ensure that we develop and 
foster critical thinking, communication, multidisciplinary 
teambuilding, and deployment skills. The first training and 
educational platform that we realigned to support our 
transformation was a head nurse course, and we named it the 
Clinical Nurse OIC and NCOIC Leader Development Course, as a 
result of recognizing the critical relationship that exists 
between the clinical nurse, the officer in charge, and the 
noncommissioned officer (NCO) in charge. The course provides 
our mid-level managers the opportunity to learn the essential 
skills to execute sound clinical and business practices.
    We are equally committed to the growth and the development 
of our NCOs and soldiers. In fiscal year 2011, we'll fund two 
senior NCOs to obtain their master's in healthcare 
administration, to ensure that we continue to meet the needs of 
the 21st century.
    We are also developing an intensive care course for our 
licensed practical nurses that will give Commanders the 
flexibility to use LPNs for transport of critical patients, 
standardized knowledge, and expand practice opportunities.
    Finally, the Leader Academy facilitates enhanced, care-long 
development through the level of our regional nurse executives. 
We adopted the American Organization of Nurse Executive 
Competencies to ensure the RNE has the knowledge, skills, and 
expertise to help manage their region's system of health. We're 
transforming Army nursing through the development of a nursing 
care delivery system, in order to perfect nursing care at the 
bedside. The patient and the family centered system of care 
has, at its cornerstone, standardized nursing practice. The 
standardized system of care will enable us to increase quality 
of care, reduce resources, and ensure standardization and 
stability of providing quality patient care. This is in 
support, and will allow the surgeon general's intent to improve 
healthcare delivery through standardization from the point of 
injury through evaluation and return to duty.
    The system of care will not only standardize nursing 
practice, but will also enable, for the first time, 
comprehensive measurements and improvement of nurse-sensitive 
patient outcomes, while leveraging evidence-based care and 
practices. Our efforts to transform Army nursing mirror the 
national initiatives to improve nursing practice in support of 
healthcare reform.
    In January 2009, we piloted elements of the system of care 
at Blanchfield Army Community Hospital at Fort Campbell, 
Kentucky. After 6 months of monitoring this program, the 
outcome measures showed an increase in nurse and patient 
satisfaction, an increase in critical lab reporting and pain 
reassessment, a decrease in nurse turnover, and a decrease in 
patients that left without being seen in our emergency room, as 
well as decreases in medication errors and risk management 
events.
    Select elements of the system of care are initially being 
implemented at three of our medical centers. For example, 
Tripler Army Medical Center has been using healing hours as a 
goal to promote rest and increase healing through consolidation 
of patient-care activities and then tailoring the provision of 
care for each of our individual patients.
    The Army Nurse Corps is aligned with our seven other Corps 
within the Army in support of Army medicine to foster evidence-
based practice. At every patient touch-point, we're ensuring 
that evidence-based practice is the foundation that supports 
the delivery of care. We're aggressively realigning expert 
clinical capability to surge as a bridge between research and 
clinical practice.
    In February 2009, the Tri-Service Nursing Research Program 
(TSNRP) invited nurse scientists from all services to meet and 
to determine new priorities for TSNRP. Not surprisingly, force 
health protection was recognized as the number one priority.
    Deployment research is designed to ask critical questions 
that cannot be answered other than on the battlefield, and Army 
nurses are leading the way. There have been 34 nursing-led 
protocols; 27 of those are from Army Nurse Corps researchers 
and one joint Army-Air Force protocol. The focus has been on 
warrior care, soldier health, trauma care, and behavioral 
health.
    We also rely on the Uniform Services University Graduate 
School of Nursing as the strongest educational platform to 
develop clinical talent.
    There has been great momentum since I've had the honor of 
introducing the Army Nurse Corps campaign plan to you last 
year. Our collective success has been the result of compassion, 
commitment, and dedication. I'm inspired by the pride, 
enthusiasm, and openness to change that I see across the Army 
Nurse Corps.
    We continue to experience amazing progress in each one of 
our strategic imperatives, and we're ensuring that the Army 
Nurse Corps remains relevant and a force multiplier for the 
Army medicine, the Army, Department of Defense, and our Nation.
    I continue to envision an Army Nurse Corps in 2012 that 
will leave its mark on military nursing and will be a leader of 
nursing practice reform at the national level. Our priority 
remains the patients and their families, and our common purpose 
is to support and maintain a system of health. In order to 
achieve this common purpose, we will let nothing hinder those 
who wear the cloth of our Nation, and those who took the oath 
to forever save, protect, and heal.
    The Army Nurse Corps is committed to embracing the past, 
engaging the present, and collectively, continuing to work to 
envision our future.
    On behalf of the entire Army Nurse Corps serving both home 
and abroad, I would like to thank you for your unwavering 
support and the entire subcommittee's unwavering support, and I 
look forward to continuing to work with you.
    Thank you, sir.
    Chairman Inouye. Thank you very much, General Horoho.
    Now may I call upon Admiral Flaherty.

STATEMENT OF REAR ADMIRAL KAREN FLAHERTY, DIRECTOR, 
            NAVY NURSE CORPS, DEPARTMENT OF THE NAVY
    Admiral Flaherty. Yes, sir. Thank you Chairman Inouye.
    And thank you for the opportunity today to highlight the 
accomplishments and opportunities facing the Navy Nurse Corps 
in 2010 as we care for the health of our force.
    Our Navy Nurse Corps, comprised of Active, Reserve, and 
Federal civilian nurses--many are here today in the room--are 
5,500 strong. My priorities, as Director, have been focused in 
three areas: people, practice, and leadership.
    Our Active component is manned at 91 percent, with 2,837 
nurses currently serving around the world, and we have already 
achieved our recruiting goal for 2010. The top three direct 
accession influences that are favorably impacting our 
recruiting efforts include the nurse accession bonus, Health 
Professions Loan Repayment Program, and the Nurse Candidate 
Program.
    Today, the Reserve component is 83 percent manned, with 
1,112 nurses. Last year, the Navy Nurse Corps Reserve component 
met 87 percent of their goal. Over 48 percent of those 
accessions were nurses coming to the Reserve component from 
Active Duty.
    We are continuing to focus closely on all the many pathways 
to achieve this goal. Leveraging current technology, the Nurse 
Corps recruitment liaison officer offers a combination of 
social networking media tools, including Facebook and Twitter 
and online discussion forums, to reach students at colleges and 
high schools, encouraging them to consider a career in Navy 
nursing. We have found that students have many thoughts, they 
have questions, and starting this discussion early is 
essential.
    Retaining Navy nurses is my top priority. Key efforts have 
positively impacted retention, including the registered nurse 
incentive specialty pay, a targeted bonus program for 
undermanned clinical and nursing specialties and our highly 
deployed nurse practitioners. My goal for this year is to 
increase retention by 50 percent in the Active Duty component 
for those with less than 10 years of service, and to retain the 
appropriate number in each officer rank in the Reserve 
component. We want our nurses to accept orders to a second and 
a third duty station, and begin early planning for their long 
career.
    I believe it is our responsibility, as Nurse Corps leaders, 
to fully understand all of the retention issues. In 2009, we 
commissioned the Center for Naval Analysis to conduct a survey 
and hold focus groups to help us understand factors that 
influence career satisfaction and dissatisfaction within our 
Nurse Corps. Our nurses told us they wanted us to be more 
understanding of family needs, career moves, and clinical 
advancement. We also learned that deployments were 
professionally fulfilling. We will do all that we can to make 
the required changes to impact this retention.
    Clinical excellence is one of the main tenets of the Nurse 
Corps clinical leadership model. In 2009, we developed and 
implemented standardized orientation in nursing competencies 
across all of our nursing specialties. Over the past several 
years, the Nurse Corps identified eight critical wartime 
specialties and developed our manning, training, and bonus 
structures to incentivize nurses to practice within those 
specialties. Each nursing specialty has an assigned specialty 
leader who is a clinical expert and understands the nursing 
practice within each community. We work closely together to 
embrace practice trends and future requirements.
    Understanding the deployments and type of care needed by 
our patients was essential when developing our nurses. To 
accomplish this goal, the specialty leaders work with senior 
nurse leaders at the military treatment facilities to create, 
again, the partnerships with our local civilian hospitals. Our 
military nurses are cross-trained in local emergency 
departments, as I mentioned, and in intensive care units. This 
is just one example of what is possible.
    We know that the wars have created both visible and 
invisible wounds, and our warriors and our families have 
experienced stress. To support the behavioral health needs of 
our warriors and their families, the Nurse Corps has increased 
its inventory of psychiatric and mental health clinical nurse 
specialists and nurse practitioners. This growth will also 
support the projected expansion of our Marine Corps. I believe 
that every nurse, as I've stated, has the ability to understand 
the unique needs of their patients, and offer support and 
guidance at every encounter.
    I am a fervent supporter of graduate nursing education, 
research, and professional growth of my nurses, and am 
committed to the sustainment and growth of the Tri-Service 
Nursing Research Program. Each year, approximately 73 Nurse 
Corps officers are selected for duty under instruction or 
graduate education program. Fields of study include behavioral 
health, anesthesia, family practice, research, and critical 
care.
    The American Association of Colleges of Nursing has made 
the decision to move the current level of preparation necessary 
for advanced nursing practice from the master's degree to the 
doctoral level by 2015. The Navy Nurse Corps supports a phased 
approach toward adopting the doctorate nursing practice (DNP), 
and will utilize a combination of short- and long-term steps to 
incorporate this degree at options part of our education 
strategy.
    Using existing funds, three nurses will graduate with a DNP 
in 2012, and the DNP degree will be incorporated into the Nurse 
Corps training plan. As we make the transition to a greater 
number of DNPs, additional education funding will be required.
    To expand this clinical leadership model that we have so 
well achieved over the last number of years to our Federal 
civilian registered nurses, we launched the Navy Graduate 
Program for Federal Civilian Registered Nurses, the first of 
its kind in the uniformed services. We expect that this new 
program will retain our current civilian nurses, incentivize 
new nurses to consider entry into Federal service, and sustain 
military treatment facilities with clinical experts, when our 
military nurses are deployed.
    We have funded five competitively selected Federal civilian 
registered nurses to pursue their master's of science in 
nursing. We are currently receiving applications to select our 
next class of candidates for the fall 2010.
    Navy nurses at our military treatment facilities in the 
United States and abroad passionately support the professional 
development of America's future nursing workforce by serving as 
preceptors, teachers, mentors for local colleges and 
universities, as well as entire health systems.
    Navy nurses deployed to Afghanistan in embedded training 
teams are teaching culturally and linguistically appropriate 
public health measures. In response to the news of H1N1 
outbreaks throughout the world, those nurses prepared emergency 
response plans and training for local forward operating bases 
and regional hospitals in eastern Afghanistan, well in advance 
of the cases appearing in theater. And they deployed critical 
counterinsurgency tactics by performing village medical 
outreaches to the local community members in Afghanistan.
    I believe that leadership at all organizational levels is 
responsible for ensuring that personnel under their charge are 
healthy and productive. My nursing leaders have developed and 
are implementing an interactive career-planning guide, useful 
for mentoring seniors and subordinates at every stage of their 
careers, because we do ask people to change and move into 
different jobs.
    A key role of these leaders is to know their people and 
help them develop the resiliency to be able to handle stressors 
and life events. Navy medicine's Operational Stress Control and 
Care for the Caregiver Programs have a direct impact on the 
health and well-being of the force, deployment readiness, and 
our retention. We know that caring for service members and 
their families and experiencing their trauma and stress can 
impact our medical staff. We must be prepared to care for 
ourselves, to be able to care for others.
    Chairman Inouye, thank you. Thank you, again, for the 
opportunity--providing me this opportunity to share with you 
the remarkable accomplishments of our Navy Nurse Corps and our 
continuing efforts to meet Navy medicine's mission.
    On behalf of the outstanding men and women of the Navy 
Nurse Corps and their families who so faithfully support them, 
I want to extend my sincere appreciation for your unwavering 
support.
    Thank you.
    Chairman Inouye. Thank you, Admiral.
    Admiral Flaherty. Yes, sir.
    Chairman Inouye. And now, may I call upon General 
Siniscalchi.

