[Senate Hearing 112-]
[From the U.S. Government Publishing Office]
DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2012
----------
WEDNESDAY, APRIL 6, 2011
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:10 a.m., in room SD-192, Dirksen
Senate Office Building, Hon. Daniel K. Inouye (chairman)
presiding.
Present: Senators Inouye, Leahy, Mikulski, Cochran, and
Murkowski.
DEPARTMENT OF DEFENSE
Medical Health Programs
STATEMENT OF LIEUTENANT GENERAL ERIC B. SCHOOMAKER,
SURGEON GENERAL, DEPARTMENT OF THE ARMY
OPENING STATEMENT OF CHAIRMAN DANIEL K. INOUYE
Chairman Inouye. I would like to welcome all of you to this
special hearing.
There will be two panels this morning. First, we will hear
from the Surgeons General, Lieutenant General Eric B.
Schoomaker, Vice Admiral Adam Robinson, Jr., and Lieutenant
General Charles Green. Then we will hear from our Chiefs of the
Nurse Corps, Major General Patricia Horoho, Rear Admiral
Elizabeth Niemyer, and Major General Kimberly Siniscalchi.
I understand that this will be the last hearing for General
Schoomaker and Admiral Robinson, and I would like to thank both
of you for your dedicated service and wish you well in your
future endeavors.
General Green, I look forward to continuing our work to
ensure the future of our military medical programs and
personnel.
Every year, the subcommittee holds this hearing to discuss
the critically important issues related to the care and well-
being of our service members and their families. As such, the
Surgeons General and nurses have been called upon to share
their insight on medical issues that need improvement and areas
that are seeing continued success and progress.
The healthcare benefits we provide to our service members
and their families are one of the most basic benefits we can
provide to the men and women serving our Nation. It is also one
of the most important effective recruiting and retention tools
we have at our disposal.
The advancements military medicine has made over the last
several decades has not only dramatically improved medical care
on the battlefield, but also enhanced healthcare delivery and
scientific achievements throughout the aspects of medicine. The
result impacts millions of Americans who likely have no idea
that these improvements were initiated by the military.
While there has been significant success and momentum
advanced in modern medicine and the care we provide, there is
much more to be done. The Department of Defense must stay ahead
of the curve and remain vigilant to the ever-changing
healthcare needs of our forces and their families. Even in this
challenging fiscal environment, we must continue to provide the
resources required to maintain and grow the expertise needed to
stay at the forefront of military medicine.
Times have certainly changed since I was a soldier. For
instance, when I was injured in World War II, it took 9 hours
to evacuate me. Now the military's goal is to evacuate within
the so-called Golden Hour. In my regiment, for example, there
were no double amputee or traumatic brain injury survivors
because they died en route. Today, thanks to military medicine
advancements and helicopter and other transport devices, our
men and women in uniform survive these grave injuries.
Despite the great progress made by the military medical
community, more and more of our troops are suffering from
medical conditions that are much harder to identify and treat,
such as traumatic brain injury (TBI), post-traumatic stress,
and depression. I know that all of you here today are striving
to address these issues, and I applaud your efforts to place
more mental health providers throughout the medical facilities,
and especially within primary care offices. In addition, you
employ more of these specialists in theater to provide early
intervention and prevent further escalation.
Due to the prolific number of medical assistance efforts
being offered, there can be confusion on where to seek help. I
have heard many stories of service members who have six
different magnets on their refrigerators identifying a website
or a phone number for where to seek help. I believe it is
essential that we offer these services, both anonymously and
officially, but it can also be very difficult to navigate
through this maze of options that are available. It is my hope
that in your efforts to provide increased and advanced
services, that you work to consolidate these services and make
it easier for service members and their families to find the
help they need.
These are some of the issues we hope to discuss today. I
look forward to your testimony and note that your full
statements will be included in the record.
I wish to now call upon the vice chairman of this
subcommittee, Senator Cochran, for his opening statement.
STATEMENT OF SENATOR THAD COCHRAN
Senator Cochran. Mr. Chairman, thank you very much.
I am pleased to join you in welcoming this distinguished
panel of witnesses to our subcommittee today, the Surgeons
General of our military forces. We appreciate your
distinguished service, and thank you for your cooperation with
our subcommittee to assess and review the budget request for
the next fiscal year.
Thank you.
Chairman Inouye. All right. Thank you very much.
Our witnesses on the first panel are Lieutenant General
Eric B. Schoomaker, Surgeon General of the Army, Vice Admiral
Adam Robinson, Jr., Surgeon General of the Navy, and Lieutenant
General Charles B. Green, Surgeon General of the Air Force.
Surgeon General of the Army.
General Schoomaker. Thank you, sir.
Chairman Inouye, Vice Chairman Cochran, and distinguished
members of the subcommittee, thank you for providing me this
opportunity to talk with you about the dedicated men and women
of the United States Army Medical Department, who bring value
and inspire trust in Army medicine.
As you noted, Mr. Chairman, I am joined today by my Deputy
Surgeon General and our Chief of the Army Nurse Corps, Major
General Patty Horoho. Some of my staff have characterized this
as an awful Broadway production of ``Beauty and the Beast''.
Despite over 9 years of continuous armed conflict, every
day our soldiers and their families are kept from injuries,
illnesses, and combat wounds through our health promotion and
prevention measures, are treated in state-of-the-art fashion
when prevention fails, and supported by a talented medical
force, including those with a warrior on the battlefield.
Army medicine partners with our soldiers, their families,
our veterans, our fellow service members, and the interagency
to provide innovations in trauma care and preventive medicine.
We save lives and we improve the well-being of our warriors,
delivering the very best care at the right time and place.
Let me discuss our work through the lens of five Es:
Enduring, early, effective, efficient, and in an enterprise
fashion.
We have an enduring commitment through initiatives, such as
our Warrior Care and Transition Program and the soldier medical
readiness campaign plan. We have an enduring responsibility as
part of the military health system and with the Department of
Veterans Affairs to provide care and rehabilitation for our
wounded, ill, and injured for many, many years to come.
The United States Army's Warrior Transition Command, under
the leadership of Brigadier General Darryl Williams, is a key
part of the enduring provision of care and provides oversight
of the Army's Warrior Care and Transition Program. Since the
inception of these Warrior Transition Units in June 2007, more
than 40,000 wounded, ill, and injured soldiers and their
families have either progressed through or are now being cared
for by these dedicated caregivers. Over 16,000 of these
soldiers have rejoined the force, and the remainder remain--
have been returned to the community with dignity and respect.
The Soldier Medical Readiness Campaign helps to maintain a
healthy and resilient force. Major General Richard Stone, our
Deputy Surgeon General for Mobilization, Readiness, and Reserve
Affairs, leads that campaign. Among the campaign's tasks are
the--are to provide commanders with a tool to manage their
soldiers' medical requirements, identify those medically non-
ready soldiers, and reduce this population so that we can have
a fully fit and capable, ready Army. The end state is healthy
soldiers and increased medical readiness.
Those soldiers who no longer meet retention standards must
navigate the Physical Disability and Evaluation System.
Assigning disability has long been a contentious issue. The
Department of Defense and VA have jointly designed a new
Disability Evaluation System that integrates DOD and the
Veterans Administration (VA) processes with a goal of
expediting the delivery of VA benefits to service members. The
pilot of the new Integrated Disability Evaluation System, or
the IDES, began in November 2007 at Walter Reed. It is now in
16 medical treatment facilities, and it will be the DOD and VA
replacement for this Legacy Disability Evaluation System that
we have had for upwards of 60 years.
But even with this improvement, disability evaluation
remains complex and adversarial. Our soldiers still undergo
dual adjudication with the military rates only for unfitting
conditions and the VA rates for all service-connected
conditions. Dual adjudication is confusing to soldiers. It
leads to serious misperceptions about the Army's appreciation
of the wounded, ill, and injured soldiers' complete medical and
emotional situation. The IDES has not changed the fundamental
nature of the dual adjudication process. Under the leadership
of our Army Chief of Staff General George Casey and the Army G-
1, we continue to forge the consensus necessary for a
comprehensive reform of the Physical Disability and Evaluation
System, which the Army and DOD only determines fitness for duty
and the VA determines disability compensation.
Our second strategic aim is to reduce suffering, illness,
and injury through early prevention. Army Public Health
protects and improves the health of Army communities through
education, the promotion of healthy lifestyles, and disease and
injury prevention.
The health of the total Army is essential for readiness,
and prevention is the key to health. Examples of our practices
include the implementation of the Patient-Centered Medical Home
for Primary Care Delivery, something that we are doing in
concert with our fellow service members, led by the Air Force,
frankly, the Army's development and use of vaccines, and the
early advocation of management of battlefield concussion.
We lead in the recognition and treatment of mild traumatic
brain injury, or concussion, through what's called the educate,
train, treat, track strategy. Under the personal leadership of
the Vice Chief of the Army, General Pete Chiarelli, and refined
by Brigadier General Richard Thomas, our Assistant Surgeon
General for Force Projection, we have fielded a program that
has led to increased awareness and screening for traumatic
brain injury and decreased the stigma associated with seeking
early diagnosis and treatment.
This leads into the use of evidence-based practices aimed
at the most effective care. As an example, Army medicine now
strengthens our soldiers' and families' behavioral health and
emotional resiliency through a campaign to align the various
behavioral health programs with the deployment and reset cycle,
a process we call the Comprehensive Behavioral Health System of
Care. Under the leadership of the Deputy Surgeon General, Major
General Patty Horoho, this program uses multiple touch points
to assess both the health and behavioral health for a soldier
and the family. Coupled with the advances in battlefield care
under the Joint Theater Trauma System, we have made great
strides in managing the physical and emotional wounds of war.
Additionally, we have developed a comprehensive pain
management strategy to address chronic and acute pain that many
of our soldiers face. This strategy uses state-of-the-art
modalities and technologies. It focuses on the use of non-
medication pain management modalities, incorporating
complementary and alternative or integrative approaches, such
as acupuncture and massage therapy, yoga, and other tools. We
were recently recognized by the American Academy of Pain
Medicine with a Presidential commendation for the impact on
pain management in the United States.
Our fourth strategic aim is optimizing efficiencies through
leading-edge business practices, partnerships with our other
services and veterans organizations, to support the DOD and VA
collaboration on treating post-traumatic stress disorder, and
pain, and other healthcare issues, and electronic health
records should seamlessly transfer patient data between
partners to improve efficiencies, effectiveness, and the
continuity of care.
No two health organizations in the Nation share more non-
billable health information than the Department of Defense and
the Veterans Administration. The Departments continue to
standardize sharing activities and deliver information
technologies to improve the secure sharing of information.
Finally, our fifth aim is the Army enterprise approach. We
have reengineered Army medicine, such as the creation of a
provisional Public Health Command, to optimally serve the
soldier. We have aligned our regional medical commands with the
TRICARE regions, resulting in improved readiness and support
from the managed care support contractor to our regions. Three
standardized continental United States-based regional medical
commands are now aligned with the three TRICARE regions in the
continental United States.
We also have regional readiness cells now that can reach
out to our Reserve components within their areas of
responsibility, ensuring that all medical services required are
identified and provided at all times. Part of this
reorganization has been the standup of a public health command
under the command of Brigadier General Tim Adams. This
consolidation has already resulted in an increased focus on
prevention, health promotion, and wellness.
As you have noticed here, this is my last congressional
hearing cycle as the Army Surgeon General and the Commanding
General of the United States Army Medical Command. I thank the
subcommittee for allowing me to highlight the accomplishments
we have made, the challenges we continue to face, to hear your
perspectives regarding health of our extended military family
and the healthcare we provide. I have appreciated your
questions, your insights, and your commitment to our Army
soldiers and their families.
PREPARED STATEMENT
On behalf of the over 140,000 soldiers, civilians, and
contractors that make up my command in Army medicine, I also
thank Congress for your continued support and for providing the
resources that we have needed to deliver leading edge health
services and build healthy and resilient communities.
I welcome your questions.
Chairman Inouye. All right. Thank you very much, General
Schoomaker.
[The statement follows:]
Prepared Statement of Lieutenant General Eric B. Schoomaker
Chairman Inouye, Vice Chairman Cochran and distinguished members of
the committee. Thank you for providing me this opportunity to talk with
you today about some of the very important work being performed by the
dedicated men and women--military and civilian--of the U.S. Army
Medical Department (AMEDD) who bring value and inspire trust in Army
Medicine.
Now in my last congressional hearing cycle as the Army Surgeon
General and Commanding General, U.S. Army Medical Command (MEDCOM), I
would like to thank the committee for the opportunities provided over
the past 4 years that have allowed me to share what Army Medicine is,
to highlight the accomplishments we have made, to detail the challenges
we have faced, and to hear your collective perspectives regarding the
health of our extended Military Family and the military healthcare we
provide. On behalf of the over 70,000 dedicated Soldiers, civilians,
and contractors that make up Army Medicine, I also thank Congress for
your continued support of Army Medicine and the Military Health System,
providing the resources we need to deliver leading edge health services
to our Warriors, Families and Retirees.
Despite over 9 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 state-of-the-art
fashion when prevention fails; and are supported by an extraordinarily
talented medical force including those who serve at the side of the
Warrior on the battlefield.
Army Medicine is a dedicated member of the Military Health System
and is equally committed to partnering with our Soldiers, their
Families, and our Veterans to achieve the highest level of fitness and
health for each of our beneficiaries. Army Medicine historically is a
leader in developing innovations for trauma care and preventive
medicine that save lives and improve well-being for our uniformed
personnel, improvements which have also favorably influenced civilian
care. We are focused on delivering the best care at the right time and
place. Army Medicine operates using the following strategic aims--The
Five E's: Enduring, Early, Effective, Efficient, and Enterprise to
reflect our commitment to selfless service.
--To provide Enduring care through initiatives such as the Warrior
Care and Transition Program and the Soldier Medical Readiness
Campaign Plan.
--To reduce the need for subsequent care through Early prevention;
for example, Army Medicine identifies medical issues early with
its concussive protocols and behavioral health practices, and
promotes healthy lifestyles with the patient-centered medical
home model of primary care delivery.
--To use evidence-based practices which provide the most Effective
treatment for medical issues such as pain management and post-
traumatic stress (PTS).
--To optimize Efficiencies through leading edge business processes
and partnerships with other services and veterans
organizations.
--To be an integral part of the Army Enterprise approach through re-
engineering Army Medicine such as the provisional Public Health
Command (PHC) to keep the Army strong and with other Army
commands and agencies to optimally serve the Soldier and
Family.
We must continue to provide the very best ongoing care for wounded,
ill, or injured Soldiers. We have an enduring responsibility--alongside
our sister services and the Department of Veterans Affairs (VA)--to
provide care and rehabilitation of our wounded, ill, and injured for
many years to come. The U.S. Army Warrior Transition Command (WTC) is a
Major Subordinate Command under the MEDCOM and a key part of the
enduring provision of care. The WTC Commander, Brigadier General Darryl
Williams is also the Assistant Surgeon General for Warrior Care and
Transition. The WTC's mission is to provide centralized oversight of
the Army's Warrior Care and Transition Program. This includes providing
the necessary guidance and advocacy to empower wounded, ill, and
injured Soldiers and Families with dignity, respect, and the self-
determination to successfully reintegrate either back into the force or
into the community. The WTC supports Army Force Generation (ARFORGEN)
by supporting those who have returned from combat and require
coordinated, complex care management to help them cope with and
overcome the cumulative effects of war and multiple deployments.
At the heart of the Warrior Care and Transition Program are 29
Warrior Transition Units (WTUs) located at major Army installations
worldwide, and nine Community Based Warrior Transition Units (CBWTUs)
located regionally around the United States and Puerto Rico. Today,
4,280 highly trained cadre and staff oversee a current population of
10,011 wounded, ill and injured Soldiers. Since their inception in June
2007, more than 40,000 wounded, ill, or injured Soldiers and their
Families have either progressed through or are being currently cared
for by these dedicated caregivers and support personnel. Over 16,000 of
those Soldiers have been returned to the force.
The Army, with great support of Congress, has spent or obligated
more than $1.2 billion in military construction projects to improve the
accessibility and quality of Wounded Warrior barracks, including the
development of Warrior Transition complexes that will serve both
Warriors in Transition and their Families. Construction of complexes
continues through fiscal year 2012 at which time 20 state-of-the-art
complexes will be in operation.
Since 2004, the Army Wounded Warrior Program (AW2) has supported
the most severely wounded, ill, and injured Soldiers. Soldiers are
assigned an AW2 Advocate who provides personalized assistance with day-
to-day issues that confront healing Warriors and their Families,
including benefits counseling, educational opportunities, and financial
and career counseling. AW2 Advocates serve as life coaches to help
these wounded Warriors and their Families regain their independence.
Since its inception, AW2 has provided support to nearly 8,000 Soldiers
and Veterans.
The WTC is refining a policy change to enhance the Army's ability
to ensure Reserve Component Soldiers recovering at home from wounds,
illnesses, or injuries incurred while on Active Duty benefit from the
same system of care management and command and control experienced by
Soldiers who are recovering in WTUs. The revised policy makes it easier
for Reserve Component Soldiers who do not require complex medical care
management to heal and transition closer to home.
To support each wounded, ill, or injured Soldier in their efforts
to either return to the force or transition to Veteran status, the Army
has created a systematic approach called the Comprehensive Transition
Plan (CTP). The CTP is a six-part multidisciplinary and automated
process which enables every Warrior in Transition to develop an
individualized plan that will enable them to set and reach their
personal goals. These end goals shape the Warrior in Transition's day-
to-day work plan while healing.
Additionally to help Warriors in Transition achieve their physical
fitness goals, WTUs offer several adaptive sports options to supplement
the Warrior in Transition's therapy, often in coordination with the
U.S. Olympic Committee's Paralympic Military Program. The WTC is also
coordinating the Army's participation in the 2011 Warrior Games to be
held at the U.S. Olympic Training Center in Colorado Springs, Colorado
May 16-21, 2011.
We created a Soldier Medical Readiness Campaign to ensure we
maintain a healthy and resilient force. Major General Richard Stone,
Deputy Surgeon General, Mobilization, Readiness, and Reserve Affairs,
is the campaign lead. The deployment of healthy, resilient, and fit
Soldiers and increasing the medical readiness of the Army is the
desired end state of this campaign.
The campaign's key tasks are to provide Commanders the tools to
manage their Soldiers' medical requirements; coordinate, synchronize
and integrate wellness, injury prevention and human performance
optimization programs across the Army; identify the medically not ready
(MNR) Soldier population; implement medical management programs to
reduce the MNR Soldier population, assess the performance of the
campaign; and educate the force.
Those Soldiers who no longer meet retention standards must navigate
the Physical Disability Evaluation System (PDES). Assigning disability
has long been a contentious issue. The present disability system dates
back to the Career Compensation Act of 1949. Since its creation
problems have been identified include long delays, duplication in DOD
and VA processes, confusion among Service members, and distrust of
systems regarded as overly complex and adversarial. In response to
these concerns, DOD and VA jointly designed a new disability evaluation
system to streamline DOD processes, with the goal of also expediting
the delivery of VA benefits to service members following discharge from
service. The Army began pilot testing the Disability Evaluation System
(DES) in November 2007 at Walter Reed Army Medical Center and has since
expanded the program, now known as the Integrated Disability Evaluation
System (IDES), to 16 military treatment facilities. DOD is now planning
on replacing the military's legacy disability evaluation system with
the IDES.
The key features of the of the IDES are a single physical
disability examination conducted according to VA examination protocols,
a single disability rating evaluation prepared by the VA for use by
both Departments for their respective decisions, and delivery of
compensation and benefits upon transition to veteran status for members
of the Armed Forces being separated for medical reasons. The DOD PDES
working group continues to reform this process by identifying steps
that can be reduced or eliminated, ensuring the service members receive
all benefits and entitlements throughout the process.
The WTC is also working with U.S. Army Medical Command staff to
develop the concept of ``Medical Management Centers.'' Medical
Management Centers utilize the case management approaches developed for
the WTUs to assist Soldiers who remain in their units but require a
PDES determination. The WTC is also working closely with Army Reserve
and Army National Guard leadership to develop and provide necessary
support to the Reserve Component Soldier Medical Support Center
(RCSMSC) being established in Pinellas Park, Florida. The RCSMSC is
intended to ensure the PDES process also runs smoothly and efficiently
for Reserve Component Soldiers not on Active Duty or in WTUs.
Army Medicine strives to reduce the need for subsequent care
through early prevention and the emphasis on health promotion. Over the
past year Army medicine has initiated multiple programs in support of
this aim and I would like to highlight a few of those starting with the
new U.S. Army Public Health Command (Provisional) (PHC).
As part of the overall U.S. Army Medical Command reorganization
initiative, all major public health functions within the Army,
especially those of the former Veterinary Command and the Center for
Health Promotion and Preventive Medicine have been combined into a new
PHC, located at Aberdeen Proving Ground in Maryland, under the command
of Brigadier General Timothy K. Adams. The consolidation has already
resulted in an increased focus on health promotion and has created a
single accountable agent for public health and veterinary issues that
is proactive and focused on prevention, health promotion and wellness.
The PHC reached initial operational capability in October 2010 and full
operational capability is targeted for October 2011.
Army public health protects and improves the health of Army
communities through education, promotion of healthy lifestyles, and
disease and injury prevention. Public health efforts include
controlling infectious diseases, reducing injury rates, identifying
risk factors and interventions for behavioral health issues, and
ensuring safe food and drinking water on Army installations and in
deployed environments. The long-term value of public health efforts
cannot be overstated: public health advances in the past century have
been largely responsible for increasing human life spans by 25 years,
and the PHC will play a central role in the health of our Soldiers,
deployed or at home.
The health of the total Army is essential for readiness, and
prevention is the best way to health. Protecting Soldiers, retirees,
Family members and Department of Army civilians from conditions that
threaten their health is operationally sound, cost effective and better
for individual well-being. Though primary care of our sick and injured
will always be necessary, the demands will be reduced. Prevention--the
early identification and mitigation of health risks through
surveillance, education, training, and standardization of best public
health practices--is crucial to military success. Army Medicine is on
the pathway to realizing this proactive, preventive vision.
While the PHC itself is relatively new, a number of significant
public health accomplishments already have been achieved. Some
examples:
--Partnering with Army installations to standardize existing Army
Wellness Centers to preserve or improve health in our
beneficiary population. The centers focus on health assessment,
physical fitness, healthy nutrition, stress management, general
wellness education and tobacco education. They partner with
providers in our Military Treatment Facilities (MTFs) through a
referral system. I hold each MTF Commander responsible for the
health of the extended military community as the installation
Director of Health Services (DHS).
--Hiring installation Health Promotion Coordinators (HPCs) to assist
the MTF Commander/DHS and to facilitate health promotion
efforts on Army installations. HPCs are the ``air traffic
controllers'' or coordinators of services and identifiers of
service needs; they work with senior mission commanders and
installation Community Health Promotion Councils to synchronize
all of the installation health and wellness resources.
--Providing behavioral health epidemiological consultations to advise
Army leaders and program developers on the factors that
contribute to behavioral health issues including high-risk
behaviors, domestic violence and suicide.
--Identifying Soldier physical training programs that optimize
fitness while minimizing injuries and resultant lost-duty days
and improve Soldier medical readiness.
--Decreasing the rate of overweight and obese Family members and
retirees by adopting the Healthy Population 2010 goals for
weight and obesity and implementing a standardized weight-
management program developed by the VA.
--Integrating human and animal disease surveillance to better assess
health risks.
The Army recognizes that traumatic brain injury or TBI is a serious
concern, and we will continue to dedicate resources to research,
diagnose, treat and prevent mild, moderate, severe, and penetrating
TBI. The Army is leading the way in early recognition and treatment of
mild TBI or concussive injuries with our ``Educate, Train, Treat, and
Track'' strategy. Under the personal leadership of the Vice Chief of
Staff of the Army, General Peter Chiarelli and refined by Brigadier
General Richard Thomas, Assistant Surgeon General for Force Projection,
we are fielding a program which some have called ``CPR for the brain''.
Our education and training efforts have led to increased awareness and
screening for TBI and have contributed to decreasing the stigma
associated with seeking diagnosis or treatment for TBI. TBI training
has been integrated into education and training initiatives of all
deploying units to increase awareness and education regarding
recognition of symptoms as well as emphasize commanders and leaders'
responsibilities for ensuring their Soldiers receive prompt medical
attention as soon as possible after an injury.
DOD policy changes in June 2010 implemented mandatory event-driven
protocols following exposure to potentially concussive events in
deployed environments. Events mandating an evaluation include any
Service Member in a vehicle associated with a blast event, collision,
or rollover; all personnel within close proximity to a blast; or anyone
who sustains a direct blow to the head. Additionally, the command may
direct a medical evaluation for any suspected concussion under other
conditions. All new medics and Physician Assistants at the Army Medical
Department Center and School are being trained on their roles in
supporting this policy. During my recent visit to Afghanistan with my
fellow Surgeons General in February 2011, discussions with Warriors and
medical personnel at a number of sites lead me to conclude that these
protocols are aggressively endorsed by commanders and are being
complied with.
