[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.]