STATEMENT OF MAJOR GENERAL KIMBERLY SINISCALCHI, 
            ASSISTANT SURGEON GENERAL FOR NURSING 
            SERVICES, AIR FORCE NURSE CORPS, DEPARTMENT 
            OF THE AIR FORCE
    General Siniscalchi. Chairman Inouye and distinguished 
members, it is an honor to represent the Air Force Nurse Corps.
    Our total nursing force is comprised of Active Duty, Air 
National Guard, and Air Force Reserve officer and enlisted 
nursing personnel.
    It is a pleasure to serve alongside my senior advisors: 
Brigadier General Catherine Lutz, Air National Guard; Colonel 
Ann Manley, Air Force Reserve; and Chief Master Sergeant Joseph 
Potts, our Active Duty enlisted career field manager. Together, 
we lead a total force team delivering evidence-based, patient-
centered care to meet global operations.
    On behalf of our total nursing force, sir, thank you for 
your outstanding support. Your unwavering commitment to our 
Tri-Service Nursing Research Program, and your continued 
support of our Nurse Corps Incentive Special Pay Program is 
genuinely appreciated.
    Nursing is integral to the support of global operations. 
Day after day, our nurses and technicians provide care to our 
Nation's heroes at home and abroad. Operational capability is 
the foundation and moral fiber of Air Force nursing.
    As an example, Lieutenant Colonel Zierold, from Salt Lake 
City, Utah, led a trauma team at Bagram, Afghanistan. In his 
words, ``Over a period of 6 months, we took care of more than 
1,000 traumas and countless medical admissions. The acuity was 
high and the injuries were horrendous, but we safely returned 
550 injured U.S. servicemembers to their families, children, 
and spouses. We forever changed the lives of 450 devastated 
Afghan nationals, and we won their hearts. And the kids; we 
will never forget the kids. At the time of their discharge, 
they reached out their little hands and smiled, as if to say, 
`Thank you. I'll be okay.' ''
    On this side of the globe, no one could have anticipated 
the total devastation that took place on January 12, when our 
Haitian neighbors experienced the massive earthquake. Special 
Operations surgical teams and critical-care evacuation teams 
deployed with the initial response aircraft, and were the first 
military medical teams on the ground. Our critical-care nurses 
worked around the clock, providing casualty evacuation of 
patients in and out of theater, as well as pre- and 
postoperative surgical and intensive care. Our anesthetists 
assisted in lifesaving surgeries and augmented the surgical and 
critical care teams.
    The vital link, sir, to saving lives, is our aeromedical 
evacuation capability. These critical missions sustain world-
class care across the continuum. Since operations began in 
2001, over 197,000 patients have been air-evac'd. In 2009 
alone, we moved 21,500 patients globally. Our superb flight 
nurses, technicians in critical care air transports teams have 
rightfully earned the title, ``Angels of the Battlefield.'' One 
such Battlefield Angel, Captain Jack Solgen, of Ballston Spa, 
New York, and his team successfully coordinated with the United 
Kingdom Aeromedical Evacuation Control Center for the transport 
of the British soldier with a traumatic pneumonectomy that 
Lieutenant General Green had mentioned.
    Two weeks ago, I had the opportunity to personally meet the 
lung team based at Ramstein Air Base, Germany. They 
passionately shared their experience of the emergency use of 
cutting-edge lung-support technology in saving the British 
soldier's life. This success story demonstrates a multinational 
effort of over 1,000 aircrew, ground, and medical personnel.
    The flexibility and responsiveness of today's aeromedical 
evacuation system demands educated and experienced flight 
nurses with enhanced clinical capability and disaster 
management expertise. I am proud to report that we created a 
master's degree in flight nursing with adult clinical nurse 
specialist focused in concentration in disaster management. 
This program--first of its kind--was designed and ready for 
students in less than 6 months. We partnered with Wright State 
University, in Dayton, Ohio, to strategically develop this 
program, and, as I mentioned earlier, our first student will 
begin this fall.
    We continue our commitment to provide the best care 
possible to our men and women in harm's way. It's imperative to 
advance operational medicine through research. Doctorally 
prepared nurses are integral to advancing multidisciplinary 
research. In March 2009, the Department of Defense Medical 
Research Program was initiated in Afghanistan, under the 
direction of Colonel Elizabeth Bridges, Air Force Reserve, 
Seattle, Washington, while Lieutenant Colonel Teresa Ryan, Air 
Reserve, Biloxi, Mississippi, was a senior nurse researcher in 
Iraq. Research conducted in Afghanistan and Iraq has led to 
important advancements in combat casualty medical care and 
therapies. Our nurse researchers provide leadership and 
guidance on scientific merit, design, and methodology.
    I am pleased to report that we developed a nursing research 
fellowship. Our first candidate will begin this spring. This 1-
year predoctoral fellowship focuses on clinical and operational 
research.
    One of our valuable skill sustainment programs is the 
Critical Care Emergency Nursing Fellowship. Our graduates 
provide the highest quality of care, both stateside and in the 
deployed environment, saving lives on a daily basis.
    To mitigate the increased demands on mental health nurses, 
we continue to recruit, educate, and train internally. 
Currently, 93 percent of our mental health nurse practitioners 
are Air Force Institute of Technology graduates. A formal 
mental health nurse training program is being developed at 
David Grant Medical Center, at Travis Air Force Base in 
California, to help train clinical nurses to become mental 
health nurses.
    Increasing our advanced life-support footprint, we have 
started several--we have started training several of our 
aerospace medical service technicians at the National Registry 
of Emergency Medical Technician Paramedic level. The inaugural 
class started and graduated 19 students, and we are programming 
for 50 students annually.
    A robust recruiting program is essential to keep our Nurse 
Corps healthy and ready to meet future challenges. While we 
have executed incentive programs to address the nursing 
shortage, we still have shortfalls. In 2009, we assessed 284 
nurses against our total accession goal of 350, for an overall 
81 percent.
    Our Nurse Enlisted Commissioning Program continues to be a 
reliable platform to assess nurses. In 2009, fully--40 
qualified candidates were selected. In 2010, we will meet our 
steady-state goal of 50 quotas annually. Assessing fully 
qualified nurses continues to be challenging. While the 
recruitment of novice nurses is going well, the limiting factor 
is their depth of clinical expertise. Our Nurse Transition 
Program advances the clinical skills of these new nurses 
through direct patient care under the supervision of seasoned 
nurse preceptors. The transition program continues to be one of 
our many successes, with eight military and two civilian 
locations. We graduated 158 nurses in 2009.
    Last year, I reported that a civilian partnership with 
Scottsdale Healthcare System in Arizona was on the horizon. 
This past December, I had the honor to deliver the commencement 
address for the second graduating class. Air Force nurses are 
gaining unprecedented clinical opportunities as a result of our 
transition programs.
    As we strive to meet our recruiting goals, we continue to 
focus on the retention of our experienced nurses. In its second 
year of execution, the Incentive Special Pay Program is 
positively impacting retention. Seventy-eight percent of our 
nurses accepted a single- or multiyear contract. With a $3.3 
million increase, this year's focus is to improve retention by 
recognizing advanced academic preparation certification and 
experience.
    Through the Tri-Service Nursing Research Program, my 
colleagues and I commissioned the first-of-its-kind joint 
research study designed to quantify factors impacting 
recruitment and retention. An associate investigator for each 
service will ensure service-specific and across-service 
initiatives are identified and validated for use in shaping 
future strategies.
    A number of scientific, societal, and professional 
developments stimulated a major change in requirements for 
licensed practitioners. The American Association of Colleges of 
Nursing endorsed the position statement on the doctorate in 
nursing practice. This decision moves the level of preparation 
for advanced practice from the master's degree to the doctorate 
level by 2015.
    With Lieutenant General Green's full support, we developed 
a phased implementation plan, starting in 2010. As I reported 
last year, we developed master clinician roles to afford our 
most clinically experienced senior nurses with advanced 
academic preparation, to remain at the bedside, without 
sacrificing promotion. We are diligently working to retain and 
field these authorizations.
    As we reflect, sir, on the achievements of the past, and 
the challenges of the present, we look forward to the future. 
By being actively engaged in education, training, and research, 
we are generating new knowledge and advancing evidence-based 
care necessary to enhance interoperability in nursing 
operations across our services.
    Through the synergy of our Active, Guard, Reserve, 
civilian, and contract forces, coupled with the collaborative 
relationships with our sister services and civilian colleagues, 
we are prepared to meet emerging challenges with strength and 
confidence.
    Air Force nursing stands ready today to embrace the 
challenges of tomorrow, as we lead, partner, and care, every 
time, everywhere.
    Mr. Chairman and distinguished members, it is my honor to 
be here with you today, representing a dedicated, strong, total 
nursing force of nearly 18,000 men and women.
    Thank you, sir.
    Chairman Inouye. I thank you very much, General.

                     ADDITIONAL COMMITTEE QUESTIONS

    General Horoho, Admiral Flaherty, and General Siniscalchi, 
on behalf of the subcommittee, thank you very much for your 
testimony, and especially for your service to our Nation. And, 
through you, the subcommittee wishes to thank those under your 
command for their unselfish service.
    Thank you very much.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]

       Questions Submitted to Vice Admiral Adam M. Robinson, Jr.
            Questions Submitted by Chairman Daniel K. Inouye

                    O-7 AND O-8 NURSE CORPS BILLETS

    Question. RADM Robinson, what mechanisms are in place to ensure the 
continuation of both an O-7 and O-8 billet for the Navy Nurse Corps?
    Answer. Currently Navy Medicine has two designated billets for Navy 
Nurse Corps, one for an O-7 (Rear Admiral Lower Half) and one for an O-
8 (Rear Admiral Upper Half). Our practice has been to have both of 
these billets manned. Currently, Rear Admiral (lower half) Elizabeth 
Niemeyer holds the O-7 billet and Rear Admiral (upper half) Christine 
Bruzek-Kohler holds the O-8 billet. RADM Bruzek-Kohler has plans to 
retire in the Fall of 2010. At the time of the 2010 DOD Congressional 
Testimony, results of the fiscal year 2010 O-8 Selection Board have not 
yet been released.

                                  CBOC

    Question. Admiral Robinson, the Army is planning to open 22 
Community Based Primary Care Clinics in 14 different market areas to 
provide better access for the thousands of beneficiaries who live off 
post. Have you looked into a similar concept for the Navy and do you 
plan to promote the Army clinics to Navy personnel and their families 
serving near them?
    Answer. A number of primary care practice models, including those 
from the Federal and private healthcare sectors, were evaluated as Navy 
Medicine developed the Navy Primary Care Model called Medical HomePort. 
Navy Medicine is launching a phased implementation of Medical HomePort 
across the enterprise as the practice standard for primary care. The 
initial phase will include NNMC Bethesda, NMC Portsmouth, NMC San 
Diego, NH Bremerton, NH Jacksonville, NH Lejeune, NH Pendleton and NH 
Pensacola. NHC Quantico will also be part of the first phase during 
fiscal year 2010.
    Medical HomePort utilizes a dedicated team of medical providers and 
support staff designed to increase access to care. The increased access 
aims to provide continuity for beneficiaries with their provider team, 
and we expect will improve the health of enrolled patients through 
preventive health practices, integrated mental healthcare and chronic 
disease management. We plan to closely monitor the Healthcare 
Effectiveness and Data Information Set (HEDIS) outcomes for the sites 
selected for implementation.
    In addition, this program will allow enrolled patients to access to 
their healthcare team 24/7 through secure messaging, schedule 
appointments through patient-preferred modes, and tailored education to 
their learning style.
    Navy personnel and their family members who reside within the 
catchment areas for the Army Community Based Primary Care Clinics would 
be notified of their enrollment options for those facilities via the 
Tricare Managed Care Support Contractor (if a Navy medical facility is 
not available within the area).

             DCOE CHAIN OF COMMAND FOR INSTALLATION REPAIRS

    Question. Admiral Robinson, I am very interested in the growing 
number of medically focused centers of excellence in the military and 
how the Department intends to 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. The current 
centers are focused around known critical areas of concern that impact 
both the Department of Defense and the Department of Veteran's Affairs: 
hearing loss, vision, extremity injury, traumatic brain injury and 
psychological health. Some of these centers will be located on the 
Walter Reed National Military Medical Center Campus. What will be the 
chain of command for responding to each Center's needs like fixing 
medical equipment or fixing a leaky roof? Will it be the medical 
center's responsibility or Naval Installation Command?
    Answer. Any Center of Excellence located on the Walter Reed 
National Military Medical Center Campus will fall under the control of 
the Medical Center Commanding Officer and his or her chain of command. 
Center of Excellence facility repairs will be the responsibility of the 
Medical Center Commanding Officer and will be resourced through the 
Defense Health Program (DHP).

               NAVY MEDICINE INTERACTION WITH SAFE HARBOR

    Question. Admiral Robinson, a tremendous amount of attention has 
been devoted to the care of our wounded warriors. The two main Navy 
programs designed to meet the needs of wounded service members are the 
Navy's Safe Harbor and the Marine Corps' Wounded Warrior Regiment. Navy 
Medicine works cooperatively with these programs to develop 
comprehensive recovery plans. How are the Services interacting with 
private sector care providers to ensure they have the necessary 
information on those Service programs relevant to their patients?
    Answer. Navy's Safe Harbor and the Marine Corps' Wounded Warrior 
Regiment were designed to take care of the non-medical needs of our 
wounded Sailors, Marines and Coast Guardsmen. Their role is to provide 
information and assist with access to the resources necessary to 
support the non-medical needs of our wounded warriors as they recover, 
rehabilitate, and reintegrate. Coordination of care when individuals 
transition from military treatment facilities to civilian care is 
accomplished through the Medical Care Case Managers (MCCMs) and the 
clinicians caring for the patients. Exchange of medical information 
occurs through provider to provider communication. Assistance in 
transition of medical care to the private sector is provided by the 
MCCM who remains engaged with the patient until they successfully 
establish a new care provider. Understanding the unique needs of the 
Reserve Component with regards to transition of care, especially 
transition of mental healthcare, Navy Medicine established the 
Psychological Health Outreach Program. This program is specifically 
designed to provide an additional layer of support to Reservists making 
their transition to private sector or VA care.

                     FUNDING A WORLD CLASS FACILITY

    Question. Admiral Robinson, there is a tremendous amount of focus 
on the establishment of the new Walter Reed National Military Medical 
Center at Bethesda. One of the latest developments is the effort to 
make it a ``World Class'' Facility and to produce a master plan for the 
campus to accommodate those changes. While Congress anxiously awaits 
the delivery of the master plan later this month, I am very concerned 
over the expected price tag for these additional projects that haven't 
been budgeted. As I understand it, this could cost upwards of $800 
million from operation and maintenance and millions more in military 
construction. As these projects are being evaluated by the Department, 
are they also determining how these projects will be funded and by 
which Service?
    Answer. To carry out the 2005 BRAC law, JTF CAPMED was established 
to oversee the realignment of Walter Reed Army Medical Center to the 
new Walter Reed National Military Medical Center in Bethesda and Fort 
Belvoir Community Hospital. JTF CAPMED reports to the Secretary of 
Defense through the Deputy Secretary of Defense. Due to the alignment 
of JTF CAPMED as an independent DOD entity, Navy Medicine does not 
direct JTF CAPMED on construction or other priorities, nor are we 
planning for future operation and maintenance requirements, since that 
by definition belongs to JTF CAPMED. These emerging priorities and 
requirements are driven by many things, all of which are outside Navy 
Medicine's budget process. As part of our mission to ensure that our 
Wounded Warriors receive the care they need and deserve, Navy Medicine 
is in regular communication with JTF CAPMED and continues to provide 
support as necessary. Because of this regular communication Navy 
Medicine is aware of the unique challenges facing JTF CAPMED, to 
include the projected increase of financial requirements. However, 
specific details of these challenges or the financial requirements 
cannot be defined or defended by Navy Medicine.