The Army along with the DOD is implementing computerized tracking
of these events for the purposes of providing healthcare providers with
awareness of an individuals' history of proximity to blast events,
allowing for greater visibility of at risk Soldiers during post-
deployment health assessment, informing Commanders, and to provide
documentation to support Line of Duty investigations for Reserve and
Guard members. The program from August to December 2010 has documented
1,472 Soldiers. We are working hard to overcome the technical barriers
for complete data input. My fellow Surgeons General and I saw this
first hand in our trip to Afghanistan last month. We saw, as well, the
complete commitment of all field commanders, small unit leaders, and
medical professionals to the implementation of these protocols.
To further the science of brain injury recovery, the Army relies on
the U.S. Army Medical Research and Materiel Command's TBI Research
Program. The overwhelming generosity of Congress and the DOD's
commitment to brain injury research has significantly improved our
knowledge of TBI in a rigorous scientific fashion. Currently, there are
almost 350 studies funded by DOD to look at all aspects of TBI. The
purpose of this program is to coordinate and manage relevant DOD
research efforts and programs for the prevention, detection, mitigation
and treatment of TBI. Some examples of the current research include
medical standards for protective equipment, measures of head impact/
blast exposure, a portable diagnostic tool for TBI that can be used in
the field, blood tests to detect TBI, medications for TBI treatment,
and the evaluation of rehabilitation outcomes. The TBI Research Program
leverages both DOD and civilian expertise by encouraging partnerships
to solve problems related to TBI. The DOD partners with key
organizations and national/international leaders, including the VA, the
Defense Centers of Excellence for Psychological Health and TBI, the
Defense and Veterans Brain Injury Center, academia, civilian hospitals
and the National Football League, to improve our ability to diagnose,
treat and care for those affected by TBI.
Similar to our approach to concussive injuries, Army Medicine
harvested the lessons of almost a decade of war and has approached the
strengthening of our Soldiers and Families' behavioral health and
emotional resiliency through a campaign plan to align the various
Behavioral Health programs with the human dimension of the ARFORGEN
cycle, a process we call the Comprehensive Behavioral Health System of
Care (CBHSOC). This program is based on outcome studies that
demonstrate the profound value of using the system of multiple
touchpoints in assessing and coordinating health and behavioral health
for a Soldier and Family. The CBHSOC creates an integrated,
coordinated, and synchronized behavioral health service delivery system
that will support the total force through all ARFORGEN phases by
providing full spectrum behavioral healthcare. We leveraged experiences
and outcome studies on deploying, caring for Soldiers in combat, and
redeploying these Soldiers in large unit movements to build the CBHSOC.
Some have been published, such as the landmark studies on concussive
brain injury and PTSD by Charles Hoge, Carl Castro and colleagues or
the recent publication of a forerunner program to the CBHSOC in the 3rd
Infantry Division by Chris Warner, Ned Appenzeller and their co-
workers. These studies will be discussed further later.
The CBHSOC is a system of systems built around the need to support
an Army engaged in repeated deployments--often into intense combat--
which then returns to home station to restore, reset the formation, and
re-establish family and community bonds. The intent is to optimize care
and maximize limited behavioral health resources to ensure the highest
quality of care to Soldiers and Families, through a multi-year campaign
plan.
Under the leadership of Major General Patricia Horoho, the Deputy
Surgeon General, the CBHSOC campaign plan has five lines of effort:
Standardize Behavioral Health Support Requirements; Synchronize
Behavioral Health Programs; Standardize & Resource AMEDD Behavioral
Health Support; Access the Effectiveness of the CBHSOC; and Strategic
Communications. The CBHSOC campaign plan was published in September
2010, marking the official beginning of incremental expansion across
Army installations and the Medical Command. Expansion will be phased,
based on the redeployment of Army units, evaluation of programs, and
determining the most appropriate programs for our Soldiers and their
Families.
Near-term goals of the CBHSOC are implementation of routine
behavioral health screening points across ARFORGEN and standardization
of screening instruments. Goals also include increased coordination
with both internal Army programs like Comprehensive Soldier Fitness,
Army Substance Abuse Program, and Military Family Life Consultants.
External resources include VA, local and state agencies, and the
Defense Centers of Excellence for Psychological Health.
Long-term goals of the CBHSOC are the protection and restoration of
the psychological health of our Soldiers and Families and the
prevention of adverse psychological and social outcomes like Family
violence, DUIs, drug and alcohol addiction, and suicide. This is
through the development of a common behavioral health data system;
development and implementation of surveillance and data tracking
capabilities to coordinate behavioral health clinical efforts; full
synchronization of Tele-behavioral health activities; complete
integration of the Reserve Components; and the inclusion of other Army
Medicine efforts including TBI, patient centered medical home, and pain
management. Integral to the success of the CBHSOC is the continuous
evaluation of programs, to be conducted by the PHC.
For those who do suffer from PTSD, Army Medicine has made
significant gains in the treatment and management of PTSD as well. The
DOD and VA jointly developed the three evidenced based Clinical
Practice Guidelines for the treatment of PTSD, on which nearly 2,000
behavioral health providers have received training. This training is
synchronized with the re-deployment cycles of U.S. Army Brigade Combat
Teams, ensuring that providers operating from MTFs that support the
Brigade Combat Teams are trained and certified to deliver quality
behavioral healthcare to Soldiers exposed to the most intense combat
levels. In addition, the U.S. Army Medical Department Center & School,
under the leadership of Major General David Rubenstein, collaborates
closely with civilian experts in PTSD treatment to validate the content
of these training products to ensure the information incorporates
emerging scientific discoveries about PTSD and the most effective
treatments.
Work by the Army Medical Department and the Military Health System
over the past 8 years has taught us to link information gathering and
care coordination for any one Soldier or Family across the continuum of
this cycle. Our Behavioral Health specialists tell us that the best
predictor of future behavior is past behavior, and through the CBHSOC
we strive to link the management of issues which Soldiers carry into
their deployment with care providers and a plan down-range and the same
in reverse.
As mentioned previously, the results of a recent Army study
published in January in the American Journal of Psychiatry by Major
Chris Warner, Colonel Ned Appenzeller and colleagues report on the
success of pre-deployment mental health support and coordination of
care that dramatically reduced adverse behavioral health outcomes for
over 10,000 Soldiers who received pre-deployment support prior to
deployment compared to a like group of over 10,000 Soldiers who were
deployed to the same battle space but were unable to receive the pre-
deployment behavioral health assessment and care coordination. These
results show the Army, as part of its Comprehensive Behavioral Health
System of Care Campaign Plan, is moving in the right direction
implementing new policies and programs to enhance pre- and post-
deployment care coordination for Soldiers. This study demonstrates the
ability to bridge the gap between identification through pre-deployment
screening, as required by the National Defense Authorization Act for
Fiscal Year 2010, Sec. 708 and actively managing and coordinating care
for Soldiers with existing behavior health concerns to insure a
successful deployment that benefits the Army and continued support to
Soldiers and Families.
The results are significant and provide the first direct evidence
that a program that combines pre-deployment support and coordination of
care that includes primary care managers, unit surgeons and behavioral
health providers is effective in preventing adverse behavioral health
outcomes for Soldiers. The study results move away from a perception of
use of mental health screenings by Army and DOD as a tool to ``weed
out'' Soldiers and service members deemed mentally unfit, to one of use
and integration of behavioral health screenings as a routine part of
Soldiers' and service members primary care during deployment. Coupled
with insights provided by Walter Reed Army Institute of Research
(WRAIR) researchers, such as Dr. Charles Hoge and COL Carl Castro about
the relationship between concussive injury and PTSD as well as 7 years
of annual surveys of BH problems and care in the deployed force through
the WRAIR Mental Health Advisory Teams, we are making giants steps
forward in prevention, early recognition, and mitigation of the
neuropsychological effects of prolonged war on our Soldiers and
Families.
Much of the future of Army Medicine will be practiced at the
Patient-Centered Medical Home (PCMH). The PCMH is a model of primary
care-based health improvement and healthcare services being adopted
throughout the Military Health System and in many venues in civilian
practice. I commend the Air Force for taking the lead on some PCMH
practices. The PCMH will be the principal enabler to improve readiness
of the force and continuity of access to tailored patient services. It
is a design that the Army will apply to all primary care settings.
Dr. Paul Grundy, Director of Healthcare Transformation at IBM,
pointed out that ``a smarter health system forges partnerships in order
to deliver better care, predict and prevent disease and empower
individuals to make smarter choices.'' In his estimation, the PCMH is
``advanced primary care.'' According to Dr. Grundy the PCMH can build
trust between patient and physician, improve the patient experience of
care, reduce staff burnout, and hold the line on expenditures.
The Medical Home philosophy concentrates on what a patient requires
to remain healthy, to restore optimal health, and when needed, to
receive tailored healthcare services. It relies upon building enduring
relationships between patient and their provider--doctor, nurse
practitioner, physician assistant and others--and a comprehensive and
coordinated approach to care between providers and community services.
This means much greater continuity of care, with patients seeing the
same physician or professional partner 95 percent of the time. The
result is more effective healthcare for both the provider and the
patient that is based on trust and rapport.
The PCMH integrates the patient into the healthcare team, offering
aggressive prevention and personalized intervention. Physicians will
not just evaluate their patients for disease to provide treatment, but
also to identify risk of disease, including genetic, behavioral,
environmental, or occupational risk. The healthcare team encourages
healthy lifestyle behaviors, and success will be measured by how
healthy they keep their patients, rather than by how many treatments
they provide. The goal is that people will live longer lives with less
morbidity, disability and suffering.
Community Based Medical Homes (CBMHs) are part of the Army's
implementation of the Patient Centered Medical Home. CBMHs are Army
operated primary care clinics located in leased space in the off-post
communities in which many of our active duty Families live. These
clinics are extensions of the Army Hospital and staffed by government
civilians. Active duty Family members receive enrollment priority. This
initiative was undertaken to improve access and continuity to
healthcare services, including behavioral health, for active duty
Family members by expanding capacity and extending MTF services off-
post. The Army has grown and consumption of healthcare services is on
the rise as a result of the war. These clinics will help Army Medicine
improve quality of care and the patient experience; improve value
through standardization and optimization of resources enabling
operations at an economic advantage to the DOD; and improve the
readiness of our Army and our Army Families. Clinics are placed where
Families lacked access to Army primary care services and currently 17
clinics are being developed in 13 markets. Recently clinics supporting
Fort Campbell, Fort Sill, Fort Stewart and Fort Bragg have opened and
initial feedback has been outstanding.
The CBMHs build upon and are in many ways the culmination of a
MEDCOM--wide campaign to closely monitor and reduce barriers to access
and continuity; improve clinic productivity through standardization of
administrative operations and support; to leverage improved health
information management tools like AHLTA; and to incentivize commanders
and providers to provide the right kind of care so as to improve
individual and community health and outcomes of healthcare delivery in
accordance with evidenced-based practices for chronic illness.
We are adopting other methods as well to ensure better outcomes for
patient care. At the MEDCOM, we have implemented a performance-based
adjustment model (PBAM) to increase hospital and department
responsibilities for how our funding is spent in health improvement and
the delivery of healthcare services. PBAM creates a justifiable budget
by a business planning process that links to outputs, such as volume or
complexity of procedures. With the need for greater accountability and
transparency, the MEDCOM has used PBAM to create performance measures
that are consistent and can be compared across our facilities. We have
experienced gains in total output, gains in provider efficiency, and
increases in coding accuracy all aimed at improved outcomes of care--a
more effective system for our beneficiaries and the Army. Incentives
which are built into the program have measurably improved health and
compliance with science--or--evidence-based care for chronic disease
like diabetes and asthma.
Army Medicine is committed to using evidence-based practices which
provide the most effective treatment for the variety of medical issues
confronting our patient population and especially those issues caused
by the almost 10 years of war such as pain management. An Army at war
for almost a decade recognizes it has accumulated significant issues
with acute and chronic pain amongst its Soldiers. In August 2009, I
chartered the Army Pain Management Task Force to make recommendations
for a MEDCOM comprehensive pain management strategy. I appointed
Brigadier General Richard Thomasas the Task Force Chairperson. Task
Force membership included a variety of medical specialties and
disciplines from the Army, as well as representatives from the Navy,
Air Force, TRICARE Management Activity, and VA.
The Pain Management Task Force developed 109 recommendations that
lead to a comprehensive pain management strategy that is holistic,
multidisciplinary, and multimodal in its approach, utilizes state of
the art/science modalities and technologies, and provides optimal
quality of life for Soldiers and other patients with acute and chronic
pain. The Army Medical Command is operationalizing recommendations
through the Pain Management Campaign Plan. I am proud to say that Army
Medicine was recognized by the American Academy of Pain Medicine with
the Presidential Commendation for its impact on pain medicine in the
United States.
An important objective of the Pain Management Task Force calls for
building a full spectrum of best practices for the continuum of pain
care, from acute to chronic, which is based on a foundation of the best
available evidence based medicine. This can be accomplished through the
adoption of an integrative and interdisciplinary approach to managing
pain. Pain management should be handled by integrated care teams that
use a biopsychosocial model of care. The standard of care should
decrease overreliance on medication driven solutions and create an
interdisciplinary approach that encourages collaboration among
providers from differing specialties.
The DOD should continue to responsibly explore safe and effective
use of advanced and non-traditional approaches to pain management and
support efforts to make these modalities covered benefits once they
prove safe, effective and cost efficient. One way to achieve an
interdisciplinary, multimodal and holistic approach to pain management
is by incorporating complementary and alternative therapies--
integrative approaches--into an individualized pain management plan of
care to include acupuncture, massage therapy, movement therapy, yoga,
and other tools in mind-body medicine. To best address the goal of
patient-centered care, providers must work in partnership with patients
and Families in providing health promotion options while maintaining
efficacy and safety standards. This integration needs to be methodical,
appropriate, and evaluated throughout the process to ensure the best
potential outcomes.
While the Pain Management Task Force has worked to expand the use
of non-medication pain management modalities, as combat operations
continue, more Soldiers are presenting with physical or psychological
conditions, or both, which require clinical care, including medication
therapy. Consequently, some of them may be treated for multiple
conditions with a variety of medications prescribed by several
healthcare providers. While the resulting ``polypharmacy''--the use of
multiple prescription or other medications--can be therapeutic in the
treatment of some conditions, in other cases it can unwittingly lead to
increased risk to patients. New Army policies and procedures to
identify and mitigate polypharmacy have reduced the risk of these
factors in garrison and deployed environments.
Polypharmacy is not unique to military medical practice and is also
a patient safety issue in the civilian medical community. The risks of
polypharmacy include overdose (intentional or accidental); toxic
interactions with other medications or alcohol; increased risk of
adverse effects of medications; unintended impairment of alertness or
functioning that may result in accident and injury; and the development
of tolerance, withdrawal, and addiction to potentially habit-forming
medications.
U.S. Army Medical Command has issued guidance for enhancing patient
safety and reducing risk via the prevention and management of
polypharmacy. For example, Soldiers and Commanders are educated to take
responsibility for, and active roles in, ensuring effective
communication between patients and primary care managers to formulate
treatment plans and address potential issues of polypharmacy. Annual
training on managing polypharmacy patients is required for clinicians
who prescribe psychotropic agents or central nervous system
depressants. And through the electronic health record, patient health
information, including prescriptions, is shared among providers to
increase awareness of those patients with multiple medications.
Evidence-based science makes strong Soldiers and we rely heavily on
the U.S. Army Medical Research and Material Command (MRMC). Under the
leadership of Major General James Gilman, MRMC manages and executes a
robust, ongoing medical research program for the MEDCOM to support the
development of new healthcare strategies. I would like to highlight a
few research programs that are impacting health and care of our
Soldiers today.
The Combat Casualty Care Research Program (CCCRP) reduces the
mortality and morbidity resulting from injuries on the battlefield
through the development of new life-saving strategies, new surgical
techniques, biological and mechanical products, and the timely use of
remote physiological monitoring. The CCCRP focuses on leveraging
cutting-edge research and knowledge from government and civilian
research programs to fill existing and emerging gaps in combat casualty
care. This focus provides requirements-driven combat casualty care
medical solutions and products for injured Soldiers from self-aid
through definitive care, across the full spectrum of military
operations.
The mission of the Military Operational Medicine Research Program
(MOMRP) is to develop effective countermeasures against stressors and
to maximize health, performance, and fitness, protecting the Soldier at
home and on the battlefield. MOMRP research helps prevent physical
injuries through development of injury prediction models, equipment
design specifications and guidelines, health hazard assessment
criteria, and strategies to reduce musculoskeletal injuries.
MOMRP researchers develop strategies and advise policy makers to
enhance and sustain mental fitness throughout a service member's
career. Psychological health problems are the second leading cause of
evacuation during prolonged or repeated deployments. MOMRP
psychological health and resilience research focuses on prevention,
treatment, and recovery of Soldiers and Families behavioral health
problems, which are critical to force health and readiness. Current
psychological health research topic areas include behavioral health,
resiliency building, substance use and related problems, and risk-
taking behaviors.
The Clinical and Rehabilitative Medicine Research Program (CRMRP)
focuses on definitive and rehabilitative care innovations required to
reset our wounded warriors, both in terms of duty performance and
quality of life. The Armed Forces Institute of Regenerative Medicine
(AFIRM) is an integral part of this program. The AFIRM was designed to
speed the delivery of regenerative medicine therapies to treat the most
severely injured U.S. service members from around the world but in
particular those coming from the theaters of operation in Iraq and
Afghanistan. The AFIRM is expected to make major advances in the
ability to understand and control cellular responses in wound repair
and organ/tissue regeneration and has major research programs in Limb
Repair and Salvage, Craniofacial Reconstruction, Burn Repair, Scarless
Wound Healing, and Compartment Syndrome.
The AFIRM's success to date is at least in part the result of the
program's emphasis on establishing partnerships and collaborations. The
AFIRM is a partnership among the U.S. Army, Navy, and Air Force, the
Department of Defense, the VA, and the National Institutes of Health.
The AFIRM is composed of two independent research consortia working
with the U.S. Army Institute of Surgical Research. One consortium is
led by the Wake Forest Institute for Regenerative Medicine and the
McGowan Institute for Regenerative Medicine in Pittsburgh while the
other is led by Rutgers--the State University of New Jersey and the
Cleveland Clinic. Each consortium contains approximately 15 member
organizations, which are mostly academic institutions.
MRMC is also the coordinating office for the DOD Blast Injury
Research Program. The Blast Injury Research Program is addressing
critical medical research gaps for blast-related injuries and is
developing partnerships with other DOD and external medical research
laboratories to achieve a cutting-edge approach to solving blast injury
problems. One of the program's major areas of focus is the improvement
of battlefield medical treatment capabilities to mitigate neurotrauma
and hemorrhage. Additionally, the program is modernizing military
medical research by bringing technology advances and new research
concepts into DOD programs.
We created a systematic and integrated approach to better organize
and coordinate battlefield care to minimize morbidity and mortality,
and optimize the ability to provide essential care required for
casualty injuries--the Joint Theater Trauma System (JTTS). JTTS focuses
on improving battlefield trauma care through enabling the right
patient, at the right place, at the right time, to receive the right
care. The components of the JTTS include prevention, pre-hospital
integration, education, leadership and communication, quality
improvement/performance improvement, research and information systems.
The JTTS was modeled after the civilian trauma system principles
outlined in the American College of Surgeons Committee on Trauma
Resources for Optimal Care.
Effectiveness and efficiency are also enhanced by electronic tools.
To support DOD and VA collaboration on treating PTSD, pain, and other
healthcare issues, the Electronic Health Record (EHR) should seamlessly
transfer patient data between and among partners to improve
efficiencies and continuity of care. The DOD and the VA share a
significant amount of health information today and no two health
organizations in the nation share more non-billable health information
than the DOD and VA. The Departments continue to standardize sharing
activities and are delivering information technology solutions that
significantly improve the secure sharing of appropriate electronic
health information. We need to include electronic health information
exchange with our civilian partners as well--a health information
systems which brings together three intersecting domains--DOD, VA,
civilian--for optimal sharing of beneficiary health information and to
provide a common operating picture of healthcare delivery. These
initiatives enhance healthcare delivery to beneficiaries and improve
the continuity of care for those who have served our country.
Previously, the burden was on service members to facilitate information
sharing; today, we are making the transition between DOD and VA easier
for our service members.
The Office of the Surgeon General (OTSG) works closely with Defense
Health Information Management System of Health Affairs/TRICARE
Management Activity in pursuing additional enhancements and fixes to
AHLTA. The OTSG Information Management Division also continues to
implement the MEDCOM AHLTA Provider Satisfaction Program, which now
provides dictation and data entry software applications, tablet
computing hardware, business process management, clinical business
intelligence, and clinical systems training and integration to the
providers and users of AHLTA. OTSG is taking the EHR lead in designing
and pursuing the next generation of the EHR by participating in DOD and
Inter-agency projects such as the EHR Way Ahead, the Virtual Lifetime
Electronic Record Pilot Project, Nationwide Health Information Network,
In-Depth EHR Training, and VA/DOD Sharing Initiatives. We are aligned
with the Air Force's COMPASS program in ensuring that our providers and
our clinics have the best and most user-friendly EHR.
The Medical Command was reorganized in October 2010, to align
regional medical commands (RMCs) with TRICARE regions with the
resulting effect of improved readiness and support for the Army's
iterative process of providing expeditionary, modular fighting units
under the ARFORGEN cycle. We are well on the way to standardizing
structure and staffing for RMC headquarters to provide efficiencies and
ensure standardized best practices across Army Medicine. Three CONUS-
based regional medical commands, down from four, are now aligned with
the TRICARE regions to provide healthcare in a seamless way with our
TRICARE partners.
In addition to TRICARE alignment, each region will contain an Army
Corps headquarters, and health-care assets will be better aligned with
beneficiary population of the regions. Each RMC has a deputy commander
who is responsible for a readiness cell to coordinate and collaborate
with the ARFORGEN cycle. This regional readiness cell will reach out to
Reserve Component elements within their areas of responsibility to
ensure that all medical and dental services required during the
ARFORGEN cycle of the Reserve units are also identified and provided.
In recent years, the Army has transformed how it provides
healthcare to its Soldiers, with improvements impacting every aspect of
the continuum of care. The Patient Centered Medical Home and the
Warrior Transition Command are examples of the Army's strong commitment
to adapt and improve its ability to provide the best care possible for
our Soldiers and their Families. We have a duty and responsibility to
our Soldiers, Families, and retirees. The level of care required does
not end when the deployed Soldier returns home; there will be
considerable ongoing healthcare costs for many years to support for our
wounded, ill, or injured Service members. They need to trust we will be
there to manage the health related consequences of over 9 years of war,
including behavioral healthcare, post-traumatic stress, burn or
disfiguring injuries, chronic pain or loss of limb. We will require
ongoing research to establish more effective methodologies for
treatment. Army Medicine remains focused on developing partnerships to
achieve the aims of the MHS as we work together to provide cost
effective care to improve the health of our Soldiers. The goal is to
provide the best care and access possible for Army Families and
retirees and to ensure optimal readiness for America's fighting forces
and their Families.
Last, I would like to join General Casey in expressing support for
the military healthcare program changes included in the fiscal year
2012 budget. The changes include modest enrollment fee increases for
working-age retirees, pharmacy co-pay adjustments, aligning Defense
reimbursements to sole community hospitals to Medicare consistent with
current statute, and shifting future Uniformed Services Family Health
Plan enrollees into the TRICARE-for-Life/Medicare program established
by Congress in the fiscal year 2001 National Defense Authorization Act.
In closing, over the past 40 months as the Army Surgeon General I
have had numerous occasions to appear before this subcommittee, meet
individually with you and your fellow members and interact with your
staff. I have appreciated your tough questions, valuable insight, sage
advice and deep commitment to your Army's Soldiers and their Families.
Thank you for this opportunity to share Army Medicine with you. I am
proud to serve with the Officers, Non-commissioned Officers, the
enlisted Soldiers and civilian workforce of Army Medicine. Their
dedication makes our Nation strong and our Soldiers and Families
healthy and resilient.
Thank you for your continued support of Army Medicine and to our
Nation's men and women in uniform.
Army Medicine: Building Value . . . Inspiring Trust
Chairman Inouye. And now may I call upon Admiral Robinson.
STATEMENT OF VICE ADMIRAL ADAM M. ROBINSON, JR.,
SURGEON GENERAL, DEPARTMENT OF THE NAVY
Admiral Robinson. Good morning.
Chairman Inouye, Vice Chairman Cochran, I am pleased to be
with you today, and I want to thank the subcommittee for the
tremendous confidence and unwavering support of Navy medicine,
particularly as we continue to care for those who go in harm's
way, their families, and all beneficiaries.
Force health protection is the bedrock of Navy medicine. It
is our duty, our obligation, and our privilege to promote,
protect, and restore the health of our sailors and marines. The
mission spans the full spectrum of healthcare from optimizing
the health and fitness of the force, to maintaining robust
disease surveillance and prevention programs, to saving lives
on the battlefield. It also involves providing humanitarian
assistance and disaster response around the world, and this is
no more evident than in our efforts currently underway in Japan
following the devastating earthquake and tsunami last month. I,
along with my fellow surgeons general, traveled to Afghanistan
in February and again witnessed the stellar performance of our
dedicated men and women, both Active and Reserve, delivering
expeditionary combat casualty care. At the NATO Role 3
Multinational Medical Unit, Navy medicine is currently leading
the joint and combined staff to provide the largest medical
support in Kandahar. We are working side by side with Army and
Air Force medical personnel, rapidly implementing best
practices and employing unique skill sets in support of their
demanding mission, leaving no doubt that the historically
unprecedented survival rate from the battlefield is the direct
result of better trained and equipped personnel, in conjunction
with improved systems of treatment and casualty evacuation.
We spend a lot of time discussing what constitutes world
class healthcare. There is no doubt in my mind that the trauma
care being provided in theater today is truly world class, as
are the men and women delivering it. I am pleased to report to
you that their morale is high and professionalism is unmatched.
We also had the opportunity to visit our Concussion
Restoration Care Center at Camp Leatherneck in Helmand
Province. The center, which opened last August, assesses and
treats service members with concussion, or mild traumatic brain
injury, and musculoskeletal injuries. The goal is safely
returning them to duty--to full duty following recovery. The
Restoration Center, along with the initiatives like OSCAR, our
Operational Stress Control and Readiness Program, where we
embed full-time mental health personnel with deployed marines,
continues to reflect our priority of positioning our medical
personnel with deploying marines--our medical personnel and
resources where they are most needed.
Navy medicine has no greater responsibility than caring for
our service members, wherever and whenever they need us. We
understand that preserving the psychological health of service
members and their families is one of the greatest challenges we
face today. We also know that nearly a decade of continuous
combat operations has resulted in a growing population of
service members suffering with traumatic brain injury. We are
forging ahead with improved screening, surveillance, treatment,
education, and research; however, there is still much we do not
yet know about these injuries and their long-term impact on the
lives of our service members.
I would specifically highlight the issuance of the
directive-type memorandum in June 2010, which has increased
line leaders' awareness of potential traumatic brain injury
exposure, and, importantly, it mandates post-blast evaluations
and removal of blast-exposed warfighters to promote recovery.
We also recognize the importance of collaboration and
partnership. Our collective efforts include those coordinated
jointly with the other services, the Department of Veterans
Affairs, the Centers of Excellence, as well as leading academic
and research institutions.
Let me now turn to patient and family centered care.
Medical Home Port is Navy medicine's patient-centered medical
home model, an important initiative that will significantly
impact how we provide care to our beneficiaries. Medical Home
Port emphasizes team-based, comprehensive care and focuses on
the relationship between the patient, their provider, and the
healthcare team. We continue to move forward with the phased
implementation of Medical Home Port at our medical centers and
family medicine teaching hospitals. An initial response from
our patients and our providers is very encouraging.
Finally, I would like to address the proposed Defense
Health Program cost efficiencies. Rising healthcare costs
within the military health system continue to present
challenges. The Secretary of Defense has articulated that the
rate at which healthcare costs are increasing and the relative
proportion of the Department's resources devoted to healthcare
cannot be sustained. The Department of the Navy fully supports
the Secretary's plan to better manage costs moving forward and
ensure our beneficiaries have access to the quality care that
is the hallmark of military medicine.
In summary, I am proud of the progress we are making, but
not satisfied. We continue to see groundbreaking innovations in
combat casualty care and remarkable heroics in saving lives.
But all of us remain concerned about the cumulative effects of
worry, stress, and anxiety on our service members and their
families brought about by a decade of conflict. Each day
resonates with the sacrifices that our sailors, marines, and
their families make quietly and without bravado. It is this
commitment, this selfless service, that helps inspire us in
Navy medicine. Regardless of the challenges ahead, I am
confident that we are well positioned for the future.
As my last cycle of hearings is now coming to a close, as
is my Navy career, I would like to thank this subcommittee and
the entire Congress for their support of Navy medicine and
everything that you have done to make sure that our men and
women have the best in every possibility, both on the
battlefield, in their recovery, and after they are out of the
service.
PREPARED STATEMENT
I appreciate the opportunity to be here today, and I look
forward to your questions. Thank you very much.
Chairman Inouye. Thank you very much, Admiral.
[The statement follows:]
Prepared Statement of Vice Admiral Adam M. Robinson, Jr.
INTRODUCTION
Chairman Inouye, Vice Chairman Cochran, distinguished Members of
the Subcommittee, I am pleased to be with you today to provide an
update on Navy Medicine, including some of our accomplishments,
challenges and strategic priorities. I want to thank the Committee
Members for the tremendous confidence and 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 delivers world class care, anytime, anywhere. We are
forward-deployed and engaged around the world every day, no matter what
the environment and regardless of the challenge. The operational tempo
of this past year continues to demonstrate that we must be flexible,
adaptable and ready to respond globally. We will be tested in our
ability to meet our 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 that Navy Medicine is responding to these challenges
with skill, commitment and compassion.
STRATEGIC ALIGNMENT, INTEGRATION AND EFFICIENCIES
Strategic alignment with the priorities of the Secretary of the
Navy, Chief of Naval Operations and Commandant of the Marine Corps is
critical to our ability to meet our mission. As a world-wide healthcare
system, Navy Medicine is fully engaged in carrying out the core
capabilities of the Maritime Strategy and the Cooperative Strategy for
the 21st Century Seapower around the globe. Our ongoing efforts,
including maintaining warfighter health readiness, conducting
humanitarian assistance and disaster relief missions, protecting the
health of our beneficiaries, as well as training our future force are
critical to our future success.
We also recognize the importance of alignment within the Military
Health System (MHS) as evidenced by the adoption of the Quadruple Aim
initiative as a primary focus of the MHS Strategic Plan. The Quadruple
Aim applies the framework from the Institute for Healthcare Improvement
(IHI) and customizes it for the unique demands of military medicine. It
targets the MHS and Services' efforts on integral outcomes in the areas
of readiness, population health and quality, patient experience and
cost. The goal is to develop better outcomes and implement balanced
incentives across the MHS.
Within Navy Medicine, we continue to maintain a rigorous strategic
planning process. Deliberative planning, constructive self-assessment
and alignment at all levels of our organization, have helped create
momentum and establish a solid foundation of measurable progress that
drives change. It's paying dividends as we are seeing improved and
sustained performance in our strategic objectives.
This approach is particularly evident in our approach to managing
resources. We are leveraging analytics to target resource decisions. An
integral component of our Strategic Plan is providing performance
incentives that promote quality and directly link back to workload,
readiness and resources. We continue to evolve to a system which
integrates requirements, resources and performance goals and promotes
patient and family centered care. This transformation properly aligns
authority, accountability and financial responsibility with the
delivery of quality, cost-effective healthcare that remains patient and
family centered.
Aligning incentives helps foster process improvement particularly
in the area of quality. Our Lean Six Sigma (LSS) program continues to
be highly successful in identifying projects that synchronize with our
strategic goals and have system-wide implications for improvement.
Examples include reduced cycle time for credentialing providers and
decreased waiting times for diagnostic mammography and ultrasound. I am
also encouraged by our collaboration with the Johns Hopkins' Applied
Physics Laboratory to employ industrial engineering practices to
improve clinical processes and help recapture private sector workload.
Navy Medicine continues to work within the MHS to realize cost
savings through several other initiatives. We believe that robust
promotion of TRICARE Home Delivery Pharmacy Program, implementation of
supply chain management standardization for medical/surgical supplies
and the full implementation of Patient-Centered Medical Home (PCMH)
will be key initiatives that are expected to successfully reduce costs
without compromising access and quality of care.
Rising healthcare costs within the MHS continue to present
challenges. The Secretary of Defense has articulated that the rate at
which healthcare costs are increasing and relative proportion of the
Department's resources devoted to healthcare, cannot be sustained. He
has been resolute in his commitment to implement systemic efficiencies
and specific initiatives which will improve quality and satisfaction
while more responsibly managing cost.
The Secretary of the Navy, Chief of Naval Operations and Commandant
of the Marine Corps recognize that the MHS is not immune to the
pressure of inflation and market forces evident in the healthcare
sector. In conjunction with a growing number of eligible beneficiaries,
expanded benefits and increased utilization throughout our system, it
is incumbent upon us to ensure that we streamline our operations in
order to get the best value for our expenditures. We have made
progress, but there is more to do. We support the efforts to
incentivize TRICARE Home Delivery Pharmacy Program and also to
implement modest fee increases, where appropriate, to ensure equity in
benefits for our retirees.
The Department of the Navy (DON) fully supports the Secretary's
plan to better manage costs moving forward and ensure our beneficiaries
have access to the quality care that is the hallmark of military
medicine. As the Navy Surgeon General, I appreciate the tremendous
commitment of our senior leaders in this critical area and share the
imperative in developing a more affordable and sustainable healthcare
benefit.
Navy Medicine has worked hard to get best value of every dollar
Congress has provided and we will continue to do so. The President's
budget for fiscal year 2012 adequately funds Navy Medicine to meet its
medical mission for the Navy and Marine Corps. We are, however, facing
challenges associated with operating under a potential continuing
resolution for the remainder of the year, particularly in the areas of
provider contracts and funding for facility special projects.
FORCE HEALTH PROTECTION
Force Health Protection is the bedrock of Navy Medicine. It is what
we do and why we exist. It is our duty--our obligation and our
privilege--to promote, protect and restore the health of our Sailors
and Marines. This mission spans the full spectrum of healthcare, from
optimizing the health and fitness of the force, to maintaining robust
disease surveillance and prevention programs, to saving lives on the
battlefield. When Marines and Sailors go into harm's way, Navy Medicine
is with them. On any given day, Navy Medicine is underway and forward
deployed with the Fleet and Marine Forces, as well as serving as
Individual Augmentees (IAs) in support of our global healthcare
mission.
Clearly, our focus continues to be combat casualty care in support
of Operation Enduring Freedom (OEF). I, along with my fellow Surgeons
General, recently returned from the Central Command (CENTCOM) Area of
Responsibility (AOR) and again witnessed the stellar performance of our
men and women delivering expeditionary combat casualty care. At the
NATO Role 3 Multinational Medical Unit, Navy Medicine is currently
leading the joint and combined staff to provide the largest medical
support in Kandahar with full trauma care to include 3 operating rooms,
12 intensive care beds and 35 ward beds. This state-of-the-art facility
is staffed with dedicated and compassionate active and reserve
personnel who are truly delivering world-class care. Receiving 70
percent of their patients directly from the point of injury on the
battlefield, our doctors, nurses and corpsmen apply the medical lessons
learned from 10 years of war to achieve a remarkable 97 percent
survival rate for coalition casualties.
The Navy Medicine team is working side-by-side with Army and Air
Force medical personnel and coalition forces to deliver outstanding
healthcare to U.S. military, coalition forces, contractors, Afghan
national army, police and civilians, as well as detainees. The team is
rapidly implementing best practices and employing unique skill sets
with specialists such as an interventional radiologist, pediatric
intensivist, hospitalist and others in support of their demanding
mission. I am proud of the manner in which our men and women are
responding--leaving no doubt that the historically unprecedented
survival rate from battlefield injuries is the direct result of better
trained and equipped personnel, in conjunction with improved systems of
treatment and casualty evacuation.
Combat casualty care is a continuum which begins with corpsmen in
the field with the Marines. We are learning much about battlefield
medicine and continue to quickly put practices in place that will save
lives. All deploying corpsmen must now complete the Tactical Combat
Casualty Care (TCCC) training. TCCC guidelines for burns, hypothermia
and fluid resuscitation for first responders have also been updated.
This training is based on performing those interventions on the
battlefield that address preventable causes of death. In addition, we
have expanded the use of Combat Application Tourniquets (CATs) and
hemostatic impregnated bandages as well as improving both intravenous
therapy and individual first aid kits (IFAKs) and vehicle medical kits
(VMKs).
We continue to see success with our Forward Resuscitative Surgical
System (FRSS) which allows for stabilization within the ``golden
hour''. The FRSS can perform 18 major operations over the course of 72
hours without being re-supplied. Our ability to send medical teams
further forward has improved survivability rates. To this end, we are
clearly making tremendous gains in battlefield medicine throughout the
continuum of care. Work being conducted by the Joint Theatre Trauma
Registry and Joint Combat Casualty Research Teams are enabling us to
capture, evaluate and implement clinical practice guidelines and best
practices quickly.
HUMANITARIAN ASSISTANCE AND DISASTER RELIEF
Navy Medicine continues its commitment to providing responsive and
comprehensive support for Humanitarian Assistance/Disaster Relief (HA/
DR) missions around the world. We are often the first responder for HA/
DR missions due to the presence of organic medical capabilities with
forward deployed Navy assets. Our hospital ships, USNS Mercy (T-AH 19)
and USNS Comfort (T-AH 20) are optimally configured to deploy in
support of HCA activities in South America, the Pacific Rim and East
Asia.
Navy Medicine not only responds to disasters around the world and
at home, we also conduct proactive humanitarian missions in places as
far reaching as Africa through Africa Partnership Station to the
Pacific Rim through Pacific Partnership and South America through
Continuing Promise. Mercy's recent deployment in support of Pacific
Partnership 2010, the fifth annual Pacific Fleet proactive humanitarian
mission, is strengthening ongoing relationships with host and partner
nations in Southeast Asia and Oceania. During the 144-day, six nation
mission, we treated 109,754 patients, performed 859 surgeries and
engaged in thousands of hours of medical subject matter expert
exchanges.
Our hospital ships are executing our Global Maritime Strategy by
building the trust and cooperation we need to strengthen our regional
alliances and empower partners around the world. With each successful
deployment, we increase our interoperability with host and partner
nations, non-governmental organizations and the interagency partners.
Today's security missions must include humanitarian assistance and
disaster response,
Enduring HA missions such as Pacific Partnership and Continuing
Promise, as well other Medical Readiness Education Training Exercises
(MEDRETEs) provide valuable training of personnel to conduct future
humanitarian support and foreign disaster relief missions. Our
readiness was clearly evident by the success of Operation Unified
Response (OUR) following the devastating earthquake in Haiti last year.
Our personnel were trained and prepared to accomplish this challenging
mission.
CONCEPT OF CARE
Patient and family centered care is our core philosophy--the
epicenter of everything we do. We are providing comprehensive,
compassionate healthcare for all our beneficiaries wherever they may be
and whenever they may need it. Patient and family centered care helps
ensure patient satisfaction, increased access, coordination of services
and quality of care, while recognizing the vital importance of the
family. Navy Medicine serves personnel throughout their treatment
cycle, and for our Wounded Warriors, we manage every aspect of medicine
in their continuum of care to provide a seamless transition from
battlefield to bedside to leading productive lives.
Medical Home Port is Navy Medicine's Patient-Centered Medical Home
(PCMH) model, an important initiative that will significantly impact
how we provide care to our beneficiaries. In alignment with my
strategic goal for patient and family centered care, Medical Home Port
emphasizes team-based, comprehensive care and focuses on the
relationship between the patient, their provider and the healthcare
team. The Medical Home Port team is responsible for managing all
healthcare for empanelled patients, including specialist referrals when
needed. Patients see familiar faces with every visit, assuring
continuity of care. Appointments and tests get scheduled promptly and
care is delivered face-to-face or when appropriate, using secure
electronic communication. PCMH is being implemented by all Services and
it is expected to improve population health, patient satisfaction,
readiness, and is likely to impact cost in very meaningful ways.
It is important to realize that Medical Home Port is not brick and
mortar; but rather a philosophy and commitment as to how you deliver
the highest quality care. A critical success factor is leveraging all
our providers, and supporting information technology systems, into a
cohesive team that will not only provide primary care, but integrate
specialty care as well. We continue to move forward with the phased
implementation of Medical Home Port at our medical centers and family
medicine teaching hospitals, and initial response from our patients is
very encouraging.
CARING FOR OUR HEROES, THEIR FAMILIES AND CAREGIVERS
We have no greater responsibility than caring for our service
members, wherever and whenever they need us. This responsibility spans
from the deckplates and battlefield to our clinics, hospitals and
beyond. This commitment to provide healing in body, mind and spirit has
never been more important. Our case management programs, both medical
and non-medical, play a vital role in the development of Comprehensive
Recovery Plans to provide our war-injured service members' optimal
outcomes. Case management is the link that connects resources and
services for our Wounded Warriors and their families.
Associated with this commitment, we must understand that preserving
the psychological health of service members and their families is one
of the greatest challenges we face today. We recognize that service
members and their families are resilient at baseline, but the long
conflict and related deployments challenge this resilience. DON is
committed to providing programs that support service members and their
families.
The Navy Operational Stress Control program and Marine Corps Combat
Operational Stress Control programs are the cornerstones of our
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; and
multidisciplinary expertise (medical, chaplains and other support
services) for more affected members.
Navy Medicine's Psychological Health (PH) program supports the
prevention, diagnosis, mitigation, treatment and rehabilitation of
post-traumatic stress disorder (PTSD) and other mental health
conditions, including planning for the seamless transition of service
members throughout the recovery and reintegration process. We have
increased the size of the mental health workforce to support the
readiness and health needs of the Fleet and Marine Corps throughout the
deployment cycle and, during fiscal year 2010, funded 221 clinical and
support staff positions at 14 Navy military treatment facilities (MTFs)
to help ensure timely access to care.
Stigma remains a barrier; however, Navy and Marine Corps' efforts
to decrease stigma have had preliminary success--with increased active
leadership support and Operational Stress Control (OSC) training
established throughout the Fleet and Marine Forces.
Within the Marine Corps, we continue to see success with the
Operational Stress Control and Readiness (OSCAR) program as well as the
OSCAR Extender program. OSCAR embeds full-time mental health personnel
with deploying Marines and uses existing medical and chaplain personnel
as OSCAR Extenders and trained senior and junior Marines as mentors to
provide support at all levels to reduce stigma and break down barriers
to seeking help. Our priority remains ensuring we have the service and
support capabilities for prevention and early intervention available
where and when it is needed. OSCAR is allowing us to move forward in
this important area.
We recently deployed our third Navy Mobile Mental Health Care Team
for a 6-month mission in Afghanistan. The team consists of three mental
health clinicians, a research psychologist and an enlisted psychiatry
technician. Their primary tool is the Behavioral Health Needs
Assessment Survey (BHNAS). The results give an overall assessment of
real time force mental health and well-being every 6 months, and can
identify potential areas or sub-groups of concern for leaders. It
assesses a wide variety of content areas, including mental health
outcomes, as well as the risk and protective factors for those outcomes
such as combat exposures, deployment-related stressors, positive
effects of deployment, morale and unit cohesion. The Mobile Care Team
also has a mental health education role and provides training in
Psychological First Aid to Sailors in groups and individually.
Ultimately, Psychological First Aid gives Sailors a framework to
promote resilience in one another.
Our Naval Center for Combat & Operational Stress Control (NCCOSC)
is one way we are developing an environment that supports
psychologically fit, ready and resilient Navy and Marine Corps forces.
The goal is to demystify stress and help Sailors and Marines take care
of themselves and their shipmates. NCCOSC continues to make progress in
advancing research for the prevention, diagnosis and treatment of
combat and operational stress injuries to include PTSD. They are
involved in over 64 ongoing scientific projects with 3,525 participants
enrolled. NCCOSC has recently developed a pilot program, Psychological
Health Pathways, which is designed to ensure that clinical practice
guidelines are followed and evidence-based care is practiced and
tracked. To date, 1,554 patients have been enrolled into the program
with 600,062 points of clinical data gathered. The program involves
intensive mental health case management, use of standardized measures,
provider training and comprehensive data tracking.
In November 2010, we launched a pilot program, Overcoming Adversity
and Stress Injury Support (OASIS) at the Naval Medical Center, San
Diego. Developed by Navy Medicine personnel and located onboard the
Naval Base Point Loma, California, OASIS is a 10-week residential
program designed to provide intensive mental healthcare for service
members with combat related mental health symptoms from post-traumatic
stress disorder, as well as major depressive disorders, anxiety
disorders and substance abuse problems. The program offers a
comprehensive approach, focusing on mind and body through various
methods including yoga, meditation, spirituality classes, recreation
therapy, art therapy, intensive sleep training, daily group therapy,
individual psychotherapy, family skills training, medication management
and vocational rehabilitation. We will be carefully assessing the
efficacy of this pilot program throughout this year.
Associated with our Operational Stress Control efforts, suicide
prevention remains a key component. Suicide destroys families and
impacts our commands. We are working hard at all levels to build the
resilience of our Sailors and Marines and their families, as well as
foster a culture of awareness and intervention by the command and
shipmates. Our programs are focused on leadership engagement,
intervention skills, community building and access to quality
treatment. All of us in uniform have a responsibility to care for our
shipmates and remain vigilant for signs of stress. A-C-T (Ask--Care--
Treat) remains an important framework of response. In 2010, both the
Navy and Marine Corps saw reductions in the number of suicides from the
prior year, with the Navy seeing a reduction of 17 percent while the
Marine Corps realized a 29 percent drop.
We are also committed to improving the psychological health,
resiliency and well-being of our family members. When our Sailors and
Marines deploy, our families are their foothold. Family readiness is
force readiness and the physical, mental, emotional, spiritual health
and fitness of each individual is critical to maintaining an effective
fighting force. A vital aspect of caring for our Warriors is also
caring for their families and we continue to look for innovative ways
to do so.
To meet this growing challenge, Navy Medicine began an unparalleled
approach in 2007 called Project FOCUS (Families OverComing Under
Stress) to help our families. FOCUS is a family centered resiliency
training program based on evidenced-based interventions that enhances
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. It is an 8-week,
skill-based, trainer-led intervention that addresses difficulties that
families may have when facing the challenges of multiple deployments
and parental combat related psychological and physical health problems.
It has demonstrated that a strength-based approach to building child
and family resiliency skills is well received by service members and
their family members. 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.
Project FOCUS has been highlighted by the Interagency Policy
Committee on Military Families Report to the President (October 2010)
and has been recognized by the Department of Defense (DOD) as a best
practice. Given the success FOCUS has demonstrated thus far, we will
continue to devote our efforts to ensuring our service members and
their families have access to this program. To date, over 160,000
Service members, families and community support providers have received
FOCUS services, across 23 locations CONUS and OCONUS.
Our programs must address the needs of all of our Sailors, Marines
and families, including those specifically targeted to the unique needs
of reservists and our caregivers. The Reserve Psychological Health
Outreach Program (RPHOP) identifies Navy and Marine Corps Reservists
and their families who may be at risk for stress injuries and provides
outreach, support and resources to assist with issue resolution and
psychological resilience. An effective tool at the RPHOP Coordinator's
disposal is the Returning Warrior Workshop (RWW), a 2-day weekend
program designed specifically to support the reintegration of returning
Reservists and their families following mobilization. Some 54 RWWs have
been held since 2008 with over 6,000 military personnel, family members
and guests attending.
Navy Medicine is also working to enhance the resilience of
caregivers to the psychological demands of exposure to trauma, wear and
tear, loss, and inner conflict associated with providing clinical care
and counseling through the Caregiver Occupational Stress Control
(CgOSC) Program. The core objectives are early recognition of distress,
breaking the code of silence related to stress reactions and injuries,
and engaging caregivers in early help as needed to maintain both
mission and personal readiness.
In addition, the Naval Health Research Center (NHRC) produced ``The
Docs'', a 200-page graphic novel, as a communication tool to help our
corpsmen with the stresses of combat deployments. ``The Docs'' is the
story of four corpsmen deployed to Iraq. While some events in the novel
are specific to Operation Iraqi Freedom (OIF), it is not intended to
depict any specific time period or conflict but rather highlight
general challenges faced by corpsmen who serve as the ``Docs'' in a
combat zone. It was developed with the intent to instill realistic
expectations of possible deployment stressors and to provide examples
for corpsmen on helpful techniques for in-theater care of stress
injuries. This format was chosen for its value in providing thought-
provoking content for discussion in training scenarios and to appeal to
the targeted age group.
Nearly a decade of continuous combat operations has resulted in a
growing population of service members suffering with Traumatic Brain
Injury (TBI), the very common injury of OEF and OIF. The majority of
TBI injuries are categorized as mild, or in other words, a concussion.
We know more about TBI and are forging ahead with improved
surveillance, treatment and research. However, we must recognize that
there is still much we do not yet know about these injuries and their
long-term impacts on the lives of our service members.
Navy Medicine is committed to ensuring thorough screening for all
Sailors and Marines prior to expeditionary deployment, enhancing the
delivery of care in theater, and the identification and testing of all
at-risk individuals returning from deployment. We are committed to
enhancing training initiatives, developing better tools to detect
changes related to TBI and sustaining research into better treatment
options.
Pre-deployment screening is prescribed using the Automated
Neuropsychological Assessment Metrics (ANAM). Testing has expanded to
Navy and Marine Corps worldwide, enhancing the ability to establish
baseline neurocognitive testing for expeditionary deployers. This
baseline test has provided useful comparative data for medical
providers in their evaluation, treatment and counseling of individuals
who have been concussed in theater.
In-theater screening and treatment has also improved over time. The
issuance of the Directive-Type Memorandum (DTM) 09-033 in June 2010 has
increased leaders' awareness of potential TBI exposure and mandates
post-blast evaluations and removal of blast-exposed warfighters from
high risk situations to promote recovery. Deploying medical personnel
are trained in administering the Military Acute Concussion Evaluation
(MACE), a rapid field assessment to help corpsmen identify possible
concussions. Additionally, deploying medical providers receive training
on the DTM requirements and in-theater Clinical Practice Guidelines
(CPGs) for managing concussions.