                      RECRUITING FOR THE RESERVES

    Question. Admiral Robinson, each Service faces unique medical 
personnel recruiting challenges but it appears all are having 
significant difficulties in the reserve component. Could you explain 
what this is attributable to and what efforts are underway to improve 
recruitment and retention for the reserves?
    Answer. Length and frequency of mobilizations are main reasons 
given for recruiting challenges.
    The financial and professional implications of being absent from a 
medical/dental practice, individual or group, for a period of time, are 
significant. Loss of patient base, medical staff, and support staff all 
contribute to these difficulties. The benefits and compensation for 
service do not adequately compensate for these losses.
    Initiatives currently underway are specific to Corps and specialty.
    Medical Corps.--Recruiting is focused on Critical Wartime 
Specialties (CWS) that are currently manned below 80 percent. In 
addition to a Loan Repayment Program and stipend, physicians who meet 
the CWS criteria are offered a bonus of $25,000 per year, for a maximum 
of 3 years. Prior service physicians who do not meet the CWS criteria 
may receive a $10,000 lump sum bonus for a 3 year drill obligation. 
However, this has not attracted enough applicants to alleviate 
shortfalls. We're currently considering establishing an accession bonus 
for Non-CWS Direct Commissioned Officers which could potentially 
attract eligible candidates.
    Dental Corps.--Reserve Dental Corps has a $10,000 lump sum 
affiliation bonus for prior service General Dentists for a 3 year drill 
obligation. Overall manning in this community is at 100 percent; 
however, oral surgeons are in high demand and are manned at only 43 
percent. Dentists who are interested in serving in the Navy as maxillo-
facial surgeons can qualify for a Loan Repayment Program, stipend, and 
a CWS bonus of $25,000 per year, for a maximum of 3 years. However, 
this has not attracted enough applicants to alleviate shortfalls. We're 
currently considering establishing an accession bonus for Non-CWS 
Direct Commissioned Officers which could potentially attract eligible 
candidates.
    Medical Service Corps.--Current recruiting incentives for clinical 
psychologists, physician assistants, and environmental health officers 
include the Loan Repayment Program, stipend, and a CWS bonus. Navy 
veterans (NAVETS) may be eligible for an affiliation bonus of $10,000.
    Nurse Corps.--Current recruiting incentives for Nurse Corps 
officers in CWS include stipend, Loan Repayment Programs, or CWS 
bonuses for the following communities: Psychiatric Care, Perioperative, 
Certified Registered Nurse Anesthetists and Mental Health Nurse 
Practitioners. An affiliation bonus of $10,000 is available to Navy 
veterans for all sub specialty programs. In February 2010, we began 
offering a $10,000 accession bonus for direct commission officers for 
medical-surgical, maternal infant, critical care, and neonatal 
intensive care unit nurses.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

                            NURSE RECRUITING

    Question. Nurses significantly contribute to the healthcare of our 
service members and their families. It is important that we maintain 
appropriate levels of highly trained nurses capable of performing a 
wide range of healthcare functions.
    a. With the maintained high operations tempo of combat in Iraq and 
Afghanistan, and the increasing requirements for healthcare for the 
service member and their families, are you able to maintain the 
required level of nurses?
    b. Are there enough nurses entering the military to ensure quality 
of care for the service members and to maintain the legacy of superb 
leadership in the future?
    c. What are you doing to prepare nurses for senior leadership roles 
and responsibilities?
    Answer. a. Retaining Navy Nurses is one of my top priorities. We 
remain committed to providing a total force of Navy Nurses, balanced in 
terms of seniority, experience, and skills, to provide the very best 
care to Sailors, Marines and their families. Key efforts have 
positively impacted retention, including the Registered Nurse Incentive 
Specialty Pay, a targeted bonus program for undermanned clinical 
nursing specialties and highly deployed Nurse Practitioners. Our nurses 
are enriched by being able to practice in both deployed and garrison 
care settings. My goal for this year is to increase retention by 50 
percent in the Active Component (AC) for those with less than 10 years 
of service, and to retain the appropriate numbers in each officer rank 
in the Reserve Component (RC).
    b. Nurse Corps AC manning is 91 percent, with 2,837 nurses in 
inventory. We have already achieved the Nurse Corps AC recruiting goal 
for fiscal year 2010, marking the fourth consecutive year we have met 
our accession goal. Nurse Corps RC manning is 83.6 percent, with 1,112 
nurses in inventory. As of late March 2010, we have met 25 percent of 
the RC fiscal year 2010 mission of 165 nurses, and we remain focused on 
this area. I attribute our recruiting successes to the continued 
funding support for our accession programs, the local recruiting 
activities of Navy Recruiters and Navy Nurses, and the continued 
positive public perception of service to our country. A recruiting 
initiative targeting direct accessions will offer entry grade credit 
for advanced education and work experience among the critical wartime 
specialties of Certified Registered Nurse Anesthetists (CRNAs), 
psychiatric/mental health, emergency room, and perioperative nursing. 
These initiatives will be expanded to include medical-surgical nurses 
and critical care nurses as well.
    c. In addition to sequential assignments to clinical and 
administrative leadership roles with increasing scope and 
responsibility, Navy Nurses are eligible and encouraged to pursue 
leadership training at all stages of their career. Leadership education 
starts with a 5-week long Basic Officer Development School (ODS) at 
Newport, Rhode Island before the officer receives their first military 
assignment. At the mid-grade career level, nurses are encouraged to 
complete the Basic Medical Department Officer Course (BMDOC), followed 
by the Advanced Medical Department Officer Course (AMDOC). Subsequent 
to completing these two courses, Nurse Corps officers are highly 
competitive for nominative assignments to the Interagency Institute for 
Federal Health Care Executives, MedXellence, and Capstone Courses. 
Nurse Corps officers interested in senior leadership and executive 
medicine positions are encouraged to obtain their Executive Medicine 
Additional Qualification Designation (AQD) through the Joint Medical 
Executive Skills Institute (JMESI). Mid and senior-level Nurse Corps 
officers compete for opportunities to attend the Navy War College 
through distance learning programs or residence assignments.

                        MENTAL HEALTH AWARENESS

    Question. The Army has partnered with the National Institute of 
Mental Health (NIMH) to conduct a long-term study of risk and 
protective factors to inform health promotion and suicide prevention 
efforts in late 2008.
    What is the Navy doing to promote mental health awareness?
    Answer. The Navy Operational Stress Control (OSC) program and USMC 
Combat Operational Stress Control (COSC) programs are working together 
to provide Sailors, Marines and their families increased education and 
awareness to early recognition of those in distress, to mitigate the 
stigma associated with seeking psychological care and to promote a 
culture of psychological wellness/health (vice the old paradigm of 
focusing on mental illness). These programs are Line-led and owned 
programs, supported by Navy Medicine, designed to provide leaders with 
tools they can use to recognize and act on early indicators of stress 
and to understand and use appropriate support resources, including 
medical and mental health treatment. The end state is a more resilient 
force. Navy Medicine has developed the Caregiver Occupational Stress 
Control (CgOSC) program to specifically address our caregivers who are 
often more prone to adhering to a ``code of silence'' pertaining to 
acknowledging personal stress-related issues. A multimedia (print, 
digital and social media) marketing campaign is underway to further 
mitigate stigma and increase awareness to resources. Additional mental 
health awareness initiatives include Project Focus--Family's Overcoming 
Under Stress; Combat and Operational Stress First Aid (COSFA); BUMED/
Navy Chaplain Corps annual Professional Development Training Seminar's 
on Combat and Operational Stress Control for deploying Sailors/Marines 
as well as a family-focused seminar; and Navy Returning Warrior 
Workshop's.
    Question. Is the Navy conducting long-term studies similar to that 
of the Army and NIMH?
    Answer. Navy Medicine is conducting a number of studies to 
investigate the longitudinal health experience of deployed military 
personnel. The Naval Health Research Center (NHRC) in San Diego, 
California, is the lead agency for the Millennium Cohort Study, which 
is the largest prospective health project in military history. It is 
designed to evaluate the long-term health effects of military service, 
including deployments. The study, which was launched in 2001, currently 
includes almost 150,000 participants and has already documented a 
number of risk factors for PTSD and depression following deployments. 
Other studies are focused on specific Navy and Marine Corps subgroups. 
For example, the Marine Resiliency Study is a collaboration between 
NHRC, the San Diego VA, Headquarters Marine Corps, and the National 
Center for PTSD, is collecting psychological and physiological data on 
Marine Corps Infantry personnel before and after combat deployments to 
identify both subtle and overt indices of combat stress. The Marine 
Resiliency Study documents the incidence of combat-related 
psychological disorders as well as risk factors for disorders. NHRC is 
also collecting longitudinal data on Navy and Marine Corps personnel 
before and after separation from military service. The goal of this 
effort is to identify factors associated with successful readjustment 
of Veterans to civilian life. In another effort, the Behavioral Health 
Needs Assessment Survey (BHNAS) is an ongoing series of surveys and 
focus groups conducted with Sailors in combat zones to identify rates 
and causes of psychological problems.

             MENTAL HEALTH ASSETS AND SERVICES FOR FAMILIES

    Question. Family Readiness and support is crucial for the health of 
the services. The health, mental health, and welfare of military 
families, especially the children has been a concern of mine for many 
years. This also includes education, living conditions, and available 
healthcare.
    Are you meeting the increased demand for healthcare and mental 
health professionals to support these families? If not, where are the 
shortfalls?
    What improvements have been made with respect to the children of 
soldiers and meeting their special requirements? What programs have you 
implemented to assist the children with coping with frequent 
deployments, re-integration, and other stresses of military families?
    Answer. Since the beginning of Overseas Contingency Operations, 
Navy Medicine has increased mental health assets across the enterprise 
to meet the increasing needs of service members and their families.
    To meet the specific needs of families, we have implemented several 
programs targeted at the types of challenges families face as a result 
of deployments and injuries to the service member.
    Examples of these programs include:
  --FOCUS (Families Over Coming Under Stress) is a family-centered 
        resiliency training program based on evidenced-based 
        interventions that enhance understanding, psychological health 
        and developmental outcomes for highly stressed children and 
        families. FOCUS has been adapted for military families facing 
        multiple deployments, combat operational stress and physical 
        injuries in a family member. FOCUS has demonstrated that a 
        strength-based approach to building child and family resiliency 
        skills is well received by service members and their family 
        members reflected in high satisfaction ratings. Notably, 
        program participation has resulted in statistically significant 
        increases in family and child positive coping and significant 
        reductions in parent and child distress over time, suggesting 
        longer-term benefits for military family wellness. In June 
        2009, the Office of the Secretary of Defense Child and Family 
        Policy determined FOCUS as a best practice program and 
        requested the support of BUMED to expand to select Army and Air 
        Force sites for services. To date over 97,000 service members, 
        spouses, children and community providers have received 
        services on FOCUS.
  --Navy Fleet and Family Support Centers (FFSCs) offer a wide-range of 
        services to families to include pre- and post-deployment 
        programs.
  --Ombudsmen/Navy Regional Family Support Liaison; Navy Expeditionary 
        Combat Readiness Center's (ECRC) Individual Augmentee (IA) 
        Family Readiness Program.
  --The Reserve Psychological Health Outreach creates a Psychological 
        health ``safety net'' for Navy and Marine Corps Reservists and 
        their families. It improves the overall Psychological Health 
        and resiliency of Reservists and their families, and identifies 
        long-term strategies to improve Psychological Health support 
        services. In addition, Psychological health Outreach Teams have 
        been in place at Navy Reserve Component Commands since fiscal 
        year 2008.
  --Returning Warrior Workshops provides 2 day workshops designed to 
        support reintegration of deployed Reservists and their family 
        using a weekend-formatted program that includes assisting 
        families in identifying issues during post-deployment, 
        providing resources for issues resolution, sharing common 
        experiences in a comfortable setting, honoring sacrifices 
        endured, and engaging family members and service members with 
        process improvement.

                TRANSITION OF WOUNDED WARRIORS TO THE VA

    Question. In the recently released Department of Defense budget 
guidance, it states that ``caring for our wounded warriors is our 
highest priority: through improving health benefits, establishing 
centers of excellence, and wounded warrior initiatives.''
    What system do you have to ensure the transition of wounded 
warriors from Department of Defense to the Department of Veterans 
Affairs is completed without any unnecessary problems?
    Answer. To ensure the transition of Wounded Warriors from 
Department of Defense to the Department of Veterans Affairs is 
completed without any unnecessary problems, Navy Case Management (both 
medical and non-medical) work collaboratively with Federal agencies 
including the VA. This collaboration includes multi-disciplinary team 
meetings with Navy and USMC Recovery Care Coordinators, Federal 
Recovery Coordinators, Non-Medical Care Managers, Medical Care Managers 
and VA Liaisons, patients and their families in developing Recovery 
Care Plans.
    Question. What do you consider a successful transition and do you 
follow-up with the service members to ensure there are no problems even 
after they have been released from Active Duty?
    Answer. A successful transition is one that results in the service 
member and his/her family's needs being met to their satisfaction. Navy 
Medicine Medical Care Managers provide a warm hand off of the medical 
case management of an individual to VA Medical Care Managers when an 
individual transitions from Active Duty to Veteran status. This hand 
off ensures smooth transition of the medical needs of the Sailor/
Marine. Navy Safe Harbor and Wounded Warrior Regiment Recovery Care 
Coordinators and the Federal Recovery Coordinators assigned to these 
wounded warriors, provide a lifetime of individually tailored 
assistance designed to optimize the success of the injured service 
member's recovery, rehabilitation and reintegration activities. Their 
involvement with the individual continues through and beyond the 
transition period.

                          MENTAL HEALTH STIGMA

    Question. General Casey recently stated that the number of Army 
soldiers who feel there is a stigma for seeking mental healthcare has 
been reduced from 80 to 50 percent. This is a significant improvement, 
but there is much more work to be done.
    Despite the reduced number of soldiers who feel there is a stigma, 
are more service members coming forward to seek treatment?
    Answer. Yes, Navy Medicine has experienced a 30 percent increase in 
outpatient mental health encounters for Sailors and Marines over the 
past 2 years. Greater data analysis is required in order to correlate 
the impact of reduced stigma and increases in demand.
    Question. What actions are the services taking to continue to 
reduce the stigma and encourage service members to seek treatment?
    Answer. Prior Navy Medicine ``innovations'' that have now become 
the norm include operationally embedded mental health providers, 
integration of Mental Health Care into primary care, Psychological 
Health Outreach Coordinators and use of our Deployment Health Centers 
as destigmatizing portals of care. Navy Medicine has also developed the 
Caregiver Occupational Stress Control (CgOSC) program to specifically 
address our caregivers who are often more prone to adhere to a ``code 
of silence'' pertaining to acknowledging personal stress-related 
issues. Another innovative program is the multidisciplinary team 
assessment of every patient that is medically evacuated from theater to 
identify potential cognitive and psychological health issues. Access is 
increased in a non-stigmatizing manner by providing this assessment to 
all patients without need for consult or self-referral. Follow on care 
is provided as indicated utilizing all members of the multidisciplinary 
team. The Navy Operational Stress Control (OSC) program and USMC Combat 
Operational Stress Control (COSC) programs are working together to 
provide Sailors, Marines and their families increased education and 
awareness to facilitate early recognition of those in distress and to 
help combat the stigma associated with seeking psychological care. A 
multimedia (print, digital and social media) marketing campaign is also 
underway to further mitigate stigma and increase awareness to 
resources.
    Question. Does your plan include the mental health of families, and 
if so what is that plan?
    Answer. Yes, Navy medical care is ``patient and family centered 
care''. The psychological health of our families is crucial in 
maintaining a health fighting force. Navy Operational Stress Control 
(OSC) is developing specific Family OSC curriculum in collaboration 
with our life educators from Fleet and Family Support Centers. Project 
FOCUS (Families Over Coming Under Stress) is a family-centered 
resiliency training program based on evidenced-based interventions that 
enhance understanding, psychological health and developmental outcomes 
for highly stressed children and families. Navy Medicine has partnered 
with the Navy and Marine Corps Public Health Center and USMC COSC to 
develop and pilot a Family component to the USMC Operational Stress 
Control and Readiness (OSCAR) program.
                                 ______
                                 
            Questions Submitted by Senator Patrick J. Leahy

                     NAVY MEDICINE USE OF SOFTWARE

    Question. DOD renewed its contract with a Vermont medical firm, 
Problem-Knowledge Couplers (PKC), last fall. DOD licenses 95 standard 
PKC tools and six custom tools used for deployment and readiness 
medical processes. PKC is presently including the six custom tools into 
a single ``CHART'' smart-questionnaire, migrating these tools from a 
Windows to a web-based interface, and preparing a set of web-based 
medical history questionnaires for patients to complete online prior to 
the medical encounter.
    DOD has not yet issued a Department-wide policy on how the Services 
are to employ the CHART tool. How does your Service plan to use CHART? 
Will you issue a policy directing how it is to be used, since employing 
it will substantially change the workflows of Service medical 
practitioners?
    As for the medical history questionnaires, the use of this tool by 
the Services will put DOD in the very forefront of medical information 
technology innovation. Can each of you describe how your Service will 
direct the use of these questionnaires, educate your medical 
professionals about their existence and value, and track and oversee 
their full integration into patient contact processes?
    Answer. PKC couplers in their current configuration are in use at a 
limited number of locations for routine screenings such as the annual 
Periodic Health Screening. The current version of the tool does not 
represent an ideal configuration for efficient use with our current 
systems.
    CHART is currently undergoing testing for use with our current 
systems. Once the testing is complete the tool can be examined for 
routine use as a screening tool by both clinical and technical experts. 
Once the technical examination is complete, Navy Medicine will consider 
how CHART can be best utilized.
    Once Navy Medicine decides how CHART may be used, web based 
training as well as live training at our individual treatment 
facilities can be utilized to train the healthcare team.

                     DEFENSE CENTERS OF EXCELLENCE

    Question. Would you each describe the relationship of your Services 
to the Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury? How do you share and receive information and 
support from these Centers? How timely are they in responding to 
requests from support from your Services?
    What is the relationship between your Services and the centers of 
excellence directed by the 2008 and 2009 National Defense Authorization 
Acts related to hearing loss and auditory system injuries, military eye 
injuries, and traumatic extremity injuries and amputations? How mature 
are these organizations, at what level are they staffed, and do you 
find that those staffing levels are sufficient to support the needs of 
your Service in each medical area?
    Answer. Navy Medicine works collaboratively with the Defense 
Centers of Excellence for Psychological Health and Traumatic Brain 
Injury and its component centers: Defense and Veterans Brain Injury 
Center (DVBIC); Center for the Study of Traumatic Stress (CSTS); Center 
for Deployment Psychology (CDP); Deployment Health Clinical Center 
(DHCC); National Center for Telehealth and Technology (T\2\); and the 
National Intrepid Center of Excellence (NICoE). Navy Medicine provides 
staffing to the DCoE, but also has been working to ensure that Navy 
Medicine professionals--clinicians, researchers, educators and program 
managers--are working collaboratively with the DCoE staff to improve 
their important research, education and outreach efforts. We are 
encouraged by the work of the DCoE and look forward to working with ASD 
(HA) and the other services to determine the best organizational 
structure and way forward. Preliminary work is underway in support of 
the ASD (HA) plan to designate each of the Services with lead 
operational support responsibilities for one of these Centers: Navy--
Vision Center of Excellence; Army--Center of Excellence for Traumatic 
Extremities and Amputations; and Air Force--Hearing Center of 
Excellence. ASD (HA), along with the Services' Surgeons General, are in 
the process of evaluating organizational models to best support the 
DCoE mission.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                      MENTAL HEALTH PROFESSIONALS

    Question. DOD has a critical shortage of mental healthcare 
professionals. During review of the Fort Hood incident where the 
alleged gunman, Major Hasad, U.S. Army psychologist, is charged with 
the deaths of 13 victims, reports show discrepancies in documentation 
and counseling as it related to his professional abilities and 
behavior. Suggestions were made that he was kept on active duty with no 
negative reprimands because he had diversity as a Muslim to our 
nation's service despite his failure to perform. What is DOD doing to 
recruit more mental health workers and to ensure they are quality 
healthcare professionals?
    What are the roadblocks to meeting the shortage of mental health 
professional?
    Answer. Navy Medicine has been successful in hiring civilian and 
contract mental health providers. The difficulty is the long training 
pipelines required to access and train our military mental health 
providers. The majority of our military mental providers are either 
trained in-house, through student pipelines or both. For example a 
Psychiatrist training pipeline includes 4 years of medical school, 1 
year of internship and a 3 year Psychiatry residency. These long 
training timelines impact our ability to replace and increase our 
inventory of military Psychiatrists with any expediency. Clinical 
Psychologists and Social Workers were recently approved by Navy for 
accession bonuses beginning in February 2010. We believe these new 
bonuses will impact direct accession of fully trained Clinical 
Psychologists and Social Workers.
    Question. What is being done to reduce the stigma and provide 
enough care givers so soldier and their families do not suffer in 
silence?
    Answer. Navy Medicine has focused much attention on reducing stigma 
and ensuring that an adequate number of mental health professionals are 
available to care for our beneficiaries. Mental health providers are 
routinely embedded with our operational units, both ashore and afloat. 
Seventeen Deployment Health Centers (DHCs) were established in fiscal 
year 2006 as non-stigmatizing portals of care in high Fleet and Marine 
Corps concentration areas. The DHCs augment existing MTF resources with 
an additional 170 multi-disciplinary contract positions, including 
psychiatrists, psychologists, and social workers, and provide a robust 
capability to screen, evaluate, and treat Service members for 
deployment related health concerns. In a major initiative, efforts are 
underway to integrate mental health providers into our Primary Care 
Clinics, further improving access and reducing stigma. Additional 
mental health providers have been hired in recent years to support a 
host of other programs, including psychological health outreach and 
family support and counseling. The Navy Operational Stress Control 
(OSC) program and USMC Combat Operational Stress Control (COSC) 
programs are working together to provide Sailors, Marines and their 
families increased education and awareness to facilitate early 
recognition of those in distress and to help combat the stigma 
associated with seeking psychological care. Navy Medicine has developed 
the Caregiver Occupational Stress Control (CgOSC) program to 
specifically address stress in our caregivers.
    Question. How is Navy Medicine integrated into the suicide 
prevention programs to ensure mental health services are getting to 
those who need it before it is too late?
    Answer. Navy Medicine personnel (military and civilian) are 
required to receive annual awareness training to improve ability to 
recognize risk factors, warning signs, and protective factors related 
to suicide and know how to assist someone in need to get care. Medical 
facilities and all Navy commands must have written crisis response 
plans with consideration of safely reaching, engaging and transporting 
an individual in acute risk to care. Navy suicide prevention is part of 
a comprehensive effort in the Navy to educate Sailors, families, and 
leaders to recognize and act on early indicators of stress and to 
understand and use appropriate support resources, including medical and 
mental health treatment.

                    WOMEN'S HEALTH: CERVICAL CANCER

    Question. Cervical Cancer is preventable. In 2009 over 11,000 
American women were expected to be diagnosed with cervical cancer and 
over 4,000 women were expected to die from the disease. More than one-
half of women who die from cervical cancer have never been screened or 
have not been screened in the past 5 years.
    Human Papillomavirus (HPV) testing is an approved and widely 
accepted test to search for cells that have the potential of turning 
cancerous. Research has proven that when performed together with 
cytology screening, it increases detection of abnormal cell changes by 
30 percent. National medical organizations and insurance companies have 
determined screening of HPV testing and cytology screening at the same 
time as the standard of care, however Tricare has deemed HPV testing 
authorized only after a negative cytology exam.
    What is Navy medicine doing to ensure its female patients are 
receiving the highest quality of cervical cancer screening available?
    a. What is the percentage of female patients who receive current 
standards of screening within the required timeframes?
    b. Is HPV tests available at all Navy MTFs?
    c. What is Navy medicine doing to increase prevention efforts of 
their female patients from developing cervical cancer?
    Answer. Navy Medicine is dedicated to ensuring that all patients 
receive the highest quality of care. All female patients who present 
for care have the opportunity to be screened for cervical cancer, 
following the guidelines of the USPSTF (United States Preventive 
Services Task Force).
    (a) The percentage of female patients who are screened is 85.9 
percent (December 2009--the most current data from the Population 
Health Navigator). To put this figure into context, the civilian HEDIS 
Benchmark for 75th percentile is 84.6 percent and for 90th percentile 
is 87.8 percent, so we fit in with national norms. Our true measure for 
cervical cancer screening is actually a little higher, as our current 
data systems are not able to exclude women who have had a hysterectomy 
and no longer need to be screened. All active duty patients are 
screened according to guidelines; however, for our family members and 
other non-active duty beneficiaries, we can screen only those who 
present for care.
    (b) Yes. HPV testing and vaccinations are available through all 
Navy MTFs.
    (c) Navy Medicine is very proactive in providing patient education 
regarding cervical cancer through both patient/physician discussions 
and community public health outreach efforts via various media formats. 
The HPV vaccine is available for all beneficiaries in accordance with 
recommended guidelines.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

                         VA SHARING AGREEMENTS

    Question. Admiral Robinson, the Department of Defense and the 
Department of Veterans Affairs are establishing joint ventures in 
hospitals that are co-located around the country, in hopes to achieve 
efficiencies with combined personnel and shared resources, thus 
eliminating duplication. Currently, as you know, the Navy and the VA 
are working on a joint venture in North Chicago, where the plan is to 
operate the facility with a single civilian staff under the VA, 
operating out of one combined facility.
    The Air Force and the VA are also working toward a joint-venture 
between Keesler and Biloxi, but have adopted a different model than the 
North Chicago model. I understand the Air Force has stated that not 
every joint venture will be applicable to every location, and thus the 
Air Force is not inclined to follow the North Chicago model. One of 
these reasons might be due to the different mission focus between the 
two locales. For example, the North Chicago facility supports mostly 
non-deployable personnel (Navy recruits) and serves as a schoolhouse 
for medical trainees. In Keesler, many of the medical Airmen deploy in 
their respective Air Expeditionary Force rotations (AEF) and for 
humanitarian missions, as needed.
    Admiral, what are your thoughts regarding the joint venture in 
North Chicago? In your opinion, is total consolidation between the Navy 
and the VA the best answer for meeting the Navy mission at Great Lakes?
    Finally, do you believe this is the model of the future for other 
Navy-VA joint ventures? Or will the Navy look at other models of 
implementation, depending upon the mission at that location?
    Answer. The total consolidation between the Navy and the VA in 
North Chicago will allow Navy Medicine to meet our mission in Great 
Lakes. The fully integrated joint venture in North Chicago is a model 
that has evolved over 10 years of expanding and developing extensive 
resource sharing between the two Departments.
    Prior to plans for consolidation in North Chicago, the Navy was 
moving forward with programmed replacement ambulatory care center to 
replace the aging Navy hospital. Simultaneously, discussions were 
taking place within the VA to close their North Chicago facility and 
reassign the workload to both Milwaukee and Chicago Veterans facility. 
A decision was made to explore a joint Federal solution to combine both 
the Navy-VA healthcare missions, which would provide a more cost 
effective solution to meet the healthcare needs of a wide array of 
active duty, veterans, and dependent beneficiary populations. This 
combined healthcare project is in its 10th year of evolving from 
planning to operational status with many of the integration challenges 
having been addressed such as the reconciliation process and the IT 
solutions for interoperability.
    The current demonstration project will commence October 1, 2010 and 
is expected to extend efficiencies gained through local consolidation 
and use of a single chain of command, as well as single systems for 
personnel, logistics, and financial management. The Department of 
Veterans Affairs, North Chicago will be the lead executive department. 
Following review of the financial and personnel systems, workload and 
patient satisfaction surveys, this fully integrated facility may become 
the model for future DOD and VA operations where appropriate. Navy 
Medicine, the Department of Defense and the Department of Veterans 
Affairs are already establishing joint ventures with the goal of 
eliminating duplication.
                                 ______
                                 
            Questions Submitted by Senator Robert F. Bennett

                             CHIROPRACTORS

    Question. I'm pleased that TRICARE has worked over the past few 
years to expand chiropractic care for service members. Indeed, I have 
heard one of the top complaints of returning soldiers has been the type 
of neck and back pain that chiropractic care would seemingly address. 
Given the strains placed upon our soldiers in theater, what 
consideration (if any) has been given to commissioning chiropractors, 
such that they can be deployed and provide care for our soldiers 
abroad? Are there any obstacles currently in place that would prevent 
you from doing so?
    Answer. Approximately 25 percent of entrants to the Navy Medical 
Corps currently have the Doctor of Osteopathy degree. The manipulation 
skill set is available in this group of physicians who are widely 
deployed in support of theater operations. More importantly, these 
physicians along with orthopedic surgeons and sports medicine 
physicians are more versatile in their use in theater and at home.
    Additionally, physical therapists, now doctorally prepared, also 
have the skill set necessary to address neck and back pain as well as 
the full spectrum of other musculoskeletal complaints widely 
experienced by deploying service members. Physical therapists are 
deploying with service members, and there is a desire to expand this 
availability.
    The Navy Medical Department prefers to use full spectrum physicians 
and physical therapists rather than limited spectrum providers to meet 
the needs of its beneficiaries.