In August 2010, the Marine Corps, supported by Navy Medicine,
opened the Concussion Restoration Care Center (CRCC) at Camp
Leatherneck in Helmand Province to assess and treat service members
with concussion or musculoskeletal injuries, with the goal of safely
returning as many service members as possible to full duty following
recovery of cognitive and physical functioning. The CRCC is supported
by an interdisciplinary team including sports medicine, family
medicine, mental health, physical therapy and occupational therapy. I
am encouraged by the early impact the CRCC is having in theatre by
providing treatment to our service members close to the point of injury
and returning them to duty upon recovery. We will continue to focus our
attention on positioning our personnel and resources where they are
most needed.
Post-deployment surveillance for TBI is accomplished through the
Post-Deployment Health Assessment (PDHA) and Post-Deployment Health
Reassessment (PDHRA), which are required for returning deplorers.
Further evaluation, treatment and referrals are provided based on
responses to certain TBI-specific questions on the assessments.
TBI research efforts are focused on continuing to refine tools for
medical staff to use to detect and treat TBI. Two specific examples are
a study of cognitive and physical symptoms in USMC Breacher instructors
(who have a high lifetime exposure rate to explosive blasts) and an
ongoing surveillance effort with USMC units with the highest identified
concussion numbers to determine the best method for identifying service
members requiring clinical care. These efforts are coupled with post-
deployment ANAM testing for those who were identified as sustaining at
least one concussion in theater. Other efforts are underway to identify
physical indicators and biomarkers for TBI, such as blood tests, to
help in diagnosis and detection. We are also conducting evaluations of
various neurocognitive assessment tools to determine if there is a
``best'' tool for detecting concussion effects in the deployed
environment. Our efforts also include those coordinated jointly with
the other Services, the Defense and Veterans Brain Injury Center
(DVBIC), and the Defense Centers of Excellence for Psychological Health
and Traumatic Brain Injury (DCoE).
I am committed to ensuring that we build on the vision advanced by
the Members of Congress and the hard work of the dedicated
professionals at all the Centers of Excellence, MTFs, research centers
and our partners in both the public and private sectors. These Centers
of Excellence have become important components of the Military Health
System and their work in support of clinical best practices, research,
outreach and treatment must continue with unity of effort and our
strong support.
Our service members must have access to the best treatment,
research and education available for PH and TBI. We continue to see
progress as evidenced by the opening of the National Intrepid Center of
Excellence (NICoE) onboard the National Naval Medical Center campus. As
a leader in advancing state-of-the-art treatment, research, education
and training, NICoE serves as an important referral center primarily
for service members and their families with complex care needs, as well
as a hub for best practices and consultation. NICoE also conducts
research, tests new protocols and provides comprehensive training and
education to patients, providers and families--all vital to advancing
medical science in PH and TBI.
Navy Medicine is also working with the DCoE, its component centers
including DVBIC, the Department of Veterans Affairs, research centers,
and our partners in both the public and private sectors to support best
clinical practices, research and outreach. We continue to see gains in
both the treatment and development of support systems for our Wounded
Warriors suffering with these injuries; however, we must recognize the
challenging and extensive work that remains. Our commitment will be
measured in decades and generations and must be undertaken with urgency
and compassion.
THE NAVY MEDICINE TEAM
Our people are our most important assets, and their dignity and
worth are maintained through an atmosphere of service, professionalism,
trust and respect. Navy Medicine is fortunate to have over 63,000
dedicated professionals working to improve and protect the health of
Sailors, Marines and their families. Our team includes officers,
enlisted personnel, government civilians and contractors working
together in support of our demanding mission. I have been privileged to
meet many of them in all environments--forward-deployed with the
operating forces, in our labs and training facilities, at the bedside
in our medical centers and hospitals--and I'm always inspired by their
commitment.
We are working diligently to attract, recruit and retain our Navy
Medicine personnel. Overall, I remain encouraged with the progress we
are making in recruiting and overall manning and we are seeing the
successes associated with our incentive programs. In fiscal year 2010,
we met our Active Medical Department recruiting goal and attained 90
percent of Reserve Medical Department goal, but there was a notable
shortfall in Reserve Medical Corps recruiting at 70 percent. Given the
relatively long training pipeline for many of our specialties, we
clearly recognize the impact that recruiting shortfalls in prior years,
particularly in the Health Professions Scholarship Program (HPSP), can
have in meeting specialty requirements today and moving forward.
Recruiting direct accession physicians and dentists remains
challenging, requiring our scholarship programs to continue recent
recruiting successes to meet inventory needs. Retention has improved
for most critical wartime specialties, supported by special pay
initiatives; however, some remain below our requirements and continue
to be closely monitored.
Within the active component Medical Corps, general surgery, family
medicine and psychiatry have shortfalls, as does the Dental Corps with
general dentistry and oral maxillofacial surgery specialties. We are
also experiencing shortfalls for nurse anesthetists, perioperative and
critical care nurses, family nurse practitioners, clinical
psychologists, social workers and physician assistants.
The reserve component shortages also exist within anesthesiology,
neurosurgery, orthopedic surgery, internal medicine, psychiatry,
diagnostic radiology, comprehensive dentistry and oral maxillofacial
surgery as well as perioperative nursing, anesthesia and mental health
nurse practitioners.
We appreciate your outstanding support for special pays and bonus
programs to address these shortages. These incentives will continue to
be needed for future success in both recruiting and retention. We are
working closely with the Chief of Naval Personnel and Commander, Naval
Recruiting Command to assess recruiting incentive initiatives and
explore opportunities for improvement.
For our civilian personnel within Navy Medicine, we are also
coordinating the National Security Personnel System (NSPS) replacement
for 32 healthcare occupations to ensure pay parity among healthcare
professions. We have been successful in hiring required civilians to
support our Sailors and Marines and their families--many of whom
directly support our Wounded Warriors. Our success in hiring is in
large part due to the hiring and compensation flexibilities that have
been granted to the DOD's civilian healthcare community over the past
several years.
Our priority remains 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.
I want to also reemphasize the priority we place on diversity. Navy
Medicine has continued to emerge as a role model of diversity as we
focus on inclusiveness while aligning ethnic and gender representation
throughout the ranks to reflect our Nation's population. Not only are
we setting examples of a diverse, robust and dedicated healthcare
force, but this diversity also reflects the people for whom we provide
care. We take great pride in promoting our message that we are the
employer of choice for individuals committed to a culturally competent
work-life environment; one where our members proudly see themselves
represented at all levels of leadership.
For all of us in Navy Medicine, an excerpt from the Navy Ethos
articulates well what we do: ``We are a team, disciplined and well-
prepared, committed to mission accomplishment. We do not waiver in our
dedication and accountability to our Shipmates and families.''
EXCELLENCE IN RESEARCH AND DEVELOPMENT AND HEALTH EDUCATION
World-class research and development capabilities, in conjunction
with outstanding medical education programs, represent the future of
our system. Each is a force-multiplier and, along with clinical care,
is vital to supporting our health protection mission. The work that our
researchers and educators do is having a direct impact on the treatment
we are able to provide our Wounded Warriors, from the battlefield to
the bedside. We will shape the future of military medicine through
research, education and training.
The overarching mission of our Research and Development program is
to conduct health and medical research, development, testing, and
evaluation (RDT&E), and surveillance to enhance the operational
readiness and performance of DOD personnel worldwide. In parallel, our
Clinical Investigation Program activity, located at our teaching MTFs
is, to an increasing degree, participating in the translation of
appropriate knowledge and products from our RDT&E activity into proof
of concept and cutting edge interventions to benefit our Wounded
Warriors and our beneficiaries. We are also committed to connecting our
Wounded Warriors to approved emerging and advanced diagnostic and
therapeutic options within and outside of military medicine while
ensuring full compliance with applicable patient safety policies and
practices.
Towards this end, we have developed our top five strategic research
goals and needs to meet the Chief of Naval Operations and Commandant of
the Marine Corps warfighting requirements. These include:
--Traumatic brain injury (TBI) and psychological health treatment and
fitness for both operational forces and home-based families.
--Medical systems support for maritime and expeditionary operations
to include patient medical support and movement through care
levels I and II with emphasis on the United States Marine Corps
(USMC) casualty evacuation (CASEVAC) and En Route Care systems
to include modeling and simulation for casualty prediction,
patient handling, medical logistics, readiness, and command,
control, communications and intelligence (C\3\I).
--Wound management throughout the continuum of care, to include
chemical, molecular, and cellular indicators of optimum time
for surgical wound closure, comprehensive rehabilitation; and
reset to operational fitness.
--Hearing restoration and protection for operational maritime surface
and air support personnel.
--Undersea medicine, diving and submarine medicine, including
catastrophe intervention, rescue and survival as well as
monitoring and evaluation of environmental challenges and
opportunities.
During my travel overseas this past year, including Vietnam,
current partnerships and future partnerships possibilities between Navy
Medicine and host nation countries were evident. Increasing military
medical partnerships are strengthening overall military to military
relationships which are the cornerstone of overarching bilateral
relations between allies. These engagements are mutually beneficial--
not only for the armed forces of both countries, but for world health
efforts with emerging allies in support of global health diplomacy.
Graduate Medical Education (GME) is vital to our ability to train
our physicians and meet our force health protection mission. Vibrant
and successful GME programs continue to be the hallmark of Navy
Medicine and I am pleased that despite the challenges presented by a
very high operational tempo and past year recruiting shortfalls, our
programs remain strong. All of our GME programs eligible for
accreditation are accredited and most have the maximum or near maximum
accreditation cycle lengths. In addition, our graduates perform very
well on their Specialty Boards--significantly exceeding the national
pass rate in almost every specialty year after year. The overall pass
rate for 2009 was 97 percent. Most importantly, our Navy-trained
physicians continue to prove themselves to be exceptionally well
prepared to provide care in austere settings from the battlefield to
disaster relief missions.
In addition to GME, we are leveraging our inter-service education
and training capabilities with the new state-of-the-art Medical
Education and Training Campus (METC) in San Antonio, Texas. Now
operational, METC represents the largest consolidation of Service
training in the history of DOD, and is the world's largest medical
training campus. Offering 30 programs and producing 24,000 graduates
annually, METC will enable us to train our Sailors, Soldiers and Airmen
to meet both unique Service-specific and joint missions. Our corpsmen
are vital to saving lives on the battlefield and the training they
receive must prepare them for the rigors of this commitment. 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
corpsmen bring to the Navy and Marine Corps--in hospitals, at sea and
on the battlefield.
COLLABORATION ENGAGEMENT
Navy Medicine recognizes the importance of leveraging collaborative
relationships with the Army and Air Force, as well as the Department of
Veterans Affairs (VA), and other Federal and civilian partners. These
engagements are essential to improving operational efficiencies,
education and training, research and sharing of technology. Our
partnerships also help create a culture in which the sharing of best
practices is fundamental to how we do business and ultimately helps us
provide better care and seamless services and support to our
beneficiaries.
The progress we are making with the VA was clearly evident as we
officially activated the Captain James A. Lovell Federal Health Care
Center in Great Lakes, Illinois--a first-of-its-kind fully integrated
partnership that links Naval Health Clinic Great Lakes and the North
Chicago VA Medical Center into one healthcare system. We are grateful
for all your support in helping us achieve this partnership between the
Department of Veterans Affairs, DOD and DON. We are proud to able to
provide a full spectrum of healthcare services to recruits, active
duty, family members, retirees and veterans in the Nation's first fully
integrated VA/Navy facility. We look forward to continuing to work with
you as we improve efficiencies, realize successes and implement lessons
learned.
Navy Medicine has 52 DOD/VA sharing agreements in place for medical
and ancillary services throughout the enterprise as well as 10 Joint
Incentive Fund (JIF) projects. When earlier JIF projects ended, they
were superseded by sharing agreements. Naval Health Clinic Charleston
and the Ralph H. Johnson VA Medical Center celebrated the opening of
the new Captain John G. Feder Joint Ambulatory Care Clinic. This newly
constructed outpatient clinic located on Joint Base Charleston Weapons
Station is a state-of-the-art 188,000 square foot facility that is
shared by the VA and the Navy Health Clinic Charleston. This project is
another joint initiative such as the Joint Ambulatory Care Center in
Pensacola that replaced the former Corry Station Clinic; and another in
Key West where the VA's Community Based Outpatient Clinic (CBOC) and
the Navy Clinic are co-located, continuing collaboration and providing
service at the site of our first VA/DOD Joint Venture.
We are also continuing to work to implement the Integrated
Disability Evaluation System (IDES) at our facilities in conjunction
with VA. To date, this program has been implemented at 15 of our MTFs.
This world-wide expansion, to be completed in fiscal year 2011, follows
the DES Pilot program and the decision of the Wounded, Ill and Injured
Senior Oversight Council (SOC) Co-chairs (Deputy Secretary of Defense
and Deputy Secretary of Veterans Affairs) to move forward to streamline
the DOD DES process.
One of our most important projects continues to be the successful
transition of the new Walter Reed National Military Medical Center
(WRNMMC) onboard the campus of the National Naval Medical Center,
Bethesda. This realignment is significant and the Services are working
diligently with DOD's lead activity, Joint Task Force Medical--National
Capital Region to ensure we remain on track to meet the Base
Realignment and Closure (BRAC) deadline of September 15, 2011. Our
priority continues to be properly executing this project on schedule
without any disruption of services. We also understand the importance
of providing a smooth transition for our dedicated personnel--both
military and civilian--to the success of WRNMMC. We recognize that
these dedicated men and women are critical to our ability to deliver
world class care to our Sailors, Marines, their families and all our
beneficiaries for whom we are privileged to serve.
THE WAY FORWARD
I am proud of the progress we are making, but not satisfied. We
continue to see ground-breaking innovations in combat casualty care and
remarkable heroics in saving lives. But all of us remain concerned
about the cumulative effects of worry, stress and anxiety on our
service members and their families brought about by a decade of
conflict. Each day during my tenure as the Navy Surgeon General, we
have been a Nation at war. Each day resonates with the sacrifices that
our Sailors, Marines and their families make, quietly and without
bravado. They go about their business with professionalism, skill, and
frankly, ask very little in return. It is this commitment, this
selfless service, that helps inspire us in Navy Medicine. Regardless of
the challenges ahead, I am confident that we are well-positioned for
the future.
I will be retiring from Naval Service later this year and I want to
express my thanks for all the support you provide to Navy Medicine and
to me throughout my tenure as the Navy Surgeon General.
Chairman Inouye. And now, may I call upon General Green.
STATEMENT OF LIEUTENANT GENERAL CHARLES B. GREEN,
SURGEON GENERAL, DEPARTMENT OF THE AIR
FORCE
General Green. Good morning.
Chairman Inouye, Senator Cochran, distinguished members of
the subcommittee, I truly appreciate the opportunity to meet
with you today and represent the men and women of the Air Force
Medical Service. 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. And we thank
you.
MILITARY HEALTH SYSTEM ACHIEVEMENTS
Military Health System achievements have changed the face
of war. We deploy and set up hospitals within 12 hours of
arrival anywhere in the world. We move wounded warriors from
the battlefield to operating rooms within minutes and have
achieved and sustained the less than 10 percent died of wounds
rate.
We move our sickest patients in less than 24 hours of
injury and get them home to loved ones within 3 days to hasten
their recovery.
We have safely evacuated more than 85,000 patients since
October 2001, 11,300 just this last year, many of them
critically injured.
The Air Force Medical Service has a simple mantra:
``Trusted Care Anywhere.'' This fits what we do today and will
continue to do in years ahead. It means creating a system that
can be taken anywhere in the world and be equally effective,
whether it is for war or for humanitarian assistance.
Air Combat Command's new Expeditionary Medical System, the
Health Response Team, is capable of seeing the first patient
within 1 hour of arrival anywhere in the world, and performing
surgery within 3 to 5 hours. Our Radiological Assessment Team
was in place quickly to assist Japan in measuring the levels of
radiation, food and water safety, overall impact on health, and
to distribute personal dosimeters for protection of our
personnel. Our deployed systems are linked back to American
quality care and refuse to compromise on patient safety.
Providing trusted care anywhere requires the Air Force
Medical Service to focus on patients and populations. By the
end of 2012, the Air Force Patient-Centered Medical Home will
provide 1 million of our beneficiaries new continuity of care
via single provider-led teams at all Air Force facilities.
Patient-Centered Care builds new possibilities in
prevention by linking the patient to a provider team, and both
the patient and the provider team to decision support from
informatics networks dedicated to improving care. Efficient and
effective health teams allow recapture of care in our medical
treatment facilities to sustain our currency and offer best
value. We will do all in our power to improve the health of our
population while working to control the rising costs of
healthcare.
The Air Force Medical Service treasures our partnership
with OSD, the Army, Navy, VA, civilian and academic partners.
We leverage all the tools that you have given us to improve
retention and generate new medical knowledge. We will continue
to deliver nothing less than world class care to military
members and their families, wherever they may serve around the
world.
PREPARED STATEMENT
And I stand ready to answer your questions. Thank you.
Chairman Inouye. All right. Thank you very much.
[The statement follows:]
Prepared Statement of Lieutenant General (Dr.) Charles B. Green
Military Health System achievements have changed the face of war.
We deploy and set up hospitals in 12 hours of arrival almost anywhere
in the world. We move wounded warriors from the battlefield to an
operating room within minutes and have achieved and sustained less than
10 percent died-of-wounds rate. We move our sickest patients in less
than 24 hours of injury and get them home to loved ones within 3 days
to hasten recovery. We have safely evacuated more than 86,000 patients
since October 2001, 11,300 in 2010 alone, many of them critically
injured. This is all pretty amazing.
The Air Force Medical Service (AFMS) has a simple mantra: ``Trusted
Care Anywhere.'' This fits what we do today and will continue to do in
the years ahead. It means creating a system that can be taken anywhere
in the world and be equally as effective whether in war or for
humanitarian assistance. This system is linked back to American quality
care and refuses to compromise on patient safety. These are formidable
challenges, but we have the foundation we need and the best creative
minds working with us to achieve this end.
Providing Trusted Care Anywhere requires the AFMS to focus on
patients and populations. Patient-centered care builds new
possibilities in prevention by linking the patient to a provider team
and both patient and provider team to an informatics network dedicated
to improving care. Efficient and effective health teams allow recapture
of care in our medical treatment facilities (MTFs) to sustain currency.
Continually improving our readiness ensures patients and warfighters
always benefit from the latest medical technologies and advancements.
PATIENT-CENTERED MEDICAL HOME
To improve Air Force primary care and achieve better health
outcomes for our patients, we implemented our Family Health Initiative
(FHI) in 2009, which is a team-based, patient-centered approach
building on the Patient-Centered Medical Home (PCMH) concept
established by the American Academy of Family Physicians. We aligned
existing resources and now have PCMH at 32 of our MTFs caring for
340,000 enrolled patients. By the end of 2012, 1 million of our
beneficiaries will have a single provider and small team of
professionals providing their care at all AFMS facilities. This means
much greater continuity of care, with our patients seeing the same
physician or their professional partner 95 percent of the time. The
result is more effective healthcare based on trust and rapport for both
the patient and the provider.
Air Force Medical Home integrates the patient into the healthcare
team, offering aggressive prevention and personalized intervention.
Physicians will not just evaluate their patients for disease to provide
treatment, but also to identify risk of disease, including genetic,
behavioral, environmental and occupational risks. The healthcare team
will encourage healthy lifestyle behavior, and success will be measured
by how healthy they keep their patients, rather than by how many
treatments they provide. Our goal is that people will live longer lives
with less morbidity. We are already seeing how PCMH is bringing that
goal to fruition. For example, diabetes management at Hill AFB, Utah,
showed an improvement in glycemic control in 77 percent of the diabetic
population, slowing progression of the disease and saving over $300,000
per year.
Patient feedback through our Service Delivery Assessment survey
shows an overall improvement in patient satisfaction for patients
enrolled in PCMH, with the greatest improvement noted in the ability to
see a personal provider when needed. As relationships develop, our
providers will increase their availability to patients after hours and
through secure patient messaging. This will further enhance patient
satisfaction and reduce costs by minimizing emergency department
visits.
Our next step is to embark on an innovative personalized medicine
project called Patient Centered Precision Care, or PC\2\, that will
draw and build on technological and genetic based advances in academia
and industry. Effective, customized care will be guided by patient-
specific actionable information and risk estimation derived from robust
Health Information Technology applications. We're excited about our
collaboration opportunities with renowned partners, such as the Duke
Institute for Genome Sciences and Policy, IBM, and others.
Patient-centered care includes caring for Air Force special needs
families, and we are working closely with our personnel community to
ensure these families receive the specialized medical or educational
support they require. The Air Force Exceptional Family Member Program
(EFMP) is a collaborative and integrated program that involves medical,
family support, and assignment functions to provide seamless care to
these families. Enhanced communication of the program will be
facilitated by an annual Caring for People Forum at each installation,
giving families an opportunity to discuss concerns and receive advice.
Starting in fiscal year 2012, the Air Force will begin adding 36 full-
time Special Needs Coordinators at 35 medical treatment facilities
(MTFs) to address medical concerns and assignment clearance processes.
An important aspect of patient-centered preventive care includes
safeguarding the mental health and well-being of our people and
improving their resilience, because no one is immune to the stresses
and strains of life. While Air Force suicide rates have trended upward
since 2007, our rate remains below what we experienced before the
inception of our suicide prevention program in 1997. The most common
identified stressors and risk factors have remained the same over the
last 10 years: relationship, financial and legal problems. Although
deployment can stress Airmen and their families, it does not seem to be
an individual risk factor for Airmen, and most Airmen who complete
suicide have never deployed. We are redoubling our efforts to prevent
suicide and specifically target those identified at greatest risk.
We use the Air Force Post-deployment Health Assessment (PDHA) and
Post-deployment Health Reassessment (PDHRA) to identify higher risk
career groups for post-traumatic stress disorder (PTSD). While most Air
Force career fields have a very low rate of PTSD, others such as EOD,
security forces, medical, and transportation have higher rates of post
traumatic stress symptoms.
Advances in treatment, such as the Virtual Reality Exposure Therapy
(VRET) system we call ``Virtual Iraq,'' have been fielded to treat
service members returning from theater with PTSD and other related
mental health disorders. This system is founded on two well established
forms of psychotherapy: Cognitive-Behavioral Therapy and Prolonged
Exposure Therapy. VRET is now deployed at 10 Air Force mental health
clinics and is lauded by patients.
The Air Force provides additional support to our most at-risk
Airmen with frontline supervisor's suicide prevention training given to
all supervisors in career fields with elevated suicide rates. Mental
health providers are seeing patients in our primary care clinics across
the Air Force. They see patients who may not otherwise seek care in a
mental health clinic because of perceived stigma. We have significantly
expanded counseling services beyond those available through the
chaplains and mental health clinic. Other helping programs include
Military Family Life Consultants, who see individuals or couples; and
Military OneSource, which provides counseling to active duty members
off-base for up to 12 sessions.
A recent example of how suicide prevention skills saved a life is
the story of how Senior Airman Jourdan Gunterman helped save a friend
from halfway around the world in Afghanistan. His training first helped
him recognize the warning signs of a friend in trouble: drinking
heavily, violent outbursts, disciplinary actions, and recent discharge
from the Air Force following a challenging deployment. A cryptic
emotional message on Facebook from the friend led Airman Gunterman to
question his friend's disturbing behavior. He discovered his friend had
ingested a bottle of pills.
When his troubled friend no longer responded, Airman Gunterman
obtained the friend's phone number on-line from another friend, Senior
Airman Phillip Sneed, in Japan. Airman Sneed promised to keep calling
the friend until he picked up. Meanwhile Airman Gunterman enlisted the
help of his chaplain to locate the suicidal friend. Finally, locating a
hometown news release about his friend, Airman Gunterman was able to
learn his friend's parents' names and then used a search engine to find
their address. He contacted the local police, who rushed to the
friend's house and saved him. Airman Gunterman is an expert with social
media--but more important--he is an incredible wingman who saved his
buddy's life.
Resiliency is a broad term that describes the set of skills and
qualities that enable Airmen to overcome adversity and to learn and
grow from experiences. It requires a preventive focus based on what we
have learned from individuals who've been through adversity and
developed skills to succeed. Distilling those skills and teaching them
will lead to a healthier force.
The Air Force uses a targeted resiliency training approach,
recognizing different Airmen will be in different risk groups. For
those who have higher exposure to battle, we have developed initiatives
such as the Deployment Transition Center (DTC) at Ramstein Air Base,
Germany, which opened in July. The DTC provides a 2-day reintegration
program en route from the war zone, involving chaplain, mental health,
and peer facilitators. The DTC provides training, not treatment--the
focus is on reintegration into work and family. Feedback from deployers
has been overwhelmingly positive.