                         CHIROPRACTORS AT MTFS

    Question. In fiscal year 2009, Congress required that 11 new 
Military Treatment Facilities be staffed with chiropractors by the end 
of last fiscal year. I have listed the specific locations of those 
positions that were announced below. To my knowledge only 4 have opened 
up--what is the status of each of those 11 new positions?
Air Force
    1st Special Operations Medical Group, Hurlburt Field, Florida.
Army
    Irwin Army Community Hospital, Fort Riley, Kansas.
    Lyster Army Health Clinic, Fort Rucker, Alabama.
    Bayne-Jones Army Community Hospital, Fort Polk, Louisiana.
    Bassett Army Community Hospital, Fort Wainwright, Alaska.
    Landstuhl Regional Medical Center, Germany.
    Grafenwoehr Army Health Clinic, Germany.
Navy
    Naval Health Clinic Quantico, Virginia.
    Naval Branch Health Clinic Groton, Connecticut.
    Naval Hospital Lemoore, California.
    U.S. Naval Hospital, Okinawa, Japan.
    Answer. Navy Medicine currently has contract chiropractors at NHC 
Quantico, NBHC Groton, and NH Lemoore. NH Okinawa presently does not 
have a chiropractor. Additionally Navy Medicine has contract 
chiropractors at NH 29 Palms, NH Beaufort, NH Bremerton, NH Camp 
Lejeune, NH Camp Pendleton, NH Pensacola, NHC Cherry Point, NHC Great 
Lakes, NHC Hawaii, NMC Portsmouth, NMC San Diego and NNMC Bethesda.
                                 ______
                                 
      Questions Submitted to Lieutenant General Eric B. Schoomaker
             Questions Submitted by Senator Byron L. Dorgan

    Question. My staff has made repeated requests for this report. In 
response I have received a letter acknowledging my request, and 
repeated assurances that the review is in process.
    Does the Department of Defense intend to complete a review of 
TRICARE standards for residential treatment centers, including the 24 
hour nursing requirement? When will the report be complete?
    Answer. Yes, the review has been completed and TRICARE is working 
to modify certain requirements related to the certification of 
residential treatment centers, including those setting standards for 
overnight medical care in such settings. However, to fulfill the 
requirements of the report, the Department must change our regulation 
on standards. The timeline for the report is predicated on how soon the 
regulation can be changed. As soon as the report is completed, it will 
be sent to all the appropriate Committees.
    Question. On March 17, 2009, the Federal Register published a final 
rule on the inclusion of the TRICARE retail pharmacy program as part of 
the DOD for the purpose of the procurement of pharmaceuticals by 
Federal agencies. This program requires pharmaceutical manufacturers to 
provide, at minimum, a 24 percent discount on prescription drugs. The 
final rule estimated the resulting savings to the Department of Defense 
would be over $12 billion in fiscal years 2010-2015.
    Is DOD on track to obtain the estimated savings? Are all drug 
manufacturers complying with the requirements? If not, what steps are 
being undertaken to ensure that the Federal pricing is obtained?
    Answer. Yes, the Department is on track to obtain savings on 
prescription drugs. However, the initial Independent Government Cost 
Estimate (IGCE) done in 2008, relied on 2007 data from Pharmacy Data 
Transaction Service. The IGCE also based several significant 
assumptions on data published by CBO that was from 2002 and 2003, a 
period which experienced higher inflation and price changes than what 
was seen in 2006 and going forward. Therefore, the IGCE based on these 
assumptions and data available at that time and calculated a initial 
savings rate of 35 percent. This calculation of 35 percent was proved 
incorrect due to the inaccurate data used.
    In order to have an accurate calculation of the savings, in 
February 2010, the Pharmacy Operations Directorate (POD) provided 
information to OMB Budget Officials concerning differences between the 
projected savings of the Federal Ceiling Price (FCP) program and our 
recalculations of projected savings based on actual refund data to 
date. The corrected calculations, provided by the POD in February 2010 
using actual data, yielded a rate of 28 percent. It is anticipated that 
our FCP refund estimates will continue to be refined as we have more 
experience with the program, receive additional quarters worth of 
refunds, and develop more precise methodologies for determining future 
refunds. As of August 27, 2010, fiscal year 2010 total collections 
(DHP/Non-DOD/MERHCF) for pharmacy rebates were $664 million.
    Yes, almost all manufacturers have opted in for all of their drugs 
for purposes of preserving preferred uniform formulary status and no 
manufacturer has opted out of the program. If that were to occur, the 
most likely outcome would be to switch to another drug in the drug 
class. In the unlikely event that this would not be medically 
sufficient, DOD could use the preauthorization, transition, and waiver/
compromise processes under the Final Rule to ensure that patient needs 
are met.
                                 ______
                                 
       Questions Submitted to Lieutenant General Charles B. Green
            Questions Submitted by Chairman Daniel K. Inouye

                  COMMUNITY BASED PRIMARY CARE CLINICS

    Question. General Green, over the years the Air Force has 
transformed its medical care more toward clinic based rather than large 
military treatment facilities. Are there lessons learned from your 
experience providing care in a clinic setting that the Army would find 
beneficial as they plan to open 22 Community Based Primary Care 
Clinics?
    Answer. A solid business plan is required to ensure long term 
viability of the clinic. Enrollment based clinics drive different 
practice than a fee for service clinic that requires many procedures to 
cover the operating costs. Most medical care is provided in the 
outpatient arena, which meets the majority of our beneficiaries' needs. 
We have learned the importance, particularly in free-standing 
outpatient clinics, of providing patients a Medical Home with good 
access to their provider, continuity of care and a relationship with a 
Family Health Team. Family Health providers require specialty care 
resources to complete the spectrum of healthcare delivered for patients 
with disease and injury. Specialty consultation can sometimes result in 
fractionated care, particularly when it requires referral outside the 
medical treatment facility. The central tenet of the Air Force Medical 
Service's Medical Home is a focus on referral management, disease 
management, and a team approach to healthcare to ensure coordinated 
care that anticipates each patient's needs over time. We are also 
working to expedite the flow of relevant research information from the 
medical journals to our providers' desktops to improve medical 
management.
    Another important effort is that the Air Force has hired 32 full-
time behavioral health providers to embed in our primary care clinics 
to facilitate mental health treatment in the primary care setting. 
Research shows that over 70 percent of physical complaints have a 
psychological component and the vast majority of psychotropics are 
prescribed in primary care. Via this program, mental health providers 
are embedded in Primary Cares to provide consultation and brief 
intervention to our beneficiaries, who often do not seek or follow 
through with specialty care. This program streamlines the process for 
beneficiaries, providing brief mental health intervention when and 
where needed.

                      HEARING CENTER OF EXCELLENCE

    Question. General Green, I am very interested in the growing number 
of medically focused centers of excellence in the military and how the 
Department intends to 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. The current 
centers are focused around known critical areas of concern that impact 
both the Department of Defense and the Department of Veterans Affairs: 
hearing loss, vision, extremity injury, traumatic brain injury and 
psychological health. Since the Air Force will likely be the executive 
agent for the Hearing Center of Excellence, can you detail the role you 
believe the Air Force should play in developing the operational and 
research requirements as well as resourcing the Center to meet those 
needs?
    Answer. The establishment of a Hearing Center of Excellence is well 
underway. The Hearing Center of Excellence is positioned to roll out 
the necessary programs to connect, coordinate and focus the Department 
of Defense (DOD) and Veterans Affairs (VA) tracking, clinical care and 
research efforts for each injured military member and our expanding 
population of auditory disabled veterans.
    In October 2009, the Air Force was designated as the lead component 
and is standing up the Hearing Center of Excellence in partnership with 
the VA, Navy, and Army. The Executive hub will be located in San 
Antonio at Wilford Hall Medical Center within the 59th Medical Wing.
    The Hearing Center of Excellence office will be comprised of a lean 
cadre of staff working as an administrative hub leveraging technology 
to create and sustain a network of regional treatment facilities. This 
network will provide coordinated research and treatment. The Center 
staff will include a cadre of otolaryngology, speech and audiology 
professionals from within DOD, VA, and civilian settings. Wilford Hall 
Medical Center is an ideal site for the Hearing Center of Excellence 
hub. With ten Air Force, and five Army otolaryngologists and nine 
audiologists, Wilford Hall is the most robust clinical otolaryngology 
and audiology department in the DOD and VA systems.
    Wilford Hall is integrated with Brooke Army Medical Center in 
Graduate Medical Education in otolaryngology and audiology. The Wilford 
Hall/Brooke Army Medical Center partnership provides support for the 
Audie Murphy and Central Texas VA hospitals, and provides didactic and 
surgical training support for the University of Texas at San Antonio 
Medical School. This local support underpinning the Hearing Center of 
Excellence hub will ensure success as links with regional DOD and VA 
facilities are developed. The BRAC-directed coalescence to the San 
Antonio Military Medical Center construct will provide convenient, top-
quality platforms that are critical for focused clinical and research 
activities.
    The Wilford Hall otolaryngology department has a strong legacy and 
understanding of deployment medicine supporting special operations, 
aeromedical evacuation, and humanitarian roles and is keenly aware of 
the ongoing dichotomy faced by our troops between hearing protection 
and the essential need for optimal situational awareness and 
communication. Wilford Hall audiology has a solid deployment and 
research foundation and a working relationship with the Army medical 
facilities, the VA system, and the Institute for Surgical Research. 
They have established collaborative teaching and research ties with the 
Navy, acclaimed universities, and national and international industry 
leaders. The San Antonio military medical community supports Fort Hood, 
the Army's largest armored post, the Center for the Intrepid, all Air 
Force entry-level enlisted training and the new Medical Education and 
Training Campus on Fort Sam Houston.
    Since the designation of the Air Force as lead component for the 
Hearing Center of Excellence, the Interim Director has worked with the 
tri-service/VA working group to draft the concept of operations and to 
direct and define the functional needs for the hearing loss and 
auditory injury registry. The lead component structure is supporting 
cross-talk between the DOD Centers of Excellence and will lead to well 
coordinated efficiency of operations by sharing many functions.

                          WILFORD HALL CLOSURE

    Question. General Green, you are dealing with the closure of 
Wilford Hall in San Antonio, Texas resulting in a combined medical 
facility with the Army. Please detail for the subcommittee how each 
Service is integrating and coordinating the various approaches to 
military medicine and serving their unique populations?
    Answer. The Base Realignment and Closure (BRAC) 2005 Law, Business 
Plan 172, states that we are to ``realign [not close] Lackland Air 
Force Base, Texas, by relocating the inpatient medical function of the 
59th Medical Wing to the Brooke Army Medical Center, Fort Sam Houston, 
establishing it as the San Antonio Military Medical Center and 
converting Wilford Hall Medical Center to an Ambulatory Care Clinic.'' 
With your support, we are on track to meet the BRAC deadline to 
transition all inpatient care to the Brooke Army Medical Center and 
establish a combined San Antonio Military Medical Center. The 59th 
Medical Wing's Ambulatory Care Clinic is also a critical component of 
this integrated military health system in San Antonio. To ensure we 
appropriately realign and integrate clinical operations, the Military 
Health System is modernizing these key facilities. The result will be 
the efficient and effective provision of world-class military medicine 
within the greater San Antonio area.
    We are capitalizing on prior collaboration and expanding new 
agreements. To ensure integration manner we are mixing resources at the 
market level to provide best value military healthcare for San Antonio. 
Examples are integration of graduate medical education under the San 
Antonio Uniformed Services Healthcare Education Consortium; fully 
integrated department leaders; collaborative basic and clinical 
biomedical research; and a San Antonio Healthcare Advisory Group to 
facilitate privileging, clinical business operations, healthcare 
management, and strategic planning. Efforts are ongoing with regard to 
governance structure, but our vision is a Service lead of the joint 
hospital and the joint ambulatory surgery facility, each staffed by 
both Army and Air Force personnel, similar to the Landstuhl Regional 
Medical Center model.
    The Army and the Air Force have worked diligently to integrate 
operations and improve military medicine delivery, while meeting the 
needs of each Service's beneficiary population and sustaining the 
readiness skills and focus of the military's medical force.

                 HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

    Question. General Green, the Health Professions Scholarship Program 
is one of the best mechanisms to recruit medical personnel into the 
Services. This program provides 4 years of tuition, books, and a 
monthly stipend, yet only 25 percent of all graduates of this program 
stay in the Service after the initial 4 year commitment. After spending 
hundreds of thousands of dollars training these medical professionals, 
how can we do a better job of retaining them in either the Active 
component or in the Reserves?
    Answer. Retaining healthcare professionals beyond completion of 
their initial Health Professions Scholarship Program obligation is both 
multi-faceted and complex. Although the current economic climate may 
assist in some regards to some specialties, data from ``exit surveys'' 
consistently indicates that the prolonged war efforts in Afghanistan 
and Iraq and the associated requirement for more frequent and/or 
extended deployments plays a significant role in influencing whether a 
service member will remain in uniform beyond his/her initial service 
commitment. We continue to seek mechanisms to create more pay equity 
with private sector salaries. New authorities for special pays are 
helping.
    To assist in retention of personnel, we also perform active 
mentorship with the Developmental Team of each Corps. Considering the 
member's professional experience, clinical expertise, and preferences 
for education/training and future assignments, the Corps leadership is 
able to evaluate their potential as leaders and clinicians and to guide 
them to future success as a valued Air Force officer and skilled member 
of the medical team.

                         NURSE CORPS PROMOTIONS

    Question. LTG Green, what are the potential adverse effects of the 
Nurse Corps Chief's non-sequential promotion from O-6 to O-8? What 
actions have been considered to mitigate these effects on the Chief of 
the Nurse Corps? Has any consideration been given to the possibility of 
allocating an O-7 billet to the Nurse Corps to ensure that the Corps 
Chief is afforded the opportunity to properly transition to the rank of 
Major General?
    Answer. Force developing our colonels and considering only those 
colonels with 26-29 years of service provides a more seasoned senior 
officer and decreases the potential for transition challenges. However, 
we would certainly welcome the opportunity for another pinnacle 
position for Nurse Corps force development and transition to the second 
star.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

               RECRUITMENT OF MENTAL HEALTH PROFESSIONALS

    Question. DOD has a critical shortage of mental healthcare 
professionals. During review of the Fort Hood incident where the 
alleged gunman, Major Hasad, U.S. Army psychologist, is charged with 
the deaths of 13 victims, reports show discrepancies in documentation 
and counseling as it related to his professional abilities and 
behavior. Suggestions were made that he was kept on active duty with no 
negative reprimands because he had diversity as a Muslim to our 
nation's service despite his failure to perform.
    What is DOD doing to recruit more mental health workers and to 
ensure they are quality healthcare professionals? What are the 
roadblocks to meeting the shortage of mental health professional?
    Answer. We are currently assessing new and emerging mental health 
requirements and determining the best mix and number of mental health 
providers required to meet future needs. As recruiting fully qualified 
psychologists, psychiatrists and mental health nurses remains 
challenging, the Air Force has focused on developing our own pool of 
mental health professionals. In addition to highly regarded social 
worker, psychology and psychiatry residencies, we are proposing to 
establish a mental health nurse training program at Travis Air Force 
Base, California. Additionally, the Air Force has consolidated our 
special pay programs to optimize accession and retention incentives.
    Question. What is being done to reduce the stigma and provide 
enough care givers so Airmen and their families do not suffer in 
silence?
    Answer. The effort to reduce stigma has been part of the suicide 
prevention program since the program's inception in 1997. We have 
shown, and spread the word, that 95 percent of patients self-referring 
to mental health treatment experience no adverse impact on career or 
military status such as occupational restrictions or discharge actions 
based on fitness for duty or security concerns. The numbers of mental 
health visits have increased steadily over the last 5 years, suggesting 
a greater willingness for individuals to seek care.
    In addition, the Air Force has leveraged several resources for non-
medical counseling in order to decrease stigma and ease an Airman's 
access into less formal counseling settings. Examples include:
  --Airman and Family Readiness Centers across the Air Force use 
        Military Family Life Counselors, who can see individuals or 
        couples with ``mild'' problems without the need to document or 
        come in to a clinic.
  --TRICARE Assistance Program is a pilot project of online counseling 
        available to adult family members and Airmen.
  --Military OneSource counselors are available for non-medical 
        counseling by self-referral through a toll-free number, also 
        without medical documentation.
  --In a growing number of Air Force Medical Treatment Facilities, 
        mental health providers are available in primary care to see 
        patients who may not otherwise seek mental healthcare or for 
        those with minor problems such as sleep difficulties which may 
        not require formal mental healthcare.
    Question. How is Air Force medicine integrated into the suicide 
prevention programs to ensure mental health services are getting to 
those who need it before it's too late?
    Answer. The Air Force Suicide Prevention Program Manager falls 
under the Surgeon General's office ensuring full engagement of the 
medical resources in preventing suicide within the service.
    The Air Force has integrated behavioral health providers within our 
primary care clinics, allowing our members to access initial mental 
health services without a separate appointment in a mental health 
clinic. For many Airmen these initial behavioral health interventions 
within primary care may be sufficient to address their needs. For 
others who may require more sustained treatment, initial contacts 
within primary care serve to ease their concerns and facilitate the 
transition to traditional mental healthcare.
    When a suicide does occur, medical providers review all care 
provided to the individual to look for potential improvements in the 
Air Force medical system that may prevent similar incidents in the 
future.
    Within our primary care system our Airmen complete annual personal 
health assessments, in addition to health assessments triggered by 
deployments. The assessments provide an opportunity for our medical 
providers to identify possible mental health concerns and risk for 
suicide and refer to mental health services as necessary.

                            CERVICAL CANCER

    Question. Cervical Cancer is preventable. In 2009 over 11,000 
American women were expected to be diagnosed with cervical cancer and 
over 4,000 women were expected to die from the disease. More than one-
half of women who die from cervical cancer have never been screened or 
have not been screened in the past 5 years.
    Human Papillomavirus (HPV) testing is an approved and widely 
accepted test to search for cells that have the potential of turning 
cancerous. Research has proven that when performed together with 
cytology screening, it increases detection of abnormal cell changes by 
30 percent. National medical organizations and insurance companies have 
determined screening of HPV testing and cytology screening at the same 
time as the standard of care, however TRICARE has deemed HPV testing 
authorized only after a negative cytology exam.
    What is Air Force medicine doing to ensure its female patients are 
receiving the highest quality of cervical cancer screening available?
    What is the percentage of female patients who receive current 
standards of screening within the required timeframes?
    Are HPV tests available at all Air Force military treatment 
facilities?
    What is Air Force medicine doing to increase prevention efforts of 
their female patients from developing cervical cancer?
    Answers: Just to clarify TRICARE does cover the assessment of women 
with Atypical Squamous Cells of Undetermined Significance cells 
detected upon initial pap smear (Source: ``Tricare Policy Manual 
Pathology and Laboratory Chapter 6 Section 1.1. E. Human Papillomavirus 
testing'' (CPT1 procedure codes 87620-87622)). TRICARE states that 
human papillomavirus (HPV) testing is authorized after a positive 
cytology exam.
    As of December 2009, 81.99 percent of women 24-64 years old 
(continuously enrolled in a military treatment facility (MTF)) have 
completed cervical cancer screening in accordance with Healthcare 
Effectiveness Data and Information Set methodology and the minimum 
screening recommendations from the American Academy of Family 
Physicians and the U.S. Preventive Services Task Force. The National 
Committee for Quality Assurance median score is 82 percent. The U.S. 
Preventive Services Task Force (USPSTF) concludes that the evidence is 
insufficient to recommend for or against the routine use of HPV testing 
as a primary screening test for cervical cancer. Rationale: The USPSTF 
found poor evidence to determine the benefits and potential harms of 
HPV screening as an adjunct or alternative to regular pap smear 
screening. Trials are underway that should soon clarify the role of HPV 
testing in cervical cancer screening.
    Cervical cancer screening is available at all Air Force medical 
treatment facilities and all Air Force medical facilities send 
specimens to Wilford Hall for routine screening. HPV testing 
capabilities includes Reflex HPV testing for specimens showing atypical 
cells, i.e., ``ASCUS PAP,'' and direct HPV testing of specimens when 
ordered by a provider.
    The Air Force Medical Service utilizes a multi-pronged approach for 
cervical cancer prevention. HPV vaccination is available to all 
eligible patients according to Food and Drug Administration guidelines. 
Health risk assessments (Web HA) are completed as part of the 
Preventive Health Assessment for Active Duty personnel. The tool 
identifies individuals at potential risk for sexually transmitted 
infections (e.g., HPV) and provides risk-reduction messaging ``alerts'' 
to patients and healthcare teams. Education and questionnaires on risk 
factors are addressed during routine clinical visits for all patients. 
Cervical cancer screening is a focus metric of Air Force Surgeon 
General Executive Global Look. Cervical cancer screening surveillance/
outreach is provided with use of the Military Health System Population 
Health Portal and provides MTFs provider level reports for cervical 
cancer screening rates and women overdue. MTFs are able to use this 
data to encourage patients to remain current on screening guidelines. 
Cervical cancer screening with availability of HPV testing is available 
at all MTFs.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

                        MENTAL HEALTH AWARENESS

    Question. The Army has partnered with the National Institutes of 
Mental Health (NIMH) to conduct long-term study of risk and protective 
factors to inform health promotion and suicide prevention efforts in 
late 2008.
    What is the Air Force doing to promote mental health awareness?
    Answer. The Air Force has implemented wide-ranging efforts to 
promote mental health awareness and decrease stigma in our service. 
Many of these efforts have roots in our suicide prevention program, 
which was launched in 1996. At this time, we marshaled the capabilities 
of all our helping agencies, mental health, family advocacy, chaplains, 
family support centers and others within what we called an Integrated 
Delivery System (IDS). The goal continues to be to provide 
comprehensive efforts at the base level to meet the needs of our 
communities. Our suicide prevention program created a way for these IDS 
members to get into our units and talk about issues that stress the 
force. By bringing these discussions to the units and focusing 
community efforts in reducing stressors we enhanced awareness of these 
issues. We integrated suicide prevention within our professional 
military education to help leaders understand the mental health factors 
that may contribute and leaders' roles in addressing these. We have 
continued to build on these efforts with our personal health 
assessments, which regularly ask our Airmen about potential mental 
health needs, and we review responses that indicate risk and make 
appropriate referrals for care as necessary.
    The Air Force has published a Leaders' Guide for Managing Personnel 
in Distress, which provides straightforward guidance to supervisors and 
other leaders how to assist their subordinates in accessing the 
appropriate services. This tool helps leaders see their role in helping 
to manage the personal needs of their subordinates, and to discuss 
these issues in a productive manner.
    We have also developed specific programs for Airmen throughout 
their careers. The Air Force Landing Gear Program was designed to help 
Airmen cope with the stressors of deployment and redeployment. This 
program, which is currently being revised to encompass enhancing 
resilience for all our Airmen, has been complemented by the creation of 
Deployment Transition Programs to facilitate the smooth reintegration 
of our Airmen who have experienced the most stressful deployment 
experiences. Air Force leadership continues to explore new ways to 
ensure our Airmen understand that their mental health is as vital to 
the success of our mission as their physical health.
    Question. Is the Air Force conducting long-term studies similar to 
that of the Army and NIMH?
    Answer. The Air Force has been conducting research on suicide 
prevention for many years. When the Air Force initiated its 
comprehensive suicide prevention program in 1996, we partnered with the 
University of Rochester and Dr. Kerry Knox to carry out research on the 
effectiveness of these efforts. The first findings of this project were 
published in the British Medical Journal in 2003 and showed the 
effectiveness of our suicide prevention initiatives. The results 
demonstrated that our broad community-based efforts were not only 
associated with a 33 percent decrease in suicides, but also with 
decreases in a wide range of other problematic behaviors such as 
domestic violence, accidental death and homicide. This research led to 
the AF program being included in the Substance Abuse and Mental Health 
Services Administration's list of the only 10 Evidence Based Practices 
for the prevention of suicide.
    The Air Force suicide prevention program has continued this 
partnership with Dr. Knox, who has another study in press that will 
show continued compliance with the Air Force suicide prevention 
program, is associated with continued lower rates of suicide.
    The Air Force Suicide Prevention Program is also engaged in a 
number of other studies with researchers at the Uniformed Services 
University of the Health Sciences to examine case data on past 
suicides, including data collected through our Suicide Event 
Surveillance System, and the Department of Defense Suicide Event Report 
and Personal Health Assessment data to look for factors that may allow 
us to better identify those at risk for suicide. Recent efforts in this 
area have allowed us to identify career fields that appear to be at 
greater risk for suicide, allowing leadership to target additional 
prevention efforts at these groups.
    The Air Force has also been collecting data on new recruits 
entering the Air Force regarding their past behavioral history. This 
appears to show promise in allowing us to identify, from a recruit's 
earliest days in the Air Force, those Airmen who may be at higher risk 
for a variety of problems. The Air Force is now exploring ways to reach 
out to these Airmen to improve their ability to cope with the rigors of 
military life.
    Finally, the Air Force is in discussion with the Army and National 
Institutes of Mental Health to see how the Air Force may be able 
participate in this important study as it moves forward.

                      FAMILY READINESS AND SUPPORT

    Question. Family Readiness and support is crucial for the health of 
the Services. The health, mental health, and welfare of military 
families, especially the children, has been a concern on mine for many 
years. This also includes education, living conditions, and available 
healthcare.
    Are you meeting the increased demand for healthcare and mental 
health professionals to support these families? If not, where are the 
shortfalls?
    Answer. The Air Force has had an increase in utilization of mental 
health services over the past 5 years both at the military treatment 
facilities and through the TRICARE network. In response to this growing 
use of mental health services, Military and Family Life Consultants 
were added at the Airmen and Family Readiness Centers to provide 
additional non-medical counseling resources for Airmen and their 
families to address issues such as stress management and relationship 
issues. In addition, the Air Force added 97 clinical mental health 
billets to perform clinical duties under the Director of Psychological 
Health. The Air Force also has hired 32 full time Behavioral Health 
providers to embed in primary care clinics to facilitate mental health 
treatment in the primary care setting.
    Question. What improvements have been made with respect to the 
children of Airmen and meeting their special requirements?
    Answer. In fiscal year 2009, 1,926 Air Force families received 
Family Advocacy Strength-Based Therapy Service (FAST Service). FAST is 
a family maltreatment prevention service for families who do not have a 
maltreatment incident but have risk factors for domestic/child 
maltreatment. Also, the New Parent Support Program (NPSP) services 
focus on providing education and support to military families related 
to pregnancy, infant/toddler care, growth and development, and safety. 
Guidance in the areas of parenting, couple communication and conflict 
management are provided. Emphasis is placed on assisting families with 
young children to deal with military lifestyle challenges, with 
particular emphasis on support before, during and after deployment. The 
Air Force NPSP screened 13,766 military families for risk of child and/
or partner maltreatment in fiscal year 2009. During fiscal year 2008, 
13,561 families were screened. During 2009, 18,608 home visits by 
Registered Nurses and Medical Social Workers were provided to NPSP 
families, an increase from the 17,470 home visits provided during 
fiscal year 2008. Services are provided with the goal of preventing 
child and partner maltreatment. In 2009, 97 percent of families who 
were at high risk for family maltreatment and received home visitation 
services did not have a substantiated child maltreatment case in the 
year following closure.
    The Air Force Medical Operations Agency is in the process of 
standing up a cell to coordinate medical support to families with 
special needs across the Air Force. The Special Needs Cell will track 
families with special needs and focus on their medical support during 
permanent change of station moves.
    Question. What programs have you implemented to assist the children 
with coping with frequent deployments, re-integration, and other 
stresses of military families?
    Answer. Air Force Family Readiness Centers provide assistance to 
families before, during and after deployments. The programs include 
advice for parents on talking to their children about deployment and 
anticipating the concerns of children during deployment. The centers 
also provide video communication with deployed family members and other 
support services. The three Services have established the Uniformed 
Services Chapter of the American Academy of Pediatrics (AAP). Their 
website contains an entire section devoted to support of military 
families. The AAP Military Youth Deployment Support Website has been 
designed to support military youth, families, and the youth-serving 
professionals caring for this population (http://www.aap.org/sections/
uniformedservices/deployment/index.html). Videos, patient handouts, 
provider information, blogging website and many more resources are 
devoted to this area. There are many additional websites and services 
helpful to military families. A short list is provided below.
    Resources for Parents include the following Web Sites: Military 
OneSource, National Military Family Association, Military Homefront, 
Military Child Education Coalition, Zero to Three Organization, 
Hooh4Health, USA4militaryfamilies.org, and Stompproject.org.

                          WOUNDED WARRIOR CARE

    Question. In the recently released Department of Defense budget 
guidance, it states that ``caring for our wounded warriors is our 
highest priority: through improving health benefits, establishing 
centers of excellence, and wounded warrior initiatives.''
    What systems do you have to ensure the transition of wounded 
warriors from Department of Defense to the Department of Veterans 
Affairs is completed without unnecessary problems?
    Answer. The Air Force has created the Warrior and Survivor Care 
office which oversees the Air Force Survivor Assistance Program, the 
Air Force Recovery Coordination Program, and the Air Force Wounded 
Warrior program in order to maintain continual contact with the 
wounded, ill or injured Airman and his or her family throughout the 
entire recovery, rehabilitation, and reintegration process. 
Professional staff from these programs provides oversight during the 
member's transition to ensure the recovering service member receives 
all military and external agencies' benefits and entitlements. The Air 
Force Survivor Assistance Program (AFSAP) is designed to marshal all 
available resources in support of family needs when an Airman becomes 
seriously wounded, ill or injured, or when an Airman dies while on 
active duty.
    At the same time, the AFSAP also provides a systematic structure 
through which offers of assistance, information and support are made 
available on the family's terms. The Recovery Coordination Program was 
designed to address reforms to existing processes within the Department 
of Defense and the Department of Veterans Affairs (VA). It improves the 
uniformity and effectiveness of care, management and transition across 
the Military Departments, as well as transfers to VA Medical Centers, 
Polytrauma Rehabilitation Centers and civilian providers, through the 
use of standardized policies, processes, personnel programs and tools.
    The Air Force Wounded Warrior Program, through the base-level 
Airman and Family Readiness Centers, provide enhanced transition 
assistance services that include one-on-one pre-separation counseling, 
one-on-one VA benefits and Disabled Transition Assistance Program, and 
personal assistance in completing and submitting a VA disability claim. 
Approximately 70 percent of our Air Force Wounded Warrior Program 
participants suffer from post traumatic stress disorder or other mental 
health conditions. Many of them also have residual physical problems. 
We provide ongoing needs assessments pre and post separation to ensure 
they receive the benefits, entitlements and care they earned. An 
Information Sharing Initiative is being designed for the sole purpose 
of ensuring flawless transition and exchange of data between DOD 
entities and the VA. The DOD-mandated working group is in the early 
stages of requirements development, and will provide a significant 
improvement to the Air Forces tracking of wounded, ill, and injured 
service members. This will result in a refined and simplified 
transition with uninterrupted medical and non-medical care and support 
to our Airmen and their families.
    Question. What do you consider a successful transition and do you 
follow-up with the Service members to ensure there are no problems even 
after they have been released from Active Duty?
    Answer. We consider a successful transition when several factors 
converge to stabilize the wounded, ill or injured Airman and his or her 
family. This includes continuum of medical care for the member, with no 
interruptions in care, including continuation of medication; 
stabilization of family finances, to include receipt of Department of 
Veterans Affairs disability compensation, military retired pay if 
retired, or accurate severance pay, if separated. Awareness of benefits 
and entitlements, and timely and accurate receipt of those benefits 
plays a big role in the psychological health and perception of the 
member and his or her family.
    Transition is also considered successful when the member and family 
receive and act on the information provided to meet their personal 
goals, whether it is to continue working or pursue higher education. We 
believe that the most successful transitions start at the beginning of 
the Medical Evaluation Board process and continue through the 
transition process. The key factor is to keep the member and family 
informed of what to expect and to normalize their experiences as much 
as possible. Family integration into the transition process is an 
important ingredient for a successful transition.
    The Air Force Wounded Warrior Program staff is in continual contact 
with Airmen and their families during the entire process. During the 
transition process, the wounded warrior counselors coordinate all 
transition actions between the Air Force and the Department of Veterans 
Affairs, including disability compensation. Ongoing contacts with the 
member and family provide the counselors with needs reassessments to 
ensure all benefits and entitlements are on track even after discharge.