We teach our Airmen that seeking help is not a sign of weakness,
but a sign of strength. Lieutenant Colonel Mary Carlisle is an Air
Force nurse who struggled with PTSD following her deployment. She
shares her story of how she was able to overcome PTSD by seeking help
and treatment. She realized that she would be affected forever, but is
now more resilient from her experience and treatment. She shared her
story with over 700 of my senior medics at a recent leadership
conference. Lt. Col. Carlisle's openness and leadership are an
invitation to others to tell their stories, and in so doing change our
culture and shatter the stigma associated with mental healthcare.
In addition to the Air Force-wide approach, some Air Force
communities are pursuing other targeted initiatives. The highly
structured program used by Mortuary Affairs at Dover AFB, Delaware,
where casualties from OIF and OEF are readied for burial, is now being
used as a model for medics at our hospitals in Bagram, Afghanistan, and
Balad, Iraq, where the level of mortality and morbidity are much higher
than most medics see at home station MTFs. The Air Force continually
seeks to leverage existing ``best practice'' programs such as Dover's
for Air Force-wide use. If we can help our Airmen develop greater
resiliency, they will recover more quickly from stresses associated
with exposure to traumatic events.
RECAPTURING CARE AND MAINTAINING CURRENCY
Trusted Care means good stewardship of our resources. In an era of
competing fiscal demands and highly sought efficiencies, recapturing
patients back into our MTFs is critical. Where we have capability, we
can provide their care more cost-effectively by managing care in our
facilities. Equally important is building the case load and complexity
needed to keep our providers' skills current to provide care wherever
the Air Force needs them. We have expanded our hospitals and formed
partnerships with local universities and hospital systems to best
utilize our skilled professionals.
We value our strong academic partnerships with St. Louis
University; Wright State University (Ohio); the Universities of
Maryland, Mississippi, Nebraska, Nevada, California and Texas, among
others. They greatly enrich our knowledge base and training
opportunities as well as provide excellent venues for potential
resource sharing.
Since the early 1970s, many Air Force Graduate Medical Education
(GME) programs have been affiliated with civilian universities. Our
affiliations for physician and dental education at partnership sites
have evolved to include partnership sponsoring institutions for
residencies. In addition, our stand-alone residency programs have
agreements for rotations at civilian sites. Our Nurse Education
Transition Program (NETP) and Nurse Enlisted Commissioning Program
(NECP) have greatly benefited from academic partnerships. The NETP is
available at 11 sites with enrollment steadily increasing, while the
NECP enrolls a total of 50 nursing students per year at the nursing
school of their choice. A nursing program partnering with Wright State
University and Miami Valley College of Nursing in Ohio, and the
National Center for Medical Readiness Tactical Laboratory has produced
a master's degree in Flight Nursing with Adult Clinical Nurse
Specialist in disaster preparedness, a first of its kind in the
country.
Our GME programs are second to none. Our first-time pass rates on
specialty board exams exceed national rates in 26 of 31 specialty
areas. Over the past 4 years, we've had a 92 percent overall first time
board pass rate. I am very proud of this level of quality in our medics
and grateful to our civilian partners who help make Air Force GME a
success.
Partnerships leveraging our skilled work force prepare us for the
future. Our Centers for the Sustainment of Trauma and Readiness (C-
STARS) in Baltimore, Cincinnati and St. Louis continue to provide our
medics the state-of-the-art training required to treat combat
casualties. In 2009 we complemented C-STARS with our Sustainment of
Trauma and Resuscitation Program (STARS-P) program, rotating our
providers through Level 1 trauma centers to hone their war readiness
skills. Partnerships between Travis AFB and University of California at
Davis; Nellis AFB, and University Medical Center, Nevada; Wright-
Patterson AFB and Miami Valley Hospital; Luke AFB and the Scottsdale
Health System; MacDill AFB and Tampa General Hospital; and others, are
vital to sustaining currency.
Our hospitals, C-STARS and STARS-P locations are enhanced by the
Air Force medical modeling and simulation Distributed High-Fidelity
Human Patient Simulator (DHPS) program. There are currently 80 programs
worldwide and the AFMS is the Department of Defense lead for medical
simulation in healthcare education and training. Over the next year, we
will link the entire AFMS using Defense Connect Online and our new Web
tele-simulation tool. This will enable all Air Force MTFs to play real
time medical war games that simulate patient management and movement
from point of injury to a Level 3 facility and back to the States.
Our partnership with the Department of Veterans Affairs (VA) has
provided multiple avenues for acquiring service, case mix, and staffing
required for enhancing provider currency. Direct sharing agreements,
joint ventures and the Joint Incentive Fund (JIF) have all proved to be
outstanding venues for currency and collaboration.
A great example is the JIF project between Wright-Patterson Medical
Center and the Dayton VA. The expansion of their radiation-oncology
program includes a new and promising treatment called stereotactic
radio surgery. This surgery, really a specialized technique, allows a
very precise delivery of a single high dose of radiation to the tumor
without potentially destructive effects to the surrounding tissues.
Without a single drop of blood, the tumor and its surrounding blood
supply are destroyed, offering the patient the hope of a cure and
treatment that has fewer side effects.
In another Air Force/VA success story, Keesler AFB, MS and VA Gulf
Coast Veterans Health Care System Centers of Excellence Joint Venture
is receiving acclaim. Ongoing clinical integration efforts have shown
an increase in specialty clinic referrals. Plans for continued
integration are on track, with many departments sharing space and staff
by fiscal year 2012 and the joint clinic Centers of Excellence in place
by fiscal year 2013.
Providing a more seamless transition for Airmen from active duty to
the VA system remains a priority. This process has been greatly
enhanced with the Integrated Disability Evaluation System (IDES).
Expansion of the initial pilot program is occurring by region in four
stages, moving west to east, and centered around the VA's Veteran
Integrated Service Networks (VISN). Phase 3 of the expansion has added
an additional 18 Air Force MTFs for a total of 24. The Services and the
VA continue to conduct IDES redesign workshops to further streamline
the process to be more timely and efficient for all transitioning
Service members. The goal is to provide coverage for all Service
members in the IDES by September 2011.
We continue to look for innovative ways and new partnerships to
meet our currency needs and provide cutting-edge care to our military
family. We will expand partnerships with academic institutions and the
VA wherever feasible to build new capabilities in healthcare and
prevent disease.
CONTINUOUSLY IMPROVING READINESS ASSETS
We have made incredible inroads in our efforts to be light, lean
and mobile. Not only have we vastly decreased the time needed to move
our wounded patients, we have expanded our capabilities. Based on
lessons learned from our humanitarian operations in Indonesia, Haiti
and Chile, we developed obstetrics, pediatrics and geriatrics modules
that can be added to our Expeditionary Medical System (EMEDS). We
simply insert any of these modules without necessarily changing the
weight or cube for planning purposes. Medics at Air Combat Command are
striving to develop an EMEDS Health Response Team (HRT) capable of
seeing the first patient within 1 hour of arrival and performing the
first surgery within 3-5 hours. We will conduct functional tests on the
new EMEDS in early 2011.
On the battlefield, Air Force vascular surgeons pioneered new
methods of hemorrhage control and blood vessel reconstruction based on
years of combat casualty experience at the Air Force Theater Hospitals
in Iraq and Afghanistan. The new techniques include less invasive
endovascular methods to control and treat vascular injury as well as
refinement of the use of temporary shunts. Their progress has saved
limbs and lives and has set new standards, not only for military
surgeons, but also for civilian trauma.
A team of medical researchers from the 59th Medical Wing Clinical
Research division has developed a subject model that simulates leg
injuries seen in Iraq and Afghanistan to enable them to try
interventions that save limbs. The team is also studying how severe
blood loss affects the ability to save limbs. Their findings show blood
flow should be restored within the first hour to avoid muscle and nerve
damage vs. traditional protocol that allowed for 6 hours. Team member
and general surgery resident Captain (Dr.) Heather Hancock, stated,
``You cannot participate in research designed to help our wounded
soldiers and not be changed by the experience.''
We are also advancing the science and art of aeromedical evacuation
(AE). We recently fielded a device to improve spinal immobilization for
AE patients and are working as part of a joint Army and Air Force team
to test equipment packages designed to improve ventilation, oxygen,
fluid resuscitation, physiological monitoring, hemodynamic monitoring
and intervention in critical care air support.
We are finding new ways to use specialized medical equipment for
our wounded warriors. In October, we moved a wounded Army soldier with
injured lungs from Afghanistan to Germany using Extracorporeal Membrane
Oxygenation (ECMO) support through the AE system--the first time we
have used AE ECMO for an adult. The ECMO machine provides cardiac and
respiratory support for patients with hearts and/or lungs so severely
diseased or damaged they no longer function. We have many years of
experience with moving newborns via the 59th Medical Wing (Wilford
Hall) ECMO at Lackland AFB, Texas, but the October mission opened new
doors for wounded care.
Another new tool in battlefield medicine is acupuncture. The Air
Force acupuncture program, the first of its kind in DOD, has expanded
beyond clinic care to provide two formal training programs. Over 40
military physicians have been trained. We recognize the success of
acupuncture for patients who are not responding well to traditional
pain management. This is one more tool to help our wounded Soldiers and
Airmen return to duty more rapidly and reduce pain medication usage.
We've made progress with electronic health records in the Theater
Medical Information Program Air Force (TMIP-AF), now used by AE and Air
Force Special Operations. TMIP-AF automates and integrates clinical
care documentation, medical supplies, equipment and patient movement
with in-transit visibility. Critical information is gathered on every
patient and entered into our deployed system. Within 24 hours, records
are moved and safely stored in our databases stateside.
Established in May 2010 with the Air Force as lead component, the
Hearing Center of Excellence (HCE) is located at Wilford Hall in San
Antonio, TX. This center continues to work closely with Joint DOD/VA
subject matter experts to fine-tune concepts of operation. Together we
are moving forward to achieve our goals in the areas of outreach,
prevention, care, information management and research to preserve and
restore hearing.
DOD otologists have worked internally and with NATO allies to
investigate emerging implant technologies and have developed plans to
test a central institutional review board (IRB) in a multi-site,
international study to overcome mixed hearing loss. The HCE is also
pursuing standardization of minimal baseline audiometric testing and
point of entry hearing health education within DOD. They are working
with the Defense Center of Excellence for Psychological Health and
Traumatic Brain Injury (DCoE) to establish evidence-based clinical
practice guidelines for management of the post-traumatic patient who
suffers from dizziness. The HCE has worked with analysts within the
Joint Theater Trauma System to develop the Auditory Injury Module (AIM)
to collect auditory injury data within the Joint Theater Trauma
Registry (JTTR). These, among others, are critical ways the HCE
supports the warfighter in concert with our partners at DCoE and the
VA.
All of these advances I've addressed are critical to improving
medical readiness, but the most important medical readiness assets are
our people. Recruiting and retaining top-notch personnel is
challenging. We continue to work closely with our personnel and
recruiting partners to achieve mission success. Optimizing monetary
incentives, providing specialty training opportunities, and maintaining
a good quality of life for our members are all essential facets to
maintaining a quality workforce.
The AFMS continues to optimize the use of monetary incentives to
improve recruiting and retention. We are working with the Air Force
personnel and recruiting communities to develop a sustainment model
specific for each of the AFMS Corps. Specifically, we are targeting the
use of special pays, bonuses, and the Health Professions Scholarship
Program (HPSP) to get the greatest return on investment. Congress'
support of these programs has helped to maintain a steady state of
military trained physicians, dentists, nurses, and mental health
professionals.
The new consolidated pay authority for healthcare professionals
allows greater flexibility of special pays to enhance recruitment and
retention of selected career fields. While we use accession bonuses to
attract fully qualified surgeons, nurses, mental health specialists,
and other health professionals to the AFMS, HPSP remains the number one
AFMS pipeline for growing our own multiple healthcare professionals.
We were able to execute 100 percent of HPSP in fiscal year 2009 and
fiscal year 2010 and were able to graduate 219 and 211 new physicians,
respectively, in these years. In fiscal year 2010, 49 medical school
graduates from the Uniformed Services University of the Health Sciences
also joined the Air Force Medical Service. These service-ready
graduates hit the ground running. Specialized military training and
familiarity with the DOD healthcare system ensures more immediate
success when they enter the workforce. Once we have recruited and
trained these personnel, it is essential that we are able to keep them.
We are programming multiyear contractual retention bonuses at
selectively targeted healthcare fields such as our physician and dental
surgeons, operating room nurses, mental health providers, and other
skilled healthcare professions to retain these highly skilled
practitioners with years of military and medical expertise.
For our enlisted personnel, targeted Selective Reenlistment
Bonuses, combined with continued emphasis on quality of life, generous
benefits, and job satisfaction, positively impact enlisted recruiting
and retention efforts. Pay is a major component of recruiting and
retention success, but we have much more to offer. Opportunities for
education, training, and career advancement, coupled with state-of-the-
art equipment and modern facilities, serve together to provide an
excellent quality of life for Air Force medics. Successful and
challenging practices remain the best recruiting and retention tool
available.
We look 20 to 30 years into the future to understand evolving
technologies, changing weapon systems, and changes in doctrine and
tactics to protect warfighters from future threats. This ensures we
provide our medics with the tools they need to fulfill the mission.
We continue to build state-of-the-art informatics and telemedicine
capabilities. Care Point now allows individual providers to leverage
our vast information databases to learn new associations and provide
better care to patients. These same linkages allow our Applied Clinical
Epidemiology Center to link healthcare teams and patients with best
practices. VTCs are now deployed to 85 of our mental health clinics
broadening the reach of mental health services, and our teleradiology
program provides digital radiology systems interconnecting all Air
Force MTFs, enabling diagnosis 24/7/365.
We are engaged in exciting research with the University of
Cincinnati to enhance aeromedical evacuation, focusing on the
challenges of providing medical care in the darkened, noisy, moving
environments of military aircraft. We are studying how the flight
environment affects the body, and developing possible treatments to
offset those effects. Clinical studies are examining the amount of
oxygen required when using an oxygen-concentrating device at higher
altitudes. Simulators recreate the aircraft medical environments and
are used extensively to train our medical crews. This new research
expands our knowledge and training opportunities, and offers the
possibility of future partnering efforts.
We are also developing directed energy detection and laser assisted
wound healing; advancing diabetes prevention and education; and
deploying radio frequency identification technology in health
facilities. We partner with multiple academic institutions to advance
knowledge and apply evidence based medicine and preventive strategies
with precision. These are some of the critical ways we seek to improve
readiness, advance medical knowledge and keep the AFMS on the cutting
edge for decades to come.
THE WAY AHEAD
While at war, we are successfully meeting the challenges of Base
Realignment and Closure as we draw near to the 2011 deadline. We have
successfully converted three inpatient military treatment facilities to
ambulatory surgery centers at MacDill AFB, Florida; Scott AFB,
Illinois; and the USAF Academy, Colorado. By September of this year,
the medical centers at Lackland AFB, Texas; and Joint Base Andrews,
Maryland are on track to convert to ambulatory surgery centers. The
medical center at Keesler AFB, Mississippi, is poised to convert to a
community hospital. Medical Groups at Joint Base Lewis-McChord,
Washington and Pope AFB, North Carolina have been effectively realigned
as Medical Squadrons. Military treatment facilities at Shaw AFB, South
Carolina; Eglin AFB, Florida; Joint Base McGuire, New Jersey; and Joint
Base Elmendorf, Alaska; have been resourced to support the migration of
beneficiaries into their catchment areas as a result of BRAC
realignments.
At Wright-Patterson AFB, Ohio, we have relocated cutting-edge
aerospace technology research, innovation, and training from Brooks
AFB. In tandem with our sister Services, we have also relocated basic
and specialty enlisted medical training to create the new Medical
Education and Training Campus (METC), the largest consolidation of
training in DOD history.
Our strategy to control DOD healthcare costs is the right approach
to manage the benefit while improving quality and satisfaction.
Adjustments to the benefit such as minimally raising TRICARE enrollment
fees for working retirees, requiring future enrollees to the U.S.
Family Health Plan to transition into TRICARE-for-Life upon turning 65
years of age, paying sole-source community hospitals Medicare rates,
and incentivizing the use of the most effective outlets for
prescriptions are prudent. There will be limited impact (prescription
only) on active duty family members. By implementing these important
measures we will be able to positively affect the rising costs of
healthcare and improve the health of our population.
The AFMS is firmly committed to MHS goals of readiness, better
health, better care and best value. We understand the value of teaming
and treasure our partnerships with the Army, Navy, VA, academic
institutions, and healthcare innovators. We will continue to deliver
nothing less than world-class care to military members and their
families, wherever they serve around the globe. They deserve, and can
expect, Trusted Care Anywhere. We thank this Subcommittee for your
support in helping us to achieve our mission.
RECRUITING MEDICAL PROFESSIONALS
Chairman Inouye. General Green, let us start with you.
The subcommittee has been advised that an important aspect
of your work is the recruiting of medical professionals, and
you need them to carry out the services. But I have been told
that it is a challenge because, for example, the Government
Accountability Office (GAO) reported that hiring civil servants
at the Defense Centers of Excellence for Traumatic Brain Injury
took an average of about 4 months. And the nomination of
medical officers can take just as long. What are you doing to
streamline this effort?
General Green. Sir, your information is correct. It can
take significant time to bring a fully qualified individual on
board. Our major effort in terms of what we as medics have been
doing is to shift some of our recruiting for fully qualified
and the dollars associated into our scholarship programs. And
over the last 3 to 4 years, we have expanded our scholarships
through the Health Professional Scholarship Program by nearly
400, from about 1,266 to 1,666. This is not just used for
physicians, but also for pharmacists and for psychologists,
trying to bring in the right expertise. And although there is a
longer trail to get these folks, we now have a more reliable
understanding of what is in the pipeline and when we will we
have solutions.
With regard to the specific questions regarding hiring
civilians, we find frequently that we have to go after
contractors rather than using general schedule (GS). It takes a
little longer to get GS positions on our books, and so, when we
have a more immediate need, we will substitute a contractor
until we can get those positions into our books where we can
use them. There has been a lot of effort in our A-1 community
to try and streamline civilian hiring, and we are making
progress. If you would have asked me this same question really
within the last 1\1/2\ or 2 years, you would not have been
talking to me about 4 months; you might have been talking about
6 months and longer. And so, we are making progress in terms of
our civilian hiring.
When you talk to the military side and the scroll process
in terms of how we get our officers, we continue to work with
our A-1 personnel community to try and shorten that process.
And when needed for specific expertise, we have been able to
come through the process more rapidly. But it remains a
process, as defined in law, that is fairly lengthy to ensure we
bring the right people when we are bringing them on our books
as Federal employees.
MEDICAL PAY SCALES
Chairman Inouye. Do you find that the pay scale provided is
competitive?
General Green. I think that we have many special pays
available, not just to the military, but also to our GS that
does make them competitive. It is on the Active duty side, we
certainly have a dynamic ability to move dollars to the
specialties that we need and make ourselves competitive. On the
civilian side, it is sometimes more difficult, but there are
pays associated that do drive for the non-super specialist
competitive pay. If you are asking me if I can get in the GS
world a competitive salary for a neurosurgeon, the answer is
no, and it has to do with what the civilian world is driving in
terms of salaries for these folks. But that is not true
necessarily for some of the areas where we are the shortest in
terms of our flight surgeons and our family practitioners. When
you start talking to trauma surgeons, particularly to try and
hire them into a GS position, that is more difficult.
And so, from a military perspective, the answer is, we have
the authorities we need to offer pay that will retain and
recruit new members on the GS side. I think that we are
competitive in the primary care specialties, but not as
competitive in the sub-specialties.
Chairman Inouye. All right. Thank you very much. I will be
submitting questions, if I may.
General Green. Yes, sir, of course.
Chairman Inouye. Admiral Robinson, when I first visited
Afghanistan, I was impressed and surprised to note that the
Navy was running the hospital, and it was landlocked.
MEDICAL SERVICES TO DEPLOYED MARINES
Admiral Robinson. It still is.
Unidentified Speaker. We are under the bridge now.
Admiral Robinson. We tried to move it to the water, but it
did not work.
Chairman Inouye. How do you provide services to, say, the
marines that are usually deployed to forward operating bases? I
notice that some of the reports coming in indicate the
difficulty involved in evacuating them. Do you have any special
techniques?
Admiral Robinson. No, sir. I am not sure I understand your
question. How do we provide support to forward deployed medical
personnel or forward deployed naval personnel?
Chairman Inouye. Forward deployed marines.
Admiral Robinson. Marines, I am sorry. Forward deployed
marines have--we have a methodology that includes having with
them FRSs, forward resuscitative surgical teams, and also
surgical trauma platoons that usually operate with the marines
in their forward areas.
The first line of medical defense or the first line of
medical operations would be the corpsmen. The corpsmen are
there and are going to provide the type of emergency care with
tourniquets and with the ABCs, airway, breathing, and
circulation control. That is going to be followed by the
corpsmen teaching buddy care to the other marines that are in
the units that are there. This is very important because very
often my corpsmen are also injured and injured in very grave
ways. So often, the immediate care that they need has to come
from a buddy who has in fact been instructed in the proper
utilization and the use of tourniquets.
As the injuries occur and as the word gets out that we have
injuries, we then have the FRSs, the forward resuscitative
surgical teams, that are forward deployed and can do
resuscitative surgery in a very timely fashion. The
resuscitative surgery is meant to be lifesaving only--to
staunch the bleeding, to meet the immediate needs of the
patient to restore circulation, to restore volume, and then to
evacuate the patient to a higher level of care, which is
usually at a Role 3 facility, such as Kandahar.
Chairman Inouye. All right. Thank you very much. And I will
be submitting more questions, if I may.
Admiral Robinson. Yes, sir.
Chairman Inouye. General, I am constantly amazed at the
advancements we have made in medicine, plus other things like
body armor and greater armor on our trucks and vehicles. And,
for example, I was pleased with some of the advancements made
in protecting hearing because of the explosions in the cars.
But I am well aware that you are currently working on many
other advancements. I will give you an opportunity to brag
about it now. What are we doing?
General Schoomaker. Well, sir, I think you have heard my
colleagues describe--and you yourself described--some of the
things that you have seen improvements in since you were a
soldier in the Second World War. And those advances are
really--have taken place, as you point out, all the way from
protecting soldiers--changing combat tactics on the
battlefield--to further protect soldiers and reduce risks, to
the development of improved body armor, vehicles, combat
goggles, ballistic goggles, hearing protection, better helmets,
and the like. In fact, we have a program that is done in a
joint environment. In fact, most of what is being described
here and what you have alluded to is actually a joint effort,
meaning all services are involved in either--even other
agencies.
The program to improve body armor, personal protective
equipment for the soldier or their vehicles, and aviation
equipment is known as the Joint Theater Analysis for Protection
of Injury in Combat, the JTAPIC program. And this tracks
injuries, both survivable and non-survivable injuries, and then
looks at the vehicle, the personal protective equipment, and
goes to the next level to develop a better protection, a better
vehicle for them. And that has been very successful.
But we have done what Admiral Robinson talked about. We
have better trained the individual combatant as to how they can
do lifesaving on themselves. We have issued better bandages to
the individual soldier, a tourniquet for every soldier, and we
train young soldiers to be almost medics, combat lifesavers.
So, it is frequent that a combatant who is injured in combat
would be first treated by himself or a colleague, and then a
medic would appear on the scene, or a corpsmen in the case of
the Navy. That corpsman is better trained and that medic is
better trained than in past wars.
And then evacuation has improved. We have seen recently in
Afghanistan when we visited that the footprint of air
evacuation, which is largely through the Army, is very robust.
In fact, every casualty in which a aircraft is not launched
within 15 minutes of having a request or does not complete the
mission within 60 minutes, is briefed all the way up to the top
of the Department of Defense really, and they have to explain
why they could not meet that Golden Hour. And that is generally
because of weather or operational, or someone makes a
decision--an appropriate clinical decision--to overfly the most
immediate, you know, surgical site to go to a better and more
definitive care site. That has been very successful.
We have also placed critical care nurses now on the--
selected medivac flights and have seen improvements in
survival.
A consequence of all of this through the Joint Theater
Trauma System is that incrementally we have improved every
stage of care of the combatant from the point of injury through
the evacuation chain to forward resuscitative care and how
surgeons are doing. We are really directing even trauma care
for the world at large in the civilian sector, who benefited
greatly from and have contributed to our understanding of this.
What we are currently seeing as a consequence of that--I
will just make a note of this--is that the survivors of some of
these really grievous wounds now are not they themselves very
grievously wounded. And we are working in concert with the
other services and the VA to better care for a much more
complex injury than we have seen in previous conflicts, or even
earlier in this conflict.
I hope that addresses your question, sir.
Chairman Inouye. Yes. I have just one other.
A couple of years ago, I learned at one of these hearings
that the man who is deployed out on the front lines has on his
body something like 100 pounds of armor and equipment. And so,
I took a special effort to weigh what I had to carry, and mine
was less than 25 pounds. That included a medical kit and
ammunition boots, helmet, my gun. Can we lighten the load?
General Schoomaker. Yes, sir. There is a very active
program in the Army, and I think in all the services. The
Soldier Program is intended to do exactly what you have talked
about, but I think there are limitations to the weight and
cube. Every item that goes into the basic load for a combat
soldier, right down to the packaging of their meals or the
material that goes into their uniforms, is evaluated for its
relative contribution for cost and weight.