                           RESERVE COMPONENTS

    Question. The Reserves and particularly the National Guard have 
unique concerns while deployed. It would seem as though there are no 
near term plans to discontinue the use of our Reserve Component in Iraq 
and Afghanistan.
    How are you determining budget requirements to accommodate the 
Reserve Component as they need Department of Defense healthcare well 
into the future?
    Answer. Medical care for deployed personnel, to include Reserve 
Component members, is a joint effort, and the Total Force receives the 
full spectrum of care to ensure members remain healthy and resilient. 
As a part of the Joint Team, the Air Force contributes comprehensive 
medical capabilities at both home station and in the deployed 
environment. Defense Health Program budget requirements for the Air 
Force Medical Service are coordinated with and resourced by the TRICARE 
Management Activity. Key drivers for resourcing include population 
projections and expected workload. Healthcare workload attributed to 
Reserve Component members and dependents is accounted for by the Air 
Force Medical Service. In addition, the fiscal year 2010 President's 
budget and fiscal year 2011 President's budget requests provided 
additional resources for wounded, ill, and injured and other enduring 
healthcare requirements resulting from Overseas Contingency Operations.

                           MENTAL HEALTH CARE

    Question. General Casey recently stated the number of Army soldiers 
who feel there is a stigma for seeking mental healthcare has been 
reduced from 80 to 50 percent. This is a significant improvement, but 
there is more work to be done.
    Despite the reduced number of those who feel there is a stigma, are 
more service members coming forward to seek treatment?
    Answer. The Air Force believes that we have seen some success in 
efforts to decrease the stigma of seeking mental health services. 
Despite a slight decrease in the strength of our force since 2003 the 
Air Force has seen a steady increase in the utilization of our of 
uniformed mental health services. Since 2003 the number of active duty 
visits to our mental health clinics has increased from 226,000 visits 
to over 300,000 visits annually. While some of these visits may be 
associated with screenings for activities such as deployments and 
security or special duty clearances, the overall trend indicates a 
greater willingness in our Airmen to seek mental healthcare within our 
system.
    Question. What actions are the Services taking to continue to 
reduce the stigma and encourage Service members to seek treatment?
    Answer. Major steps the Air Force has taken include:
    Actively working to decrease stigma through statements from senior 
leaders encouraging all Airmen to seek help when needed and through 
efforts to counter myths related to mental health treatment within the 
Air Force. As part of the annual suicide prevention training, Airmen 
are presented with data showing that the vast majority of those who 
self-refer to mental health experience no adverse outcome and their 
confidentiality is maintained. This is presented to encourage Airmen to 
seek help early before stress or mental health problems increase to the 
point that a command directed referral maybe necessary.
    Conducting an annual ``Wingman Day'' at each base. These activities 
focus on the role all Airmen play in being a Wingman, that is, caring 
for their fellow Airmen. Wingman day is an opportunity to review the 
importance of teamwork and helping fellow Airmen perform their best. 
This includes helping Airmen realize when they may need help and 
facilitating access to that care.
    Integrating behavioral health providers within our primary care 
clinics, allowing our members to access initial mental health services 
without a separate appointment in a mental health clinic. For many 
Airmen, these initial behavioral health interventions within primary 
care may be sufficient to address their needs. For others who may 
require more sustained treatment, initial contacts within primary care 
serve to ease their concerns and facilitate the transition to 
traditional mental healthcare.
    Publishing a Leaders' Guide for Managing Personnel in Distress 
provides straightforward guidance to supervisors and other leaders on 
how to assist their subordinates in accessing the appropriate services.
    Establishing Directors of Psychological Health at each base to 
serve as a consultant to leaders at the base level in addressing the 
mental health needs present in the community.
    Establishing policy to provide greater confidentiality to those 
Airmen under investigation who are also at risk for suicide. This 
limited privilege suicide prevention program ensures Airmen under 
investigation and deemed to be at risk for suicide are protected from 
information shared in the context of their mental health treatment 
being used against them in court or in the characterization of 
discharge.
    Question. Does your plan include the mental health of families, and 
if so what is that plan?
    Answer. The mental health of families is of significant concern to 
the Air Force as family support is essential for effective functioning 
of our service members. In response to this need for family services, 
the Air Force added Military and Family Life Consultants at the Airmen 
and Family Readiness Centers to provide additional non-medical 
counseling resources for Airmen and their families to address issues 
such as stress management and relationship issues.
    In addition, the Air Force added 97 clinical mental health billets 
to perform clinical duties under the Director of Psychological Health 
allowing increased access to care services at the military treatment 
facilities. The Air Force has also hired 32 full-time behavioral health 
providers to embed in primary care clinics to facilitate mental health 
treatment in the primary care setting. In addition to traditional 
mental health clinic services, the Air Force Family Advocacy program 
offers Family Advocacy Strength-Based Therapy Service (FAST Service). 
FAST is a family maltreatment prevention service for families who do 
not have a maltreatment incident but have risk factors for domestic/
child maltreatment. Also in Family Advocacy, the New Parent Support 
Program services focus on providing education and support to military 
families related to pregnancy, infant/toddler care, growth and 
development, and safety.
    Guidance is provided in the areas of parenting, couple 
communication and conflict management. Emphasis is placed on assisting 
families with young children to deal with military life-style 
challenges, with particular emphasis on support before, during and 
after deployment. Military One Source and the Web-based TRICARE 
Assistance Program are also available for families to utilize for 
support.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

              JOINT VENTURE KEESLER-BILOXI MEDICAL SYSTEM

    Question. General Green, the Department of Defense and the 
Department of Veterans Affairs are establishing joint ventures in 
hospitals that are co-located around the country, in hopes to achieve 
efficiencies with combined personnel and shared resources, thus 
eliminating duplication. Currently, as you know, the Navy and the VA 
are working on a joint venture in North Chicago, where the plan is to 
operate the facility with a single civilian staff under the VA, 
operating out of one combined facility.
    The Air Force and the VA are also working toward a joint-venture 
between Keesler and Biloxi, but have adopted a different model than the 
North Chicago model. I understand the Air Force has stated that not 
every joint venture will be applicable to every location, and thus the 
Air Force is not inclined to follow the North Chicago model. One of 
these reasons might be due to the different mission focus between the 
two locales. For example, the North Chicago facility supports mostly 
non-deployable personnel (Navy recruits) and serves as a schoolhouse 
for medical trainees. In Keesler, many of the medical Airmen deploy in 
their respective Air Expeditionary Force rotations (AEF) and for 
humanitarian missions, as needed.
    General, can you please give your thoughts on the other reasons as 
to why the current model at Keesler-Biloxi has been so successful and 
why it is the best model for the Gulf Coast region? Also, are there 
other Air Force-VA joint venture locations where you think this model 
is more applicable to improve treatment efficiency and provide quality 
care?
    Answer. The joint venture between the 81st Medical Group, Keesler 
AFB, Mississippi, and the Gulf Coast Veteran Affairs Health Care 
System, Biloxi, Mississippi, is relatively new and not yet complete, so 
assessing their successes at this time is difficult. However, despite 
the fact they are still in the process of integrating and moving some 
services, their centers of excellence model is already showing signs of 
success. Success for this joint venture, as well as any other joint 
venture model, is largely based on a willingness to work together to 
ensure the organization keeps the patient's needs as priority one. 
Communication and commitment to success is essential at all levels of 
the organization, especially with senior leadership. This commitment is 
very obvious at the Keesler/Biloxi joint venture as the leaders from 
both sites are very involved in the operation of the joint venture. 
Another key factor to success is a commitment to provide services for 
the other partner that they need for their patient population in the 
facility vice sending them out to the network--this is true for all 
partners in the joint venture. An excellent example is the Department 
of Veterans Affairs providing inpatient mental health services for 
Department of Defense beneficiaries, and Department of Defense 
providing women's health services for Department of Veterans Affairs' 
beneficiaries.
                                 ______
                                 
            Question Submitted by Senator Robert F. Bennett

                           CHIROPRACTIC CARE

    Question. I'm pleased that TRICARE has worked over the past few 
years to expand chiropractic care for service members. Indeed, I have 
heard one of the top complaints of returning soldiers has been the type 
of neck and back pain chiropractic care would seemingly address. 
Unfortunately, our servicemen and women from Utah (particularly Hill 
AFB) are not able to receive this beneficial service that they have 
been promised because of the lack of approved providers.
    Shouldn't all soldiers have an opportunity to receive promised 
care? What alternatives for chiropractic care are available to airmen 
and soldiers, such as allowing them to receive private care, the cost 
of which would be reimbursed for those who are not within 50 miles of 
such a center, or are unable to be seen within 30 days?
    Answer. The Chiropractic Health Care Program is available to Active 
Duty service members (including activated National Guard and Reserve 
members) at designated military treatment facilities (MTFs) throughout 
the United States. This program is currently offered at 60 designated 
MTFs throughout the United States. There is currently no expansion set 
for 2010. The Department of Defense considers this program fully 
implemented, however, if directed to expand by Congress, the Air Force 
would certainly consider places such as Hill AFB, Utah.
    Alternatives to chiropractic care are non-chiropractic healthcare 
services in the Military Health System (e.g., physical therapy or 
orthopedics), referred care when care not available in a timely fashion 
at the MTF, or to seek chiropractic care in the local community at 
their own expense. Chiropractic care received outside of the designated 
locations is not covered under the Chiropractic Health Care Program. 
Major Air Force locations offering chiropractic care are listed below:

Andrews Air Force Base
Barksdale Air Force Base
Davis-Monthan Air Force Base
Eglin Air Force Base
Elmendorf Air Force Base
Hurlburt Field
Keesler Air Force Base
Kirtland Air Force Base
Lackland Air Force Base
Langley Air Force Base
Luke Air Force Base
MacDill Air Force Base
Maxwell Air Force Base
McGuire Air Force Base
Offutt Air Force Base
Scott Air Force Base
Tinker Air Force Base
Travis Air Force Base
U.S. Air Force Academy
Wright Patterson Air Force Base
                                 ______
                                 
           Questions Submitted to Rear Admiral Karen Flaherty
            Questions Submitted by Chairman Daniel K. Inouye

                      BEHAVIORAL HEALTH PROVIDERS

    Question. Admiral Flaherty, what innovative, multidisciplinary 
efforts has the Navy implemented to increase access to behavioral 
health providers?
    Answer. Increasing access to care for Behavioral Health remains a 
top priority for Navy Medicine. Prior ``innovations'' that have now 
become the norm include operationally embedded mental health providers, 
integration of Mental Health Care into primary care, Psychological 
Health Outreach Coordinators and use of our Deployment Health Centers 
as destigmatizing portals of care. Current innovation efforts are 
focusing on the use of intensive, outpatient, multidisciplinary group 
sessions for the treatment of Post Traumatic Stress Disorder (PTSD) and 
combat related mental health issues. One example of this type of 
innovative program is the ``Back on Track'' program at Naval Hospital 
Camp Lejeune. This 2 week program is built on the foundation of our 
Operational Stress Control (OSC) curriculum and outcome measures from 
the program are demonstrating statistically significant decreases in 
depression symptoms. Another innovative program is the 
multidisciplinary team assessment of every patient that is medically 
evacuated from theater to identify potential cognitive and mental 
health issues. Access is increased in a non-stigmatizing manner by 
providing this assessment to all patients without need for consult or 
self-referral. Follow on care is provided as indicated utilizing all 
members of the multidisciplinary team.

                DEPARTMENT-WIDE NURSE RESIDENCY PROGRAM

    Question. Admiral Flaherty, I understand that the civilian nursing 
community has established nurse residency programs in order to better 
prepare new graduates and novice nurses to care for more complex 
patients. I am also aware that each military service has implemented 
similar nurse intern and transition programs. Has there been any 
consideration on the development of a Department wide Nurse Residency 
Program?
    Answer. The Navy Nurse Corps has Nurse Intern Programs designed to 
mentor and train new graduates at our three largest medical centers 
(Naval Medical Center Portsmouth, Naval Medical Center San Diego, and 
the National Naval Medical Center) and at Naval Hospital Jacksonville. 
These programs are designed to orient recent graduate and registered 
nurses with limited clinical experience to the role of professional 
nursing. Training consists of classroom lectures, simulation lab, 
seminars, and hands on clinical experience. Classroom subject matter 
includes physical assessment, pathophysiology, diagnosis, nursing 
interventions, and general military training. Participants have direct 
patient care contact in the hospital setting. As medical treatment 
facilities within DOD merge, I think it is wise for the services to 
compare core curriculum and outcomes of their programs and blend best 
practice into a standardized program across the Department of Defense, 
while allowing for local leeway of program specifics based on 
individual needs of the local facility.