But you heard Sergeant Giunta, who is our first living
recipient of the Medal of Honor, when you honored him here in
Congress, mentioned that he used to complain about those
ceramic sappy plates and his body armor until he was shot twice
and survived it. And he said, I'll never complain about
carrying that load again. It is a very delicate balance, and I
do not mean to trivialize or minimize what the soldier or the
marine, any combatant is carrying. But I think it is an active
process of looking at reducing that weight.
Chairman Inouye. Thank you very much.
Senator Cochran.
Senator Cochran. Mr. Chairman, thank you.
Thank you all for being here this morning and helping us
with your assessment of the needs for funding of the programs
and activities of the U.S. military. We appreciate your careers
of service.
I was especially taken with the comments about how in our
medical assessment of fitness for duty--I think General
Schoomaker made this point--after a person has fulfilled a
requirement of service of tours of duty on a voluntary basis,
and there is a question about fitness or physical impairment
caused by service in the military, that there are two really
distinct questions that have to be answered when there is a
claim for disability. One is an assessment of fitness for duty,
which is a military issue, and the other is a medical issue.
How do you sort out the differences and what the impacts are in
terms of individual claims under our current state of the law?
Would you like to take a shot at that first, General
Schoomaker?
General Schoomaker. I will, then I would love to hear from
General Green, who is actually one of the co-chairs of the
Disability Evaluation System for the--a review for the
Department of Defense. I do not mean to pass the buck here, but
we have been sort of fighting this war for, literally and
figuratively, for a very long time, Senator, so I appreciate
that question.
The current law and policy that governs the disability
adjudication for an individual soldier--I am a solider, so I
will use the term soldier, but it extends to sailors, airmen,
and marines as well--is a dual system in which the military
makes a judgment about any conditions which are unfitting for
service, and then makes a decision about the unfitting
condition that would lead to separation of that soldier.
Ironically, the termination of the disability that derives
from that condition is identical to what the Veterans
Administration uses. We actually use the same tables; they were
developed in concert. But then the Veterans Administration--the
Veterans Benefits Administration--looks at the same soldier and
the same constellation of problems, but adjudicates disability
on the basis of the whole person concept, in which every
individual illness or injury, current or past, can be put into
the equation, and comes up with a whole person disability kind
of equation.
The two are high disparate. The difficulty we face is that
soldiers get direct benefits from the military on the basis for
that single unfitting condition. And as benefits have improved,
especially--health benefits under the TRICARE program, if you
can pass in the military side a critical threshold of 30
percent disability, you are entitled then to the benefits of
healthcare for yourself, which follow any military medical
disability, but for your family as well. It has become a very,
very desirable benefit to have. And soldiers are confused and
their families are angered by the fact that we adjudicate for
only that one unfitting condition and yet pass to the VA, and
they see that, you know, had you been evaluated by a much
more--a much larger, more composite system, it might have been,
I would have been eligible for a higher degree of benefit from
that.
So we have eliminated some of the confusion and
miscommunication, and we have accelerated the rate at which
soldiers and their families can get VA benefits by this
integrative process whereby a single physical exam is conducted
by the VA in an adjudication of the total disability. But we
still are required under the current state to adjudicate in the
military system for the unfitting condition and in the VA
system for the total person. We are advocating for the DOD--the
Army--to adjudicate for--excuse me, determine unfitness, which
is our title X authority and requirement, but then pass to the
VA, which is--are the experts in disability adjudication, the
responsibility for doing more comprehensive disability
evaluation.
With that, with your permission, sir, I will just pass to
General Green.
Senator Cochran. Sure.
General Green.
ASSESSING PHYSICAL DISABILITY
General Green. Yes, sir. I am the co-chairman with Dr.
Karen Guice from the VA on the Recovering Warrior Task Force,
which has now had three meetings and basically three site
visits. We are still in our discovery phase, if you will, in
terms of the differences in approach between the services.
Within the current constraints, we do see--or current laws,
basically--we do see some differences as--in terms of each
service's approach. But there are similarities, and that is the
area where Dr. Schoomaker is talking. Basically, we now are all
using a single physical for the assessment of disability.
Because we all use the same tables, it makes sense for everyone
to use the same physical assessment.
The place where there is some variance is in the service's
assessment of ability to continue on active duty. Today once
the average soldier, sailor, or airman go through the DES
process, the current return to duty, even having gone all the
way through the DES, is about--I will use the Air Force's
numbers--17 to 20 percent in terms of being a little high. And
so, you would think that once the physical is done that we
could assess whether that person could stay on Active duty or
not and that it would not necessarily go through the remainder
of the disability system evaluation. But the way it is
currently being run, there are slight differences in terms of
each service.
The other thing that happens, as Dr. Schoomaker was
outlining, is that the VA looks at a total person for their
disability rating. So, whereas--I will use something non-combat
related. Whereas your cardiovascular disease may be significant
enough to prevent you from being able to stay on Active duty,
some of the other things that are rated in terms of the total
disability are not necessarily disabling for DOD service,
things like flat feet, or a recurrent rash, or mild hearing
loss, things that could actually--you could stay on Active duty
if you did not have the cardiovascular disease. And so, if we
were to move to a system wherein the DOD simply paid for the
total disability, there is a significant cost to the
Government, whereas the current system basically has DOD paying
for that ailment, if you will, that is disabling from further
service.
I think that as the task force continues, we will have some
recommendations. You folks have been kind enough to give the
task force some time to look at this as we kind of check out
whether the systems that have been put in place are providing
the best service to our recovering warriors. I do not want to
speak for the committee because we really are still in
discovery phase, but just to reaffirm the things we are seeing
confirmed, some of the things that Dr. Schoomaker is talking
about.
DISABILITY SERVICES
Senator Cochran. Admiral Robinson, do you have any comments
you would like to share with the subcommittee on that subject?
Admiral Robinson. Sir, I think it has been covered very
well. I just would make one comment. Usually General Schoomaker
makes a note about the fact that the disability system that we
use needs an overhaul since it is about 40 or 50 years old. And
I think that actually General Green's committee and a lot of
the input that we have given as SGs through the last 3 or 4
years--is getting us there. We are working hard on this.
Senator Cochran. Thank you very much.
Thanks, Mr. Chairman.
Chairman Inouye. Thank you.
Senator Mikulski.
Senator Mikulski. Mr. Chairman, and the Surgeon Generals.
First of all, we in Maryland feel very close to military
medicine. We are the home of Naval Bethesda, and in a short
time, sir, will be the home to Walter Reed Naval Bethesda, and
I hope this later this summer, perhaps the subcommittee could
go out and take a tour of what is being done there. And I think
we would be very proud of it.
We are proud of USU, which is the Military Medical School
in Nursing and Public Health, and Battleship Comfort--or, I
should say, not battleship. It fights other battles, but
Hospital Ship Comfort and Fort Detrick. So, we feel very close
to you.
In terms of our work here today, I am going to pick up on
the Dole-Shalala report. And I would like, General, to talk to
you because we went through a lot. And I want to just use that
as kind of the grid to see progress made and where we are
heading, okay?
So, in Dole-Shalala, first of all, remember what happened--
the terrible national scandal at Walter Reed. Secretary Gates
immediately responded. There was a change in personnel and I
think a real commitment to upgrade. And then, our own
colleague, Senator Dole, and Secretary Shalala issued this
great report.
Now, I am going to focus on issues related to preventing
and treating post-traumatic stress disorder and brain injury,
strengthening support for the families, and their
recommendations to transfer the work with VA-DOD, and the
workforce issues at Walter Reed.
The workforce issues, though, I think go well beyond acute
care medicine, and I will be raising that with our nurses in a
short time.
But, General, let us go to what Dole-Shalala recommended,
and I know you might not have the report before you. But it
said that we should aggressively treat post-traumatic stress
and traumatic brain injury, and yet now we are seeing in that--
so, could you tell me where we are in the progress made, how
you see it improving, and then tell me why we have such
increased rates of suicides and such increased rates of
addictions to the very drugs that are supposed to treat post-
traumatic stress?
General Schoomaker. Well, ma'am, a complex question with
several parts.
I think the last----
Senator Mikulski. But it goes to the heart of kind of where
we are in this.
General Schoomaker. Yes, ma'am. I do not deny that.
Let me try to address, first, suicides. I think the suicide
question is--remains a challenge and is perplexing for all of
the services. The Army saw a very disturbing doubling or more
of the suicide rate from where it was 6 or 7 years ago in which
it was age and employment adjusted and gender adjusted
comparison to the public at large, kept by the Centers for
Disease Control and Preventive medicine in Atlanta. We went
from roughly one-half of a comparable population in the United
States to being on par, if not exceeding that.
This is a problem that was tackled by the Vice Chief of
Staff of the Army himself, stood up a task force, which has
been in operation for almost 2 years now looking very carefully
at all the factors. And as it recently----
Senator Mikulski. But what are we doing where we are?
General Schoomaker. We have made this a commanders' and a
leaders' issue and problem. The factors that go into reducing
risks and identifying soldiers and families at risk, and the
many factors that lead to our soldiers turning to suicide in
desperation--as we have said, a permanent solution to temporary
problems that they may suffer----
Senator Mikulski. But do you feel that you are on track to
cracking this?
General Schoomaker. I think we are making progress, ma'am.
We are beginning to see--let me give you a----
Senator Mikulski. And this is not meant to be aggressive to
you. We have been down this road now for over 4 years.
General Schoomaker. Yes, ma'am, and it is--frankly, it has
involved bringing in national leaders in this--the National
Institutes for Mental Health for the $50 million Stars Program.
But as a real quick example of this, we got a notice the
other day from one of our posts that one of our warriors in
transition--that is, one of the soldiers going through an
injury and illness recovery--in interacting with the small unit
leader, dropped clues that she was in distress, wanted a
chronic pain problem solved permanently for her. And when she
could not be reached, the NCO leadership reached out to her,
actually drove to her home off post. When they could not get in
the door or she would not respond, they called the police. The
police broke down the door and found her hung in the home, but
still alive, got her to the hospital in time. So, I think that
is a small example of what we see as----
Senator Mikulski. Yes, but, General, that is indeed a
poignant problem. And, I mean, that is a very poignant story. I
have very limited time here.
General Schoomaker. Yes.
Senator Mikulski. So, here are my questions. Let us go at
this way. I love hearing stories. Remember me, I am the social
worker at the table.
General Schoomaker. Yes, ma'am, I know.
Senator Mikulski. So, and I am going to approach it as a
social worker. Do you feel you have adequate mental health
personnel? And do you feel that they are adequately trained in
the warrior culture? As you know, there is a great gap growing
between civilian culture and military culture. Also, from what
I understand from other data, that often in the first hour of
the first treatment, the military facing this problem walks out
and tells the counselor essentially to go to hell because they
do not feel they get it, and they are so upset. So, my question
is, let us go to adequacy of capacity and adequacy of training.
And then we will go to new techniques and approaches, because
obviously standard talk therapy and meds, as we know it, are
not working. Can you----
General Schoomaker. We are working very actively in finding
evidence-based approaches to the treatment of post-traumatic
stress disorder, which I think in the main is--can be treated
successfully. And we are seeing that.
Suicide, I think, is far more complex. It is not a medical
problem. I think this is one of the things that vice has said,
it is a larger command problem. Frankly, one-half or more of
people who commit suicide have never seen a mental health
provider or been identified as having a problem.
We are working very hard----
Senator Mikulski. Do you have adequacy of mental health
professionals?
General Schoomaker. I think the Nation is facing a problem
with mental health professionals----
Senator Mikulski. No, do you have it? I am not talking
about the Nation.
General Schoomaker. As a microcosm of the Nation, we have
problems, especially as----
Senator Mikulski. Again, I am not being--I really----
General Schoomaker. We have problems, ma'am.
Senator Mikulski. I so admire what you have done and the
leadership you have provided. I want to be very clear about
that. But do you see my level of frustration? They are calling
my office because they need help accessing services, not
knowing where to go. So----
General Schoomaker. I think the two things that we face----
Senator Mikulski. And what about the tying in the warrior
culture?
General Schoomaker. The things that we face most--and,
frankly, I think is a subordinate element of this warrior
culture issue might be present in some cases, but not
universally. Our people do a good job with that. We are working
hard to prevent post-traumatic stress by rapid identification
of concussion on the battlefield and reducing that. We have got
a comprehensive behavioral health system of care now that ties
every phase of soldier deployment to each other phase and
passes information. That has resulted in remarkable reductions
in stress problems.
And what we have residual problems with in the Reserve
component who go home to communities where access to care is a
problem for all care, but especially behavioral health, and in
remote size within the Army where it is tough to compete for
civilian employees of any kind. But in some of our places where
we have camps, posts, and stations, in the desert in
California, for example, it is hard to recruit and retain high-
quality people.
Senator Mikulski. All right. So, here is what I would like
in my limited time. I appreciate that and the challenges. But I
would really like to hear, based on the Dole-Shalala
recommendations, what, from your--and I mean the group--
perspective--on what is the progress made. But the Army assumed
primary responsibility for implementing Dole-Shalala. And then
also on the adequacy of training.
The other question I have is, we have to--and, Mr.
Chairman, with your indulgences--support for the families. You
know, when a warrior bears this either permanent wound or
permanent impact, it is the spouse or the mother or the family,
and it is also the children who bear this often--well, there is
a saying in both the civilian and military world, post-
traumatic stress is contagious. In other words, if one person
has it, the family has it. So, it is not like isolated like
cardiovascular disease where you have got it. Maybe the spouse
is helping with a better diet and lifestyle. Can you tell me--
again, going to Dole-Shalala--where we are in the support for
the family?
General Schoomaker. Yes, ma'am. We are working very
actively on programs to support families, especially children,
but spouses as well. We are reaching out into communities,
engaging schools, churches, other community members, to extend
the reach of insulation-based services into the communities to
highlight that these are families of the military that face
great stresses in their lives and identify children who are at
risk and spouses who are at risk.
Ma'am, in an earlier meeting several years ago, you
challenged me, without any data at the time, to rank order
three elements of deployment in terms of their impact on
soldiers and families: the frequency of deployment, the length
of a deployment----
Senator Mikulski. Right.
General Schoomaker [continuing]. The time between
deployments we call dwell. And what I told you was we suspect
that probably of the three, the most important is the dwell
between deployments, and then after that, the length of the
deployment, and then the frequency of deployment. We have
special operations units that have deployed and individuals
that have deployed a dozen times or more. But they are shorter
deployments and they have adequate dwell between.
One thing we cannot--we now have good science to document,
through surveys on the battlefield and from returning soldiers,
that not allowing a soldier and a family to have a minimum of
24 months of dwell between deployments does not allow them to
restore their psychological state.
Senator Mikulski. That is a good point.
General Schoomaker. And one of the things that I think we
need real support from the Congress in is to not--is to allow
us to resume a, we call boots on the ground to dwell rate of
one to two; that is, 2 years back home for every year that you
are in combat. That, I think, will make a significant--have a
significant impact on the mental state and the psychological
state of both families and soldiers.
Senator Mikulski. Well, General Schoomaker, thank you.
Mr. Chairman, you have been indulgent. I could talk all day
with this panel. Perhaps you and I could meet and talk over
this in more detail, and then take some ideas to the chairman.
Thank you very much.
Chairman Inouye. Thank you.
Senator Mikulski. But, you know, this deployment is a big
issue. If we are going to cut the military, then we got to
cut--like, we are going to shrink the Marine Corps, you know,
the old budget? But if we are going to shrink the Marine Corps,
then we should shrink what we ask the Marine Corps to do. And
that would go for every military service, so I think we have
got to keep this in mind.
Chairman Inouye. It is a major challenge to all of us here.
Senator Mikulski. For every year you are deployed, you need
2 years at home to stay connected to your family to deal with
exactly some of these really horrific situations you and I have
just discussed.
General Schoomaker. Yes, ma'am. And the Army, in 10 years
of war, has never been able to achieve a 2-year dwell. In fact,
on average it has been at 1.3 years----
Senator Mikulski. Well----
General Schoomaker [continuing]. Of dwell for every year of
deployment.
Senator Mikulski. Thank you.
Chairman Inouye. Thank you very much.
Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
And I want to recognize the comments of my colleague from
Maryland, talking about not only the impact to the individual,
to the soldier, to those that are actively serving, but to the
health and well-being of the families that are at home and
supporting them. So I appreciate, General, your comments and
recognition that it is the health of the whole family, not just
the soldier, that we need to address here. It is a considerable
challenge, but I think when we think about our effectiveness,
our ability to recruit, our preparedness, it all has to come
together. And I appreciate the discussion here this morning.
Gentlemen, welcome, and thank you all for your service,
greatly appreciate it in so many ways.
General Green, it was a pleasure to have the opportunity to
meet with you when you were in Alaska to attend the retirement
ceremony for a friend of ours, Colonel Powell. At that time, we
discussed the efforts to bring Fisher House to Alaska, and that
is now a reality. We greatly appreciate that--your efforts and
then your support for what Colonel Powell was trying to do,
which was to focus on the hometown healing, has been remarkably
successful. So we have got some good news to report up north.
My question today, and this is for you, General Green, is
regarding the Elmendorf Hospital facility. As you know, it is a
joint venture facility with the Air Force and the VA. And
recognizing that it truly is joint venture in the sense that we
have got the other services involved--Air Force, Army, and also
serving our Coast Guard families. So, it clearly is a benefit
to the region.
What I want to ask you today is whether or not the Air
Force and the VA are in alignment when it comes to meeting the
staffing needs there at Elmendorf Hospital.
We have got a situation where within the VA, far too many
of our veterans are being sent outside--being sent to Seattle
and parts outside the State simply because the services cannot
be obtained there, or because the VA says we are going to do it
outside, even when the services are available. I had an
opportunity to discuss this with Secretary Shinseki at an
Approps meeting last week, and he has pledged to me we are
going to work to do better in purchasing care for our veterans
there.
But what I am trying to determine is whether or not within
this joint venture hospital we are truly able to meet the
needs, given the strains that we have on capacity within the
community, given the issues that we have in meeting the needs
for certain specialties. And what I am looking for this morning
is an assurance that we can be working to ensure that the joint
venture hospital has what it needs--the people--to serve both
the active military populations as well as our veteran
population.
ELMENDORF HOSPITAL--A JOINT VENTURE FACILITY
General Green. Yes, ma'am. Thank you, and I appreciate our
luncheon with Eli Powell, too, who is a good friend of mine.
Senator Murkowski. Yeah.
General Green. In answer to your question, I think that you
will kind of get a sense of the commitment we have to this
venture.
The joint venture with the VA at Elmendorf is one of six
that the Air Force is now doing with the VA. We have now
invested about $7 million in JIF funds just at Elmendorf. We
have about $100 million in all of our joint ventures across the
world where we are partnered with the VA. My commitment up
there has been to basically increase the manpower by about just
under 200 positions to try and augment the staffing at
Elmendorf to pick up on some of the workload, strongly
encouraging further joint ventures with the Indian Health
Service, which, as you know, is one of the larger hospitals in
the Federal system there. And we have had people working in the
Indian health hospital as well as we try to--they are a level 2
trauma hospital now--as we try to maintain skills.
We have also increased the budget up at Elmendorf by about
$4 million annually in addition to just adding manpower, and we
have seen an output from that of nearly 40 percent increase in
surgeries that can be now in Alaska instead of people being
sent elsewhere.
My commitment to the joint venture is very solid. I would
love to see Elmendorf thrive. We have talked about whether or
not we can bring graduate medical education up there. I have
worked with some of your community physicians as they look to
bring a pediatric residency to see if we can join them in that
effort. And we have also talked with the family practice
residency up there to see how we can basically partner.
Some of this has to do with how the hospital grows and how
long it takes for construction in your State sometimes. The new
VA clinic up there has been very successful, and my hope is we
can do even more. And my hope is we can do even more. So, you
have my commitment, and I won't speak for the VA, but when I
talk with them, they are very committed also to expanding
services.
Senator Murkowski. Well, what we would like to do is to be
able to identify those areas or perhaps those gaps within the
VA system, whether it is in orthopedics, ENT, neurology,
wherever that is, and see if in fact there is a--there is the
ability within the Air Force to kind of reach in and fill those
gaps as we look to how we staff and truly meet the needs of,
again, our Active service men and women and our veterans up
there. But I appreciate your commitment, and I look forward to
working with you on that.
General Green. Yes, ma'am. We send you very talented people
that I----
Senator Murkowski. Yes, you do.
General Green [continuing]. Expect to help me grow that
particular area.
Senator Murkowski. We appreciate that as well.
General Schoomaker, this is probably for you as the Army is
the one that administers the congressionally directed Medical
Research Program. And my question to you this morning is about
the research program as it pertains to ALS, or Lou Gehrig's
disease, a horrible disease for all--those of us that know of
it, but a concern for us in the military as we look to the
exceptionally high incidence--incident rate of those who
contract ALS, who are our military heroes. It strikes those in
the military at approximately twice the rate as the general
public.
Back in 2008, ALS, as I understand, was determined to be a
presumptive disability by the VA, a service-related disease.
And again, those of us who have been in a situation where we
know someone with ALS know that this is a condition that moves
quickly--5- to 6-year life expectancy from diagnosis, and a
terribly, terribly horrific and debilitating disease that cost
incredible amounts of money as we provide for that level of
care and that level of treatment.
And so, when we look to the statistics, it causes one to
wonder, well, what will the impact to our military systems be
as we pick up the costs for those that are afflicted with ALS?
We are all very cognizant that we are in times of greatly
reduced budgets, and some would look at these programs--these
congressionally directed medical research programs--as being
something that are perhaps nice, but not necessary. So, I would
like to hear from you this morning kind of where you are coming
from on these congressionally directed medical research
programs, more specifically, ALS, whether you think that it is
something that should be continued to be funded in terms of the
research, and whether or not you think that that research is
making a difference in the lives of our service members who
have been afflicted.
General Schoomaker. Yes, ma'am. Thanks for that question.
And I think you have made exactly the case I would make for
these programs.
Congress has been remarkably enlightened and forthcoming
with funds for congressionally directed research dollars and
for programs which are, as you point out, ma'am, administered
through the Medical Research and Materiel Command at Fort
Detrick under the congressionally directed medical research
program and other congressional special interest programs.
They currently--we have got a very effective, I think, and
efficient process by which research dollars and programs are
targeted for our review for both scientific credibility and for
programmatic integrity; that is, that they will be successfully
executed. We have a very good program of soliciting the best
investigators from across the country, both inside and outside
the military, but largely outside the military, to conduct
this. And the programs that they--that are addressed in these
include amyotrophic lateral sclerosis that you have talked
about, ALS, but also prostate cancer, breast cancer, and a
variety of other problems that afflict not only the population
at large, but military members and families as soldiers,
sailors, airmen, and marines.
We try to make these as appropriate as possible to the
military population, but we admit that a lot of these
breakthroughs have overflow or application to other neurologic
problems. I mean, insights into ALS will give us insights into
other problems from an injury or illnesses that afflict
soldiers.
Currently, the limit on earmarks is going to threaten about
50 percent of the total research that is done within the
Medical Research and Materiel Command.
Senator Murkowski. What do you think that will do to the
status of research?
General Schoomaker. Well, I mean, it is going to take down
my structure. It is very hard to rebuild the structure that is
the people and the programs that administer these programs for
the military. You cannot snap your fingers and rebuild them,
and so we are going to have to take those down over the next
few months and have already started that process.
I am very eager to see the Congress come up with a solution
that allows us to keep some of the critical programs because
they have been very innovative and been very successful in
delivering, you know, insights into new products to improve the
lives of people who are suffering from these problems.
Senator Murkowski. Well, it is difficult to hear that we
would go backward on our research--go backward on the progress
that we have made. And I hate to try to put a dollar on, you
know, what it costs to deal with somebody that is afflicted,
again, with a disease where, again, you are looking at
incidence rates within our military that are twice the number
within the general population out there. You would hate to
think that somebody would hesitate to join up and become a
member of our military because they are concerned that somehow
or other they may be afflicted with a disease that they really
want to steer clear of.
I recognize that these are difficult budget times, but I
also recognize that the advancements that we have made, the
investments that we have made in our research and technology,
are not something that we want to dial back on. So, I would
hope that we could work with you as we try to make more forward
progress in this area.
Mr. Chairman, I have yet another question, but I have taken
plenty of time this morning. But I will defer to Senator Leahy.
Chairman Inouye. Thank you very much.
Senator Leahy.
Senator Leahy. Thank you, Mr. Chairman.
I have found the questions here and answers interesting.
You have a panel of three very, very well qualified people to
answer them, and I appreciate that.
General Schoomaker, recently 42 Members of Congress joined
me in sending a letter to the Army and the Guard Bureau asking
them to fund eight States' National Guard outreach programs.
The programs are going to expire soon. Now, in full disclosure,
one of them is in my own State of Vermont.
But I think when we have heard the questions, especially
those of the last two Senators, I would add to their points by
saying these programs fill a serious gap in the Guard
behavioral health. These programs are kind of like the MRAP,
although it was an entirely different thing, but the program
seemed like an idea where the Army and the Congress can work
together to do the right thing. We did, getting the troops that
equipment. Now we are talking about our soldiers and how we
take care of them.