                     NAVY NURSE CHALLENGES AT FHCC

    Question. Admiral Flaherty, what are the major challenges facing 
Navy nurses as we move to a joint medical facility with the VA in 
Chicago, Illinois and how are the two Departments coordinating efforts 
to eliminate them before this facility becomes operation in the fall of 
2010?
    Answer. The nursing leadership in both communities has held 
multiple joint meetings over the past 18 months to communicate 
information and ideas on issues surrounding the Veteran's 
Administration (VA)--Navy merge of the joint facility in Chicago, 
Illinois. Action items have focused on credentialing and privileging, 
the setting of nursing standards, and staff education and training. We 
are educating the VA about the skill set of Hospital Corpsman and have 
joined each other's Executive Committee of the Nursing Staff (ECONS), 
and are merging toward a joint committee. Last, we are merging the Plan 
for Provision of Nursing Care between the VA's plan while adding Navy 
specific components. We are excited about the future possibilities and 
look forward to sharing our success with others.

                    NAVY NURSE RECRUITING MECHANISMS

    Question. Admiral Flaherty, what are some of the best mechanisms 
that the Navy has instituted for recruitment and retention that might 
be beneficial for all services?
    Answer. Retaining Navy Nurses is one of my top priorities. Key 
efforts that have positively impacted retention include the Registered 
Nurse Incentive Specialty Pay (RN-ISP), a targeted bonus program for 
undermanned clinical nursing specialties and highly deployed Nurse 
Practitioners, graduate education programs through Duty Under 
Instruction (DUINS), and the Health Professions Loan Repayment Program 
(HPLRP) for baccalaureate nursing education, which assists nurses in 
reducing their student loan debt.
    The Navy Nurse Corps includes both uniformed and civilian 
professionals. In recent years, we have implemented two very exciting 
programs to incentivize our civilian nurses to work and stay working as 
Navy Nurses. Civilian nurses are now allowed to attend the 
Perioperative Nurse Training Program which will train them for a new 
career as Operating Room Nurses. We also introduced the Graduate 
Program for Federal Civilian Registered Nurses. This program provides 
opportunities for civilian nurses to obtain a graduate degree in 
nursing while receiving full pay and benefits of their permanent 
nursing position. Nurses selected for this program must have served at 
least 3 years in the Federal civilian service at a Navy Medicine 
activity prior to applying. While in graduate school they work a 
compressed work schedule while participating in full-time graduate 
education. We are confident that these two innovative programs will 
work to both recruit and incentivize civilian nurses to stay employed 
as Navy Nurses.

                 NAVY NURSE CORPS COLLABORATION WITH VA

    Question. Admiral Flaherty, has the Navy Nurse Corps engaged in any 
collaborative nursing research efforts with the Veteran's 
Administration?
    Answer. Yes, one of my Nurse Researchers, Captain Patricia Kelley, 
is the Principal Investigator on a study titled ``Clinical Knowledge 
Development: Continuity of Care for War Injured Service Member.'' The 
purpose of this research study is to gather first person accounts of 
how nurses learn to care for wounded service members along with service 
members' memories of their care. This study will obtain interviews from 
over 250 nurses and 50 injured service members at military hospitals 
and Veterans Administration Medical Centers. From this study we hope to 
expand the nurse's understanding of care for the wounded warrior. I am 
pleased to report that this study was funded by the TriService Nursing 
Research Program (TSNRP).
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

                        RESILIENCY IN THE FORCE

    Question. Admiral Flaherty, the Navy is in the process of 
``rebalancing'' the force to reduce battle fatigue from multiple 
deployments and give service members a chance to ``reset'' mentally and 
physically in a time of high operational tempo. Specific programs 
within the Navy include ``FIT'' for right-sizing the force and the 
Operational Stress Control Program.
    These programs require a great deal of support from medical units 
within each respective Service. The concern is that while implementing 
these programs, the high demand, low density medical career fields will 
remain stressed and unable to reset, as well.
    Admiral, can you please comment on if these programs have increased 
the demand on your nursing corps? Can you also comment on if these same 
programs are effective in helping medical personnel reset, also?
    Answer. The Navy's Operational Stress Control (OSC) program and the 
United States Marine Corps Combat Operational Stress Control (COSC) 
programs are line-owned and line-led programs. They focus on leader's 
responsibilities for building resilient Sailors, Marines, units, and 
facilities, mitigating the stigma association with seeking 
psychological healthcare, and promote early recognition of troublesome 
stress reactions before they develop into stress injuries or illness. 
Navy Medicine, to include the Navy Nurse Corps, plays a supporting 
role. Both programs are built on the time-proven leadership continuum 
and have formal curriculum being delivered at various points throughout 
a Sailor's or Marine's career. Navy Fleet and Family Support Centers 
and Marine Corps Community Services are contributing heavily to the 
Family OSC/COSC modules.
    Stress unique to our caregivers, such as compassion fatigue and 
burnout, requires a more dedicated approach. Navy Medicine has 
developed the Caregiver Occupational Stress Control (CgOSC) program 
with the core objectives of early recognition of caregivers in 
distress; breaking the code of silence related to occupational stress 
reactions and injuries, and engaging caregivers in early help as needed 
to maintain mission and personal readiness. The concept of 
``caregiver'' in this context refers to medical personnel (from 
corpsmen to physicians), clinically and non-clinically trained 
chaplains, religious program specialists, and family service 
professionals working within Navy Medicine. The Navy OSC, COSC and 
CgOSC programs actually enhance Navy Nurses as clinical leaders by 
leveraging a common framework for recognizing and responding to 
operational and occupational stress injuries. The increased demand by 
these programs on the Navy Nurse Corps is negligible because of the 
foundation of patient and staff education that is a core competency for 
all Navy Nurses. Anecdotally, we have seen our mid-grade nurses and 
Hospital Corpsmen rapidly integrate the principles of stress first-aid 
into their cores skills in a way that enhances their ability to address 
patient, family, and peer psychological distress. Their increased 
competency and skill used when providing complex and challenging care 
contributes to compassion satisfaction which buffers the adverse 
effects of compassion, fatigue and burnout.
                                 ______
                                 
       Questions Submitted to Major General Kimberly Siniscalchi
            Questions Submitted by Chairman Daniel K. Inouye

                    0-7 AIR FORCE NURSE CORPS BILLET

    Question. Major General Siniscalchi, how would the addition of a 0-
7 billet benefit the Air Force Nurse Corps?
    Answer. It would provide an additional force development 
opportunity for the Air Force Nurse Corps. However, all five Corps 
within the Air Force Medical Service have general officer billets for 
force development. An added star for the Nurse Corps should not be at 
the expense of another Corps.

                            NURSE RESILIENCY

    Question. Major General Siniscalchi, as nurses continue to deploy 
in support of service members world-wide, what efforts has the Nurse 
Corps made to ensure that we are also caring for our caregivers and 
instilling resiliency in our nurses?
    Answer. The Air Force has continued to monitor the well-being of 
all Airmen through multiple measures. Among these measures are our 
Post-Deployment Health Assessments (PDHAs) and Post-Deployment Health 
Reassessments (PDHRAs) administered following a deployment. Medical 
career groups (including nurses) are among the top three career groups 
for self-reported symptoms of post-traumatic stress on PDHA/PDHRA. Air 
Force leadership supported Lt. Gen. Green's plans to provide targeted, 
tiered Resiliency Training for higher-risk career groups including the 
formation of a Deployment Transition Center (DTC) in United States Air 
Forces in Europe. The DTC is a 2-day resiliency training and 
decompression stop on a deploying Airman's way home. Included in the 2-
day training are JET Airmen and other medics who participate in 
``outside-the-wire'' missions. In addition to the DTC, plans are 
underway for enhanced pre and post deployment resiliency training for 
these groups and targeted interventions for high risk groups, with 
enhanced small group or face to face training. Finally, medics at both 
Bagram and Balad have a high exposure rate to injury and death, and 
plans are to implement a resiliency program based on the mortuary 
affairs model at Dover Air Force Base, Delaware integrating physical, 
spiritual, social, and psychological resiliency across their 
deployment.

                   CIVILIAN NURSE TRANSITION PROGRAMS

    Question. Major General Siniscalchi, I understand that the Air 
Force has established collaborative agreements with several civilian 
nurse transitions programs. Has any consideration been given to 
partnering with the Army or Navy Transition programs?
    Answer. Consideration has been given; however, we have not 
``formally'' partnered with the Army or Navy nurse residency/transition 
programs. We have chartered a working group to evaluate our Air Force 
Nurse Transition Program platform and compare and contrast our program 
with the Army, Navy and civilian nurse residencies/transition programs. 
We have an ongoing study to evaluate the performance and effectiveness 
of our Nurse Transition Programs and to identify potential 
opportunities for Tri-Service nurse training consolidation efforts.

                         JOINT MEDICAL POLICIES

    Question. Major General Siniscalchi, as the military moves toward 
more joint medical treatment facilities among the tri-services and the 
Department of Veterans Affairs, do you see a future in merging Nurse 
Corps policies for governance, education, training, and the provision 
of nursing care?
    Answer. At those locations that have tri-service and Department of 
Veterans Affairs nursing, there are opportunities to establish tri-
service/Veterans Affairs nursing teams to collaborate efforts for 
governance, policy development, education and training and the plan for 
the provision of nursing care. It is, as always, important to note that 
patient care and advocating for the patient and their family remain a 
key nursing focus in whatever uniform or setting. There are many 
similarities in providing nursing care and the emphasis the Services 
place on the use of Professional Organization policies, education/
training and nursing care guidance is a key link to those similarities. 
Currently we have tri-service teams in Joint Task Force National 
Capital Region Medical which are working toward a collaborative 
approach in providing standardized orientation, education and training 
of our enlisted medics.

                         NURSE CORPS RETENTION

    Question. Major General Siniscalchi, despite well known shortages 
in the nursing profession, I see that all three corps expects to meet 
or exceed their recruiting goals this year. How does the Air Force plan 
to retain these nurses for follow on tours as the economy improves?
    Answer. For those nurses joining the Air Force due to the current 
economy, we are confident the reasons that made the Air Force an 
attractive option will also be the reasons they would continue to serve 
as the economy improves. Initial accessions for fiscal year 2010 
consistently speak in positive terms about the benefits of funded 
graduate education opportunities, professional and collegial 
relationships within the healthcare team, retirement pension, and 
continuity for seniority with assignment moves, opportunity for travel 
and the Air Force as great way of life for their families and children. 
As we look at retention of our current Air Force nurses, the number of 
nurses leaving the Air Force in 2009 was the lowest since 2002. 
Additionally, of the nurses who separate from the Air Force, over one-
half are separating to retire after reaching retirement eligibility. In 
2009, 59 percent of the nurses who left active duty did so after 
serving at least 20 years in uniform. With special pay programs such as 
the Nurse Corps Incentive Special Pay started in fiscal year 2009 to 
recognize advanced clinical and educational preparation, we hope to see 
an added benefit of increased retention.

                 AIR FORCE NURSING RESEARCH INITIATIVES

    Question. Major General Siniscalchi, what are some of the Air Force 
Nursing Research Initiatives that focus on the specific needs of combat 
veterans?
    Answer. Areas of research conducted by the U.S. military in 
Afghanistan and Iraq have led to advancements in combat casualty 
medical care and therapies to include tourniquet application, combat 
gauze, life-saving interventions, en-route care, resuscitation, blood 
product administration, burns, wound care, post traumatic stress 
disorder, traumatic brain injury and infectious diseases.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray

                       NURSE CORPS CONTRIBUTIONS

    Question. Nurses significantly contribute to the healthcare of our 
Service members and their families. It is important that we maintain 
appropriate levels of highly trained nurses capable of performing a 
wide range of healthcare functions.
    With the maintained high operations tempo of combat in Iraq and 
Afghanistan, and the increasing requirements for healthcare for the 
Service member and their families, are you able to maintain the 
required level of nurses?
    Answer. Recruiting fully qualified nurses continues to be a 
challenge. Historical and current statistics tell us this will be an 
issue for years to come. In fiscal year 2009, we accessed 284 nurses 
against our total accession goal of 350 (81 percent), down 12 percent 
from what I reported the previous year. Currently, the recruiting of 
novice nurses has been successful. At present our recruitment of novice 
nurses is at 166 percent of our projected fiscal year 2010 goal. While 
the recruitment of novice nurses is going well, the limiting factor is 
their depth of clinical experience. Our Nurse Transition Program 
advances the clinical skills of these new nurses through direct patient 
care under the supervision of seasoned nurse preceptors.
    Question. Are there enough nurses entering the military to ensure 
quality of care for the Service members and to maintain the legacy of 
superb leadership in the future?
    Answer. Recruiting fully qualified nurses continues to be a 
challenge. Historical and current statistics tell us this will be an 
issue for years to come. In fiscal year 2009, we accessed 284 nurses 
against our total accession goal of 350 (81 percent), down 12 percent 
from what I reported the previous year. Currently, the recruiting of 
novice nurses has been successful. At present our recruitment of novice 
nurses is at 166 percent of our projected fiscal year 2010 goal. While 
the recruitment of novice nurses is going well, the limiting factor is 
their depth of clinical experience. Our Nurse Transition Program 
advances the clinical skills of these new nurses through direct patient 
care under the supervision of seasoned nurse preceptors.
    Question. What are you doing to prepare nurses for senior 
leadership roles and responsibilities?
    Answer. We grow our future leaders through professional military 
education, encouraging certification in clinical specialties, advanced 
academic preparation and deliberate force development.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran

                        RESILIENCY OF THE FORCE

    Question. General Siniscalchi, the Air Force continues to 
``rebalance'' the force to reduce battle fatigue from multiple 
deployments and give service members a chance to ``reset'' mentally and 
physically in a time of high operational tempo.
    The Air Force continues to work toward Total Force Integration 
(TFI) to provide the best support possible in a variety of missions 
world-wide. Multiple deployments, however, do increase the mental and 
physical stress on the Airman, and many programs have been created in a 
short time to address these concerns.
    However, these programs require a great deal of support from 
medical units within each respective Service. The concern is that while 
implementing these programs, the high demand, low density medical 
career fields will remain stressed and unable to reset, as well.
    General Siniscalchi, can you please comment on if these programs 
have increased the demand on your nursing corps? Can you also comment 
on if these same programs are effective in helping medical personnel 
reset, also?
    Answer. At this time we have not experienced an increased demand on 
the Air Force Nurse Corps as a result of current programs. However, we 
will continue to assess requirements as new initiatives such as 
Deployment Transition Centers come to fruition.

                          SUBCOMMITTEE RECESS

    Chairman Inouye. Our next hearing of the Defense 
Appropriations Subcommittee will be on Wednesday, March 17, at 
10:30 a.m., and at that time we'll receive testimony from the 
Navy and Marine Corps.
    And we'll stand in recess.
    [Whereupon, at 12:18 p.m., Wednesday, March 10, the 
subcommittee was recessed, to reconvene at 10:30 a.m., 
Wednesday, March 17.]
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