You have made great strides, and I listened to what you and
Senator Mikulski were saying about suicide prevention in recent
years. But last year's doubling of Army Guard suicides shows
that the Army falls short when it comes to the needs of the
Army Guard and Reserve. They do not have a base. They are not
going back to a port or a base where you can have the services
within a limited geographical area. A State like Vermont, which
has no active duty installations, the Guard uses its outreach
programs to reach out to personnel where they live in home
towns across the State. That may be a town like the one I live
in with 1,500 people; it may be in one with 100 people, or it
may be a community like Burlington that has a larger
population. And our own adjutant general, Mike Dubie, whom I
believe you know, told me that there had been many potential
suicides that had been averted by this outreach program.
Now, the funds needed to preserve these programs are less
than $10 million for the remainder of the fiscal year. Are
these programs going to be funded for this year and for the
future?
General Schoomaker. Well, sir, first of all, I want to
thank you for the advocacy you showed for the 86th Infantry
Brigade Combat Team that did deploy and then redeployed through
Fort Drum, and I think illustrated the progress we have made in
trying to bring back, redeploy, and then demobilize our Guard
and Reserve.
What you have highlighted, and other members of the
subcommittee have highlighted, are the problems that are
inherent within the operationalization of the Reserves. The--
our Guard and Reserve, which was within the Army, conceived of
in past times as a strategic reserve ready to get launched one
time for a major Nation-threatening, you know, war or conflict
has now been, for the last 10 years, integrated fully into the
deployment of the Army through an operational Reserve. And in
doing that, what we have identified are shortcomings and
challenges in providing care for National Guard and Reserve
soldiers and families when they get back to their communities.
Senator Leahy. And providing that care is a little bit
different than going back to a base, going back to----
General Schoomaker. Sure. No question.
Senator Leahy [continuing]. Fort Hood or somewhere else.
General Schoomaker. And the rules that govern access to
that care are quite different. I mean, while the soldier is on
Active duty, if the soldier incurs an injury or an ailment as a
consequence of that deployment or that training to go to
deployment, there is no question we have ready access to
military units and military healthcare, and our TRICARE
network, for that matter. But it does become a challenge when
soldiers are redeployed and demobilized and then sent back home
where they may face environments. And you are not alone in
Vermont in facing this problem.
I am working very closely with the Guard and Reserve. I
think one of the major efforts that Major General Rich Stone,
who is a mobilized reservist in the South out of Michigan, and
a physician in practice, but has left his practice to work with
us and orchestrate a program to look at how we can better
support the Guard and Reserve. We have been looking for the
last couple of years at exactly how we can better care for and
reach out to the Guard and Reserve through TRICARE and our
other efforts. So, we are looking at the programs that are
threatened by the loss of funding, sir.
Senator Leahy. Well, please look carefully and work with my
office. We have had, you know, a redeployment. We talked about
the Warrior Transition Program. And I know that there is a
pilot program established at Fort Drum which still has some
issues to work out. It is far superior than what the 86th
Brigade had before, though. And I just would like to see these
things around the country because when you have been in Iraq
and you have been in Afghanistan, as I have, and you see these
people out in the field, you cannot look at the soldiers going
in and say, well, that one is a Guard member and--you cannot
tell, nor are their duties any different.
And I have one other question, and actually I pass this on
to all of you, General, to you, and Admiral Robinson, and
General Green. I have long supported improvements in military
medical care through information technology and increased use
of it. I have supported a military medical decisionmaking tool
called CHART. The Office of the Secretary of Defense plans to
mandate it for use by the services in pre- and post-deployment
healthcare screening. A recent study by an Army doctor in the
American Journal of Psychiatry linked deployment screenings to
improved mental health outcomes. Are your services going to be
using CHART and interface with your readiness systems?
Admiral Robinson, would you like to----
Admiral Robinson. Sir, I----
Senator Leahy [continuing]. Take a swing at that one?
Admiral Robinson. I will take a swing at it. I am not
familiar with CHART, so I do not know whether we will be using
it or not. But I can certainly take this for the record and get
back to you.
Senator Leahy. Would you please?
Admiral Robinson. I certainly will do that.
Senator Leahy. Thank you.
[The information follows:]
An electronic tool to integrate multiple health assessment
questionnaires and display results in the DOD electronic health
record system would he beneficial. In its current Conn, CHART
has multiple shortcomings, and requires major enhancement
before it can be considered as an acceptable solution for the
Services.
Each of the Services currently possesses operational
readiness information systems with an integrated health
assessment questionnaire capability. These systems manage each
Service's unique readiness requirements and operate in their
unique fielding environments. CHART as a health assessment
questionnaire tool would duplicate and fragment our ability to
assess and monitor readiness of Soldiers, Airmen, Sailors, and
Marines. For these reasons, CHART is currently ranked very low
in the overall funding priority.
General Schoomaker. Sir, and for the Army, I am not
familiar with that as well, but I will--this is a good point
for me to make a pitch for this behavioral health system of
care that Major General Horoho is taking personal leadership
in. It allows us to look at programs like CHART, or any other
program, in an objective way and do a head-to-head comparison
with our existing systems, and see if it delivers a better
outcome. So, I think----
Senator Leahy. I mean, we all want the same thing. We want
the best outcome. And I am just pushing to make sure we have
it.
And, General Green? And certainly all three of you please
do give me something for the record on this.
General Green.
ELECTRONIC HEALTH RECORDS
General Green. Yes, sir. And I will take the question for
record on the CHART, specific question.
I would add that we now have almost 5 years of data from
our electronic health record. And so, leveraging the data that
is in AHLTA and basically linking that with the pharmacy
transaction databases as well as the M-2, we are now leveraging
informatics to try and get to new levels of decision support
that will really change medicine over time. I strongly believe
that if we can get better information to the patient so that
they make sound decisions, that we can then also get them to
the healthcare team which can augment and give them even
further information, we will see tremendous change in medicine
because we will be able to pinpoint prevention back to the--
what is necessary for patient care.
Senator Leahy. Well, take a look at this one and take a
look at any of the DOD directives on it, because there has to
be follow-up to make it work, and that is what I am most
concerned about. I worry very, very much that some of these
brave men and women we have deployed fall off the screen
because they are not treated properly. I do not pretend to be
knowledgeable on this, but I know when my wife was working as a
registered nurse, she saw a lot of these people that should
have been helped--that was a different time--should have been
helped, could have been helped. And I go to some places where
the care is superb, and the person might have committed suicide
somewhere else, or might have dropped off the screen somewhere
else, or had debilitating illness that could have been
corrected and was not. We ask them to put their lives on the
line, then--I mean, you know that, and you believe as I do. I
think we owe them something when they come back. So, let us see
what this is going, let us see what the directives are, and let
us see what the implementation might be.
Thank you.
Mr. Chairman, thank you for this hearing.
Chairman Inouye. All right. Thank you very much.
And, General Schoomaker, Admiral Robinson, General Green, I
thank you very much on behalf of the subcommittee. And I wish
you well also.
And now we will have the second panel: Major General
Patricia Horoho, Chief, Army Nurse Corps, Rear Admiral
Elizabeth S. Niemyer, Director of the Navy Nurse Corps, Major
General Kimberly Siniscalchi, Assistant Air Force Surgeon
General for Nursing Services.
STATEMENT OF MAJOR GENERAL PATRICIA HOROHO, CHIEF, ARMY
NURSE CORPS, DEPARTMENT OF THE ARMY
General Horoho. Good morning, sir.
Chairman Inouye, Vice Chairman Cochran, and distinguished
members of the subcommittee, it is an honor to speak before you
today on behalf of the nearly 40,000 officer, civilian, and
enlisted team members that represent Army nursing. Your
continued support has enabled Army nursing in support of Army
medicine to provide exceptional care to those who bravely
defend and protect our Nation.
It is a privilege to share with you today what is happening
across Army nursing.
Our strategic priority, the Patient CareTouch System, was
implemented in February of this year at three medical treatment
facilities, Madigan, Brooke, and Womack Army Medical Centers,
and then this month we began the roll out of the remaining
facilities. Army-wide implementation of Patient CareTouch will
be complete by December 2011. This system is fully embraced by
all medical leaders and is successfully being implemented
across Army medicine.
The Patient CareTouch System is comprised of five elements,
which we truly believe guide, gauge, and ground patient-
centered care delivery. The elements are patient advocacy,
enhanced care team communication, clinical capability building,
evidence-based practices, and healthy work environments. There
are 10 supporting components that enhance these elements.
A key element of the Patient CareTouch System is evidence-
based practice, and nursing researchers, embedded in newly
formed centers for nursing science and clinical inquiry,
translating research into practice to optimize the quality of
care provided to our patients.
Army nursing is continuing to answer the call of the
combatant commander for critical care nurses who are prepared
and dedicated to care delivery in the back of medical
evacuation helicopters.
In December 2007, nurses assigned to the Medical Task Force
in Iraq leveraged the capabilities of our critical care and
emergency nurses. We created and then codified a premier en
route care transport program that ensured our wounded, ill, and
injured receive the right care at the right time by the right
provider. Since last year, we have performed nearly 450 en
route care transport missions. This capability directly
impacted the 98 percent survival rate for wounded service
members in Iraq, and is now the standard across all theaters of
operation.
The demand for increased numbers of trauma nurses in both
theaters of operation prompted me to make a decision this year
to establish a separate area of concentration for trauma
nurses. This required a consolidation of critical care and
emergency nursing specialties from which this new specialty,
the 66th Tango, was established. This consolidation will
provide unparalleled level of trauma nursing capability for
military medicine, and it will be the force multiplier in both
our fixed and deployed hospitals.
I would like to provide you with an update of several
programs that I introduced to you last year.
The Brigadier General Retired Anna May Hayes Clinical Nurse
Transition Program continues to prepare our novice nurses to
provide patient-centered care. Since 2009, over 520 novice
nurses have completed this program, achieving a higher advanced
beginner competency. This program continues to exceed the
national standard.
Since the inception of the Virtual Leader Academy, we have
graduated over 500 officers, non-commissioned officers, and
civilians from our courses. This Academy focuses on capability
and facilitates lifelong learning.
Army nursing is committed to the education of its advanced
practice nurses. To that end, Uniformed Services University has
once again proven to be the stalwart partner of Army nursing,
as well as to our sister services to ensure the development of
the curriculum to tackle the requirements for transition from
Masters to DMP Program by 2015.
An area that we have focused our effort pertains to
behavioral health. We have refined the clinical capability for
the Advanced Practice Army Behavioral Health Nurse
Practitioners, a key member of the behavioral health team. We
have leveraged their capability toward building resiliency in
our deployed service members and their families.
Over the past year, 424 Army nurses deployed with two
medical brigades and four combat support hospitals in support
of Operation New Dawn and Operation Enduring Freedom. We had
the extreme honor of celebrating the successful command tour of
two combat support hospital nurse commanders. These nurses were
integral in leading healthcare delivery and facilitating
medical diplomacy across Iraq.
Army nurses are writing our history with each patient they
touch, with each experience they have, and each story that they
tell.
On February 2, we celebrated 110 years of proud service to
our Nation. We thank you, Mr. Chairman, and Senator Murkowski
for introducing Senate Resolution 31 to commemorate this
historic occasion.
Mr. Chairman, we also thank you for the very touching,
heartfelt video message for the many years of unwavering
support of Army and Army nursing.
I continue to envision an Army Nurse Corps of the future
that we leave its mark on military nursing and will be a leader
of nursing practice reform at the national level. We are
committed to leveraging lessons learned from the past, engaging
present innovation, and shaping the future of professional
nursing. Our priority remains our patients and their families,
and our common purpose is to support and maintain a system for
health. In order to achieve this common purpose, we serve with
the courage to care, the courage to connect, and the courage to
change, so that we may provide the best possible healthcare to
those that wear the cloth of our Nation.
PREPARED STATEMENT
On behalf of the entire Army Nurse Corps, serving both home
and abroad, I would like to thank each of you for your service
to our Nation and your unwavering support.
Thank you.
Chairman Inouye. General Horoho, thank you very much for
you testimony. We appreciate it very much.
[The statement follows:]
Prepared Statement of Major General Patricia D. Horoho
Chairman Inouye, Vice Chairman Cochran 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 exceptional care to those who bravely
defend and protect our Nation.
PATIENT CARETOUCH SYSTEM
I am pleased to provide you with an update on Army Nursing and to
share with you my strategic priority, the Patient CareTouch System. The
Patient CareTouch System implementation began on February 7, 2011 at
three medical treatment facilities: Madigan Army Medical Center, Brooke
Army Medical Center, and Womack Army Medical Center. Seven facilities
will begin their roll out this month: Walter Reed Army Medical Center,
DeWitt Army Community Hospital, Tripler Army Medical Center, Landstuhl
Regional Medical Center, William Beaumont Army Medical Center, Carl
Darnall Army Medical Center, and Blanchfield Army Community Hospital.
The remaining facilities will join the process in three implementation
phases beginning in mid-May. Army-wide implementation at every patient
touch point will be completed by December 2011. The Patient CareTouch
System spans all care environments where nurses touch patients by
ensuring quality care is delivered carefully, compassionately and in
accordance with standards for best practice. The Patient CareTouch
System is comprised of five elements, which we believe guide, gauge,
and ground patient centered care. These elements include: Patient
Advocacy, Enhanced Care Team Communication, Clinical Capability
Building, Evidence-Based Practices, and Healthy Work Environments. The
elements are supported by 10 components that include core values for
patient care, care teams, peer feedback, standardized documentation,
skill building, talent management, clinical leader development,
optimized clinical performance, Centers for Nursing Science and
Clinical Inquiry (CNSCI), and shared accountability for quality of
patient care delivery.
The Patient CareTouch System provides a sustainable framework for
our transition from a healthcare system to a system for health. It
cultivates trust by providing a standard by which care can be measured
across Army Medicine, and it allows us to look critically at what we
do, how we do it, and how we can improve. The Patient CareTouch System
ensures that our patients know that we have their best interest at the
forefront of all care decisions and it promotes standards, not
standardization, for nursing care Army-wide. We found, when we piloted
the Patient CareTouch System at Fort Campbell, Kentucky, that we had a
positive impact on patient outcomes, patient satisfaction, clinical
communication, provider-nursing staff collaboration, and provider
satisfaction. We believe these results will be reproducible across Army
Medicine and we are using evidence based metrics to benchmark nurse
sensitive indicators against national standards. This will validate our
firm belief that our patients are receiving world class, high quality
nursing care.
OPTIMIZING PATIENT CARE DELIVERY
Evidence based practice is a key element in the Patient CareTouch
System and nursing researchers, embedded within newly formed CNSCIs are
translating research into practice to optimize the quality of care
provided to our patients. The CNSCIs are promoting enhanced nursing
decision support, evidence-based practice and research. Nurse
scientists, Clinical Nurse Specialists, and Nurse Methods Analysts
comprise the CNSCI. These experts working together are affecting the
transition from a ``question-to-answer model'' to the more valuable
``question-to-translation-to-evaluation model.'' Consolidating nursing
support assets who are working on a common sense research priority
agenda increases the capacity for evidence-based management and
evidence-based practice Army Nursing wide.
Research and evidence-based practice are overarching and core
constructs in the Army Nursing Campaign Plan. Army Nursing is
transforming from an expert-based practice model to a systems-based
care model in order to leverage nursing assets and realize the benefits
of knowledge management and research translation. This is critical to
improve patient outcomes, safety, healthcare value, and quality. Tenets
of a systems-based care model includes system resourcing, healthcare
economics, teamwork, cost-benefit considerations, and practice
management. Key to success is uniting various types of nursing support
experts to better meet the needs of bedside nurses and the nurse
leaders who provide and direct the delivery of patient care.
Army Nurse scientists are collaborating in joint, multinational and
academic settings to infuse nursing practice with evidence based
science. The premier Army Nursing Practice Council (ANPC), established
in the fall 2010, is providing the critical connection between nursing
science and nursing practice. The ANPC meets monthly to review
evidence, data, and science to develop evidence-based nursing tactics,
techniques and procedures (TTP) that then become the standards across
Army Medicine. Recently published standards include an innovative falls
prevention program, structured nursing hourly rounding, and bedside
shift reporting. TriService Nurse Research Program (TSNRP) funded
studies support several evidence-based nursing TTPs. For example, in
the Emergency Room at Bayne Jones Army Community Hospital, Fort Polk,
Louisiana, white boards in the patient rooms facilitate real time
status updates on medications, procedures, and tests completed to
enhance communication between emergency room staff and the patient and
family members.
The TSNRP funded an evidence-based practice project titled:
``Evaluating Evidence-Based Interventions to Prevent Falls and Pressure
Ulcers.'' This study was the basis for revising clinical practice
guidelines for prevention of falls and skin breakdown within the
Madigan Army Medical Center. It was also the means by which their CNSCI
team introduced patient-centered rounds and monitoring of nurse-
sensitive outcomes such as nurse satisfaction, patient satisfaction,
and rates of falls and pressure ulcers.
WARRIOR CARE
Enroute care transport is not a new mission for Army Nursing; we
have been providing this type of care for over 60 years. In 1943 the
first Army nurses formally trained in air evacuation procedures were
assigned to secret missions in North Africa, New Guinea, and India.
Army nurses cared for patients on helicopter ambulances, transporting
over 17,700 U.S. casualties of the Korean War. During the Vietnam war,
Army Nurses were aboard helicopters moving almost 900,000 United States
and allied sick and wounded Soldiers.
Army Nursing is continuing to answer the call of the combatant
commander for critical care nurses who are prepared and dedicated to
care delivery in the back of a medical evacuation helicopter. In
December 2007, nurses assigned to the medical task force in Iraq
leveraged the capabilities of our critical care and emergency nurses
and created, then codified, a premier enroute care transport program
that ensured our wounded, ill and injured service members received the
right care, at the right time, by the right provider. This program
directly impacted and sustained the 98 percent survival rate for
wounded service members in Iraq.
The Army Nursing Enroute Care Transport Program was so successful
in Iraq in decreasing the incidence of hypothermia, accidental
endotracheal tube extubation, and prevention of hypovolemic shock in
our Wounded Warriors that the program is currently in place in
Afghanistan. Army nurses continue to refine and improve the program,
maintaining a focus on nursing TTPs for critical care patients
transports. I am so proud of our Army nurses who, at the beginning of
the war in Iraq, saw a gap in rotor wing critical care patient
transport and identified processes to fill the gap. As a result, our
enroute care transport program is unparalleled in terms of the quality
of nursing care that our combat veteran critical care nurses provide to
Wounded Warriors. The quality of care during the strategic evacuation
care continuum does not end in the theater of operation. Landstuhl
Regional Medical Center's (LRMC) unique TriService Air Evacuation
mission processes all casualties through the Deployed Warrior Medical
Management Center. The nursing care provided to wounded, ill and
injured Warriors and coalition armed forces air evacuated from
Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn
and other Overseas Contingency Operations to LRMC significantly
contributed to LRMC being awarded the Association of Military Surgeons
of the United States (AMSUS) 2010 Facility-based Healthcare (Hospital)
Top Federal Hospital for fiscal year 2010. Continuing their high
operational tempo, the LRMC's triservice nursing team cared for 11,185
casualties (4,284 inpatient casualties and 6,901 outpatients) in fiscal
year 2010.
Nursing staff augmented the Contingency Aeromedical Staging
Facility on Ramstein Air Base, enabling continuous casualty flow from
LRMC to CONUS medical centers. Receiving casualties from over 500 Air
Evacuation flights, LRMC nurses have significantly supported the
aeromedical evacuation process. On any given day at LRMC, nursing staff
on the medical-surgical units will discharge 10 inpatients and admit 11
new patients, illustrative of the high operational tempo that is
commonplace at LRMC.
Nurse researchers like Lieutenant Colonel Betty Garner, are
augmenting warrior care efforts by conducting studies designed to
produce evidence for new nursing care modalities. Lieutenant Colonel
Garner and her team are determining the impact nursing care has on
injured Soldiers and their families after a traumatic brain injury
(TBI). Understanding the needs of the Wounded Warrior and their
families are imperative to improve the quality of life among those
affected by TBI.
These examples of Army Nursing's clinical initiatives illustrate an
amazing flexibility and agility to ensure that we are responsive to the
needs of our wounded, ill, and injured service members. I would like to
provide you with an update of several programs that I introduced to you
last year, and are key enablers of Army Nursing's strategic
initiatives.
CAPABILITY BUILDING
Talent Management
Inherent in clinical capability building is leadership, and in
order to best leverage the capabilities of our nursing team, we
examined the methods by which we identified, managed, and developed
clinical leader talent. The Army Nurse Corps' (ANC) talent management
strategy is a mission critical process that ensures the Corps has the
right quantity and quality of leaders in place to meet the current and
future Army Medical Department missions and priorities. Our strategy
covers all aspects of the ANC life cycle, to include aligning the Corps
strategic goals with capability requirements and distributing the right
talent for the right position at the right time and rank.
We partnered with U.S. Army Accessions Command and implemented
precision recruiting to ensure we are recruiting the right capability
in order to develop clinical leader talent. In spring 2010, for the
first time, our Human Resources Command, Army Nurse Corps Branch
executed a formalized capability-based assignment process, placing
senior officers in key positions based on their skills, knowledge, and
behaviors instead of on availability. In addition, we defined and
established a sustained succession plan for key leadership positions in
the ANC. Our talent management strategy enables us to assign full
spectrum leaders across all care environments in support of the Army
Medicine mission.
Leader Academy
Since the inception of our virtual Leader Academy, we have
graduated over 500 officers, non-commissioned officers and civilians
from our courses. Over the past year we analyzed ways to optimize the
Leader Academy to ensure agility in meeting evolving requirements. We
have sequenced learning and redesigned a ``building block'' curriculum
to facilitate lifelong learning at all professional development phases.
The five core elements of the Patient CareTouch System serve as the
foundational framework for the Leader Academy and the key components
are threaded throughout the curriculum of all courses offered.
The BG(R) Anna Mae Hays Clinical Nurse Transition Program (CNTP)
continues to prepare our novices with good results. Preliminary program
evaluation results presented at the 2010 Phyllis J. Verhonick Nursing
Research conference indicate that of the four cohorts evaluated, all
participants achieved advanced beginner competency at the end of the
program. In order to stabilize the program, all director positions are
now being filled by competitively selected non-rotating civilians, two
of which are Doctoral prepared and the remaining are Master's prepared.
A review of current studies revealed that standardized preceptorship
programs (preceptor training and tracking) increases nurse transition
from academia to practice. As a result of this evidence, the CNTP
directors adopted a Preceptor Development Program and established
guidelines now being implemented at all transition sites. The Patient
CareTouch System provides a framework for the program and the evidence
and science inform the standards by which nurses deliver care across
the age spectrum. Patient responses have been favorable, specifically
complimenting nurse transition program participants in hospital
satisfaction surveys. As we interview new lieutenants in the program,
we have found that many, who were planning to leave at the end of their
initial service commitment, are instead continuing their careers in the
ANC as a result of the enculturation process that is inherent in the
CNTP. Retaining new graduate nurses preserves the knowledge, experience
and confidence gained during the first year of professional practice
and has a positive impact on the quality of patient care.
There has been an array of secondary benefits resulting from the
creativity of the nurses participating in the CNTP. At Madigan Army
Medical Center, novice nurses developed and implemented a program to
track chart audits and produced a training video on ``Preventing
Patient Falls.'' At Womack Army Medical Center, novice nurses presented
an abstract entitled ``Response to Enhance the Quality and Consistency
of Shift Reports'' at the Karen A. Reider Federal Nursing Research
poster session during the AMSUS conference.
PORTFOLIO OF EXPERTISE
We are constantly refining our clinical capabilities to meet the
ever-changing complexity of providing care in challenging care
environments. As a result of increasing demands for trauma nurses and
the complexity of care required in both theaters of operation we made
the decision to establish a separate area of concentration
consolidating intensive care unit (ICU) and emergency nursing with the
educational and clinical focus on combat trauma care. This new area of
concentration will provide us a flexible and agile economy of force,
while providing an economy of effort for training.
We are re-shaping our ICU and emergency nursing courses into one
curriculum focused on acquisition of trauma nursing and critical care
competencies. The Army trauma nurse area of concentration will result
in assignment flexibility in both our hospitals and deployed combat
support hospitals (CSH) and provide an unprecedented level of trauma
nursing capability for military medicine. We are also analyzing ways to
leverage potent Army medicine force multipliers such as our psychiatric
nurse practitioners and psychiatric nurses.
This year, in response to increasing requirements for trauma
trained nurse, we expanded our emergency nursing course by adding a
second training site at Madigan Army Medical Center and graduated our
first class at this location in December 2010. This additional program
doubles the number of emergency nurses trained annually and enhances
our ability to provide world class care at home and abroad.
Through the efforts of our Perioperative Nurse Consultant, in
collaboration with the national perioperative nursing organization, we
have added additional sterilization procedures to the curriculum for
both our Perioperative Nurse and Operating Room Technician programs.
This proactive initiative addresses a national health concern regarding
potential infectious disease transmission resulting from improper
sterilization processing of surgical scopes. Currently, we are
developing a pilot program for the utilization of graduate prepared
Perioperative Clinical Nurse Specialists as Perioperative Nurse Case
Managers responsible for the coordination of clinical care across the
perioperative continuum from preoperative preparation to post-
anesthesia care. We are closely examining operating room processes,
with a focus on the perioperative nurse.
The operating room can be one of the busiest touch points in a
facility, and as a result an area that we want to ensure quality and
safe care delivery. We believe that a critical examination of an
expanded role of the perioperative clinical nurse specialist is needed.
This role will concentrate on quality assurance with a focus on patient
safety and perioperative arena efficiency to include the operating room
and the centralized sterile processing department. This role is unique
in that it cannot be replaced by a non-perioperative advanced practice
nurse.
Last year I discussed our initiative related to critical care
skills for our enlisted licensed practical nurses (LPN). In October, we
conducted our first pre-deployment critical care course for enlisted
practical nurses from one of our deploying CSH. The Soldiers received
didactic instruction and clinical rotations in critical care and burn
care at Brooke Army Medical Center and the Institute of Surgical
Research. Three enlisted practical nurses from the deploying 115th CSH
attended a ``critical care skills during deployment'' pilot. On
average, students demonstrated a 42 percent increase in self-reported
skills related to chest tube drainage system set up, cardiac strip
interpretations, and patient report/handoff. With the success of this
pilot, we are currently developing a pre-deployment LPN course that
will prepare deploying LPN's for the complex trauma missions they will
support. Every Army Nurse is a trauma nurse.
During calendar year 2010, Army nurses deployed with two Medical
Brigades and four CSHs in support of Operation New Dawn and Operation
Enduring Freedom to provide force health protection and combat health
support to United States and coalition forces. Two CSHs were commanded
by Army nurses--Colonel Barbara Holcomb, Commander of 21st CSH, Iraq
and Colonel Judy Lee, Commander of 14th CSH, Iraq--who facilitated
healthcare delivery and medical diplomacy.
Major Pamela Atchison, an Army nurse, deployed with Task Force MED
East in support of Operation Enduring Freedom, developed the
Afghanistan Trauma Mentorship Program for the Afghanistan Theater of
Operation. Major Atchison implemented the Afghanistan Trauma Mentorship
Program at two Afghanistan civilian hospitals and trained over 500
medical personnel (Physicians, Medics and Nurses) assigned to the
Afghanistan National Security Force and Afghanistan National Army. Her
contribution to Health Sector Development for Afghanistan, will have a
lasting effect for both the civilian and military medical communities
throughout the Afghanistan Theater of Operation.
Major Michael Barton developed the United States Forces Afghanistan
policies for Infectious Diseases, Needle Stick Injuries, and
Surveillance. Major Barton's efforts had a significant impact on the
quality of care that U.S. Service Members and Coalition Forces received
throughout the Afghanistan Theater of Operation. Major Barton also
compiled monthly reports for Task Force Medical commanders throughout
the theater, which consisted of information regarding epidemiological
investigations and disease non-battle injuries. The report enabled the
Task Force Medical commanders to focus on medical readiness issues for
both U.S. and Coalition Soldiers.
Colonel William Moran deployed with Task Force (TF) 62 MED as the
Patient Safety Officer for the Afghanistan Theater of Operation. He
implemented the first ever formal Patient Safety Program in that
theater that positively impacted over 1,900 service members, 3 Level
III hospitals, and 12 Level II Forward Surgical Teams/Elements. In
order to decrease variance in patient safety management, Colonel Moran
travelled to each TF 62 MED subordinate units to train 28 Patient
Safety Officers and establish unit based patient safety programs.
Colonel Moran significantly improved patient safety and the overall
delivery of healthcare in theater by establishing an environment of
trust, teamwork, and communication based on standards that improved
patient safety and prevented adverse events.
Army nurses are contributing significantly to the success of
multinational operations and working collaboratively with coalition and
Afghan healthcare professionals. I'm very proud of the medical
diplomacy efforts, displayed by the nursing leaders in command of the
Forward Surgical Teams (FST) in Afghanistan.
Lieutenant Colonel Ruth Timms commanded the 160th FST in support of
Operation Enduring Freedom. Her team was embedded within a German NATO
Role III hospital and provided direct support to over 11,000 U.S. and
Coalition Soldiers that comprised 15 nations. Lieutenant Colonel Timms
was an integral proponent for initiating mentorship programs between
United States, German, and Afghan providers which is enabling an Afghan
Healthcare system fully capable of providing comprehensive healthcare
services to the people of Afghanistan.
Captain Roger Beaulieu commanded the 934th FST in support of
Operation Enduring Freedom. He and his team cared for over 460 wounded
service members, performed over 160 surgeries and improved the medical
capabilities of the local national hospital by training four Afghan
Surgeons and nearly 100 Afghan medical support personnel.
These Army nurses are writing Army nursing history, and on February
2 of this year, we celebrated 110 years of proud service to our country
as a recognized Corps of the United States Army. We thank you, Mr.
Chairman, Vice Chairman Cochran and Senator Murkowski for introducing
Senate Resolution 31 to commemorate this historic occasion. Chairman
Inouye, we also thank you for the very touching, heartfelt video
message and for your many years of unwavering support of Army nursing.
We marked this day and its meaning by laying a wreath at the Nurse
Memorial located in Arlington Cemetery to pay respect to all Army
nurses who came before us. We honor them for their service, dedication,
and vision.
In the National Capital Area over 500 nurses, active, retired,
reserve, and civilian, family and friends of nursing gathered on
February 5, 2011 to commemorate this monumental milestone in our rich
history. Together, we celebrated ``Touching Lives for 110 Years,''
which really resonated with me and illustrated what I believe is the
true essence of Army Nursing. We have been on the battlefield, serving
with our fellow Soldiers, throughout our remarkable history and we
continue to do so today. Our collective success has been the result of
compassion, commitment, and dedication. I am inspired by the pride,
enthusiasm, and openness to change that I see across the ANC in support
of Army Medicine and our Nation's missions. My number one priority is
the Patient CareTouch System that will serve as the cornerstone to
improving the healthcare that provides patient care to our Soldiers and
the Families that support them.
I continue to envision an ANC of the future that will leave its
mark on military nursing, and will be a leader of nursing practice
reform at the national level. Our priority remains our patients and
their families, and our common purpose is to support and maintain a
system for health. In order to achieve this common purpose, we serve
with the courage to care, the courage to connect, and the courage to
change so that we may provide the best possible care to those who wear
the cloth of our Nation. The ANC is committed to leveraging lessons
learned from the past, engaging present innovations, and shaping the
future of professional nursing.
On behalf of the entire Army Nurse Corps, serving both at home and
abroad, I would like to thank each of you for your unwavering support,
and I look forward to continuing to work with you. Thank you.
Chairman Inouye. Admiral Niemyer.
STATEMENT OF REAR ADMIRAL ELIZABETH S. NIEMYER,
DIRECTOR, NAVY NURSE CORPS, DEPARTMENT OF
THE NAVY
Admiral Niemyer. Good morning.
Chairman Inouye, Vice Chairman Cochran, and distinguished
members of the subcommittee, thank you for the opportunity to
speak today on the state and future vision of the Navy Nurse
Corps.
Nowhere is Navy nursing's commitment to the operational
forces more evident than in our active engagement in military
operations in Southwest Asia, at the Expeditionary Medical
Facilities in Kuwait and Kandahar, and with the 1st Marine
Logistics Group in Afghanistan. We are clearly essential to our
military's medical successes on the front lines of Operation
Enduring Freedom.
Nurse practitioners manage the clinical operations at NATO
Role 3 in the urgent care clinic and participate in the
Shoulder-to-Shoulder Project at Kandahar Regional Military
Hospital. In this role, they mentor Afghan nurses in the
classroom and in the clinical setting. The promise of enhanced
clinical care in the Afghan healthcare system is a vision
shared by all those stationed at NATO Role 3.
Navy nurses are also members of embedded training teams and
provincial reconstruction teams, collaborating with Coalition
partners and offering assistance to military and civilian
healthcare providers in Afghanistan.
We played a key role in humanitarian assistance and
disaster relief operations in support of Operation Unified
Response in Haiti, Pacific Partnership 2010, and Continuing
Promise 2010. These operations present a unique opportunity to
test our education and clinical skills in rudimentary
healthcare environments while strengthening our capability to
partner with host nations, U.S. Government agencies, non-
governmental agencies, and academic institutions.
Navy nurses continue to support the fleet and expand the
services they provide to our sailors and marines at sea. Nurses
assigned to aircraft carriers and fleet surgical teams are
actively involved in operational missions around the globe and
are essential members of shipboard medical teams.
The role of Navy nurses assigned to the Marine Corps
continues to expand and diversify. Currently, 18 nurses are
directly attached to the Marine Corps serving in clinics and
advanced leadership roles. For the first time in our history,
the 2d Marine Expeditionary Fleet surgeon is a nurse.
Today Navy Nurse Corps' active component is manned at 92
percent, and for the fifth consecutive year, we have achieved
Navy nursing's active component recruiting goal. The Reserve
component is 85.9 percent manned and has reached 48 percent of
their fiscal year 2011 recruiting goal. I attribute our
recruiting successes to the continued funding and support for
our accession and incentive programs, the local recruiting
efforts of Navy recruiters, direct involvement of Navy nurses,
and the continued positive public perception of service to our
country.
Mr. Chairman, I am privileged to provide an update to you
and your subcommittee on the progress of our initiative for
doctoral preparation of nurse practitioners and nurse
anesthetists.
For the past 2 years, we have selected nurses to transition
their education programs to a doctorate of nursing practice,
either to transition from a master's program to the Doctorate
of Nursing practice, or transition from a bachelors program
directly to doctoral level work.
Staff members from my office are diligently working on a
promotion and schooling plan to maximize opportunities to send
newly trained nurse practitioners and nurse anesthetists to
study directly for their doctoral education. I am committed to
making this education transition the standard for our advanced
practice nurses.
We have numerous Navy nursing and joint research and
evidence-based projects in progress, and continue to be
extremely grateful for your ongoing support of the Tri-Service
Nursing Research Program. One study of interest is a
collaborative project the Navy is leading that will gather
first-person accounts of nurses caring for wounded service
members and the memories of the experience from the service
members themselves. The knowledge gained about their wounded
care journey is essential in order to develop and sustain
nursing competencies, and to examine the factors affecting
reintegration of the wounded warrior.
Coordination of seamless care is a top priority for the
ongoing care of our wounded warriors. This year, we will staff
a Navy Nurse Corps officer directly to a newly created position
at the VA headquarters. This nurse will work directly with the
Federal Recovery Coordinator Program to uncover process issues
and craft solutions to streamlined care.
In September 2010, I met with a core group of leaders to
formulate my 2011 Navy Nurse Corps Strategic Plan. We
identified objectives within five areas of focus: workforce,
nursing knowledge, nursing research, strategic partnerships,
and information management. I look forward to updating you on
Nurse Corps accomplishments on these initiatives in support of
Navy medicine.
Being in the military has its challenges, yet it is these
challenges that allow Navy nurses to excel both personally and
professionally. Our Navy medicine concept of care is patient
and family focused, never losing perspective in the care for
those wounded, ill, or injured, their families, our retirees
and their families, and each other.
PREPARED STATEMENT
Chairman Inouye, thank you for your unwavering support of
the commitment to the Navy Nurse Corps, and thank you for
providing me this opportunity to speak today. I am honored to
represent the total force, Navy Nursing Team, and look forward
to continued service as the 23d Director of the Navy Nurse
Corps.
Thank you.
Chairman Inouye. I thank you very much, Admiral.
[The statement follows:]
Prepared Statement of Rear Admiral Elizabeth S. Niemyer
INTRODUCTION
Good Morning. Chairman Inouye, Vice Chairman Cochran, and
distinguished members of the subcommittee, I am Rear Admiral Elizabeth
Niemyer, the 23d Director of the Navy Nurse Corps. Thank you for the
opportunity to speak today on the state and future vision of the Navy
Nurse Corps. I first want to recognize Rear Admiral Karen Flaherty, the
22d Director of the Navy Nurse Corps, who turned over the helm to me
this past August, and now serves as the Deputy Surgeon General. I
sincerely thank her for her hard work and dedication which provided for
a smooth transition for the Nurse Corps.
Dr. Jonathan Woodson, our new Assistant Secretary of Defense for
Health Affairs, recently spoke about the well-being of service members
at the 2011 Warrior Resiliency Conference. The 2-day conference focused
on Total Force Fitness, an initiative by the Joint Chiefs of Staff.
Attendees delved into a more holistic approach to the health of service
members and their families. Woodson said; ``Resiliency is key to the
welfare of the modern troop, as extended warfare is now commonplace.''
He echoed Admiral Michael Mullen, Chairman of the Joint Chiefs of
Staff, by saying; ``Resiliency training must be incorporated into all
levels of leadership and stages of a service member's military
career.'' Navy nurses understand the importance of fostering resiliency
in our patients, their families, our staff, and ourselves as we adapt,
overcome, and grow stronger in the enormous challenge of supporting
healthcare in a variety of contingencies.
Today, I will highlight the accomplishments of the Navy Nurse Corps
over the past year and discuss issues facing the Navy Nurse Corps in
2011, as we care for the health of the Force. The total Navy Nurse
Corps is comprised of 3,987 Active and Reserve component nurses and
almost 2,000 government service civilian nurses. Working together, we
are a collegial team of clinicians, patient advocates, mentors, and
leaders, who are a caring and compassionate face to those affected by
armed conflict, natural disasters and the day-to-day challenges of
work, life and family.
I will also tell you about the successes and accomplishments
achieved by our Corps since we last presented to you, concluding with a
discussion of the future of the Navy Nurse Corps as we forge ahead to
advance nursing care, integrate evidence into practice, and elevate
nursing at all levels. My strategic focus is on five key areas: Our
Workforce, Nursing Knowledge, Research, Strategic Partnerships, and
Information Management. It is within these five areas that I will talk
about our successes and address our future efforts. However, before
discussing these areas of focus, I want to share the many incredible
accomplishments of Navy nurses in operational settings with the Fleet
and Fleet Marine Forces, as well as review the increasingly important
role that Navy nurses play in humanitarian and disaster relief
missions.
OPERATIONAL SUPPORT
Nowhere is Navy nursing's commitment to the operational forces more
evident than in our active engagement in military operations in
southwest Asia at the Expeditionary Medical Facilities in Kuwait and
Kandahar, and with the 1st Marine Logistics Group in Afghanistan.
Currently there are over 70 Active and 60 Reserve component nurses
deployed in a variety of missions in the Central Command Area of
Responsibility. At the NATO Role 3 Multinational Medical Unit in
Kandahar, Afghanistan, Navy nurses have taken unprecedented leadership
positions both in the hospital and in the battle space of southern
Afghanistan. We are clearly essential to our military's medical
successes on the front lines of Operation Enduring Freedom. For
example, nurse practitioners manage the clinical operations of the NATO
Role 3 Urgent Care Clinic, responsible for providing urgent, emergent,
and non-emergent healthcare services to 30,000 NATO, coalition, and
civilian Afghan personnel residing on the Kandahar Air Field. Navy
nurses have taken a lead role in the highly successful enroute care
program where specially trained flight nurses are being stationed with
outlying Forward Surgical Teams, providing critical care in the air
during patient transfers from distant locations to the NATO Role 3.
Having flown over 100 flights in 2010, this program has recorded a
remarkable 100 percent survival rate. An initiative undertaken by Navy
nurses at the NATO Role 3, and one which contributes greatly to our
efforts to improve conditions in Afghanistan is their participation in
the Afghan National Army Nurse Corps' Shana baShana (Shoulder-to-
Shoulder) Project at the Kandahar Regional Military Hospital. In this
project, Navy nurses work in concert with a U.S. Air Force mentoring
team in a recurring 2-week curriculum where Navy nurses enhance and
update the nursing skills of Afghan military nurses in both a classroom
and clinical setting. The promise of enhanced clinical care in the
Afghan healthcare system is a vision all those stationed at the NATO
Role 3 share.
Navy nurses are also members of Embedded Training Teams and
Provincial Reconstruction Teams, collaborating with coalition partners
and offering assistance to military and civilian healthcare providers
in Afghanistan. Let me share with you the experience of one of our
nurses, LCDR Zaradhe Yach, who served with the Provincial
Reconstruction Team (PRT) at the Forward Operation Base (FOB) Ghazni.
This base is located in one of the largest and most dangerous provinces
in the Regional Command East. During the first 90 days in country, FOB
Ghazni was rocketed by enemy forces over 40 times. During this same
timeframe the PRT experienced more than 15 significant activities while
conducting mounted combat patrols throughout the province and LCDR Yach
was present each time, providing medical assessments and emergency
treatments to wounded service members. Patrols were engaged in complex
attacks of multiple improvised explosive devices (IEDs), rocket
propelled grenades (RPGs), indirect fire, and small arms fires. One IED
struck her vehicle, causing catastrophic damage and injuries. The
convoy was able to suppress fire and return, while LCDR Yach and her
team, along with the Air Force Forward Surgical Team (FST) staff,
ensured all injuries were thoroughly evaluated and treated.
During her deployment LCDR Yach facilitated health sector
development between coalition partners, meeting multiple times with
Afghan leaders. Additionally, she served as a mentor while leading the
daily operations of the PRT aid station which provided care for
coalition forces, contractors and local interpreters. Under her
leadership and guidance, her clinic was able to help over 3,000
patients and distribute over $150,000 in humanitarian aid and medical
supplies, greatly enhancing the quality of life of the Afghan people.
Her selfless performance of duties in a combat zone resulted in
awarding of the Bronze Star Medal by the Secretary of the Army.
Navy nurses played a key role in humanitarian assistance and
disaster relief operations in support of Operation Unified Response in
Haiti. On January 16, 2010 USNS Comfort (T-AH 20) deployed to Haiti
within 72 hours notice to provide disaster relief following a magnitude
7.0 earthquake that devastated the Haitian capital and surrounding
countryside. The first patient was received on January 19, just 7 days
after the disaster. Nearly 200 patients were admitted within the first
40 hours on station, and the inpatient census peaked at 411 patients on
January 28. There were a total of 1,002 admissions and 931 surgical
procedures conducted during this mission. Seven operating rooms ran 12
hours per day and three ran ``around the clock'' to accommodate
surgical emergencies. For three weeks, Comfort was the most advanced
and busiest orthopedic trauma center in the world.
Nurses aboard USS Bataan (LHD 5) and USS Carl Vinson (CVN 70) also
made significant contributions to Operation Unified Response. Fleet
Surgical Team EIGHT nurses aboard the Bataan participated in the care
of 97 patients who were evacuated to the ship and assisted in the
delivery of a healthy newborn. The sole Ship's Nurse on Carl Vinson
worked with a small group of medical augmentees in caring for 60
patients admitted to the ship for medical, surgical and post-partum
care. The magnitude of the mission brought an unprecedented number and
complexity of casualties. Once again, Navy nursing demonstrated its
flexibility, commitment, and professionalism in responding to a
humanitarian crisis. Mr. Chairman, I am exceedingly proud of this
amazing demonstration of how nurses from joint and international
military services and non-governmental organizations united together as
a global force to support the population of Haiti in their time of
need.
Other significant humanitarian operations included the deployments
of USNS Mercy (T-AH 19) during Pacific Partnership 2010, and USS Iwo
Jima (LHD 7) for Continuing Promise 2010. In support of these missions,
Navy nurses traveled to Vietnam, Cambodia, Indonesia and Timor-Leste,
as well as Haiti, Colombia, Guatemala, Nicaragua, Costa Rica, Panama,
Suriname and Guyana. These operations presented a unique opportunity to
test our education and clinical skills in rudimentary healthcare
environments, while strengthening our capability to partner with host
nations, U.S. government agencies and academic institutions,
international military medical personnel, regional health ministries,
and nongovernmental agencies through medical, dental, and engineering
outreach projects
Navy nurses continue to support the Fleet and expand the services
they provide to our Sailors and Marines at sea. Nurses assigned to
aircraft carriers and Fleet Surgical Teams are actively involved in
operational missions around the globe and are essential members of
shipboard medical teams. The nurse aboard USS Harry S. Truman (CVN 75)
deployed with Strike Group 10 and Carrier Air Wing 3 in support of the
wars in Afghanistan and Iraq. During this deployment, our nurse
provided training to over 5,000 personnel, to include instruction in
basic wounds, First Aid, and Basic Cardiac Life Support. Aboard Iwo
Jima, a certified registered nurse anesthetist (CRNA) from Fleet
Surgical Team FOUR assisted in a research study conducted by the Navy
Environmental and Preventive Medicine Unit to evaluate occupational
exposure to anesthetic gases among operating room personnel at sea.
Furthermore, Fleet Surgical Team nurses flew 20 medical evacuation
missions from large deck amphibious ships to USNS Comfort or various
shore-based facilities, configuring rotary wing aircraft to accommodate
critically ill or injured patients, and providing life sustaining
enroute nursing care under dangerous and austere conditions.
The role of Navy nurses assigned to the Marine Corps continues to
expand and diversify. Currently, 18 nurses are directly attached to the
Marine Corps, serving in clinics and in advanced leadership roles. For
the first time in the history of the Navy Nurse Corps, the Second
Marine Expeditionary Fleet Surgeon is a nurse. Battalion nurses provide
operational nursing support to the Forward Resuscitative Surgical
Systems (FRSS), the Shock Trauma Platoons (STPs), and to enroute care
missions. The nurse at the Marine Corps Training and Education Command
oversees the training plans and the Readiness Manual for Marine Corps
Health Services, while nurses at the Field Medical Training Battalions
provide training for all corpsman and officers attached to Marine units
in support of operational missions.
Navy nurses remain inherently flexible and capable of supporting
multiple missions in many settings and various platforms. I am
continually awed by the men and women in the Navy Nurse Corps. They
demonstrate daily that they are uniquely suited to answer the call when
a medical response is required.
Mr. Chairman, the remainder of my testimony is organized around my
five key areas of strategic focus: Our Workforce, Nursing Knowledge,
Research, Strategic Partnerships and Information Management.
OUR WORKFORCE
Today's Navy Nurse Corps active component (AC) is manned at 92.0
percent with 2,852 nurses currently serving around the world. For the
fifth consecutive year, we have achieved Navy nursing's AC recruiting
goal. This is quite an accomplishment only 7 months into the current
fiscal year. The reserve component (RC) is 85.9 percent manned with
1,135 nurses in inventory, and has reached 48 percent of their fiscal
year 2011 recruiting goal with 5 months remaining this fiscal year. I
attribute our recruiting successes to the continued funding support for
our accession and incentive programs, the local recruiting activities
of Navy Recruiters, direct involvement of Navy nurses, and the
continued positive public perception of service to our country.
The top two direct accession programs that favorably impact our
recruiting efforts in the Active component include the Nurse Accession
Bonus and the Nurse Candidate Program. The Nurse Accession Bonus
continues to offer a $20,000 sign-on bonus for a 3-year commitment and
$30,000 for a 4-year commitment; and the Nurse Candidate Program,
tailored for students who need financial assistance while attending
school, provides a $10,000 sign-on bonus and $1,000 monthly stipend. I
would like to thank you Mr. Chairman, Vice Chairman Cochran, and all
committee members for this ongoing and vital support.
For the RC, a vigorous recruiting plan requires flexible tools to
ensure we target high quality officers with appropriate skill sets.
Incentive programs have proven to be key to recruiting the correct
number of officers with the right skills. It is essential that our
critical shortage of registered nurses in the specialties of CRNAs,
critical care, medical-surgical, perioperative, and psychiatric nursing
as well as mental health nurse practitioners are offered competitive
incentives. The new officer affiliation and incentive program available
to registered nurses in our critical shortage specialties is favorably
impacting our reserve component recruiting efforts this fiscal year.
The new incentives offer $10,000-$25,000 per year depending on the
specialty area of practice and service obligation incurred. Loan
repayment programs have also proven to be of great value in attracting
critical shortage specialties, such as, advanced practice CRNAs and
mental health nurse practitioners.
We know that as the economy improves and civilian nursing
opportunities expand through the Affordable Care Act we might once
again be faced with recruiting and retention challenges. In
anticipation of these challenges, we are inviting nursing students and
new graduate nurses to participate as American Red Cross volunteers at
our hospitals and clinics to enhance exposure to the military.
Additionally, we assigned a Nurse Corps fellow to my staff to monitor
recruitment and retention, and to ensure that both remain a priority.
The education and training department at Naval Medical Center
Portsmouth assists with a monthly recruitment seminar in which Corps
representatives speak to prospective nurses and physicians about Navy
Medicine. These sessions allow for arranging tours and one-on-one
meetings with junior nurses to answer questions about military
healthcare. Additionally, nurses aboard aircraft carriers, hospital
ships and on Fleet Surgical Teams contribute to the recruiting effort
by providing shipboard tours to prospective nurses, dentists,
physicians and other healthcare professionals, ultimately enhancing
their knowledge of and exposure to operational medicine and shipboard
life.
With the ongoing war, we are keenly aware of the need to grow and
retain nurses in our critical war-time subspecialties. Though loss
rates have improved overall, there remains a gap in the inventory to
authorized billets for junior nurses with 5 to 10 years of commissioned
service. Key efforts which have positively impacted retention continue
to include Registered Nurse Incentive Special Pay (RN-ISP), which
targets bonuses to undermanned clinical nursing specialties, and the
Health Professional Loan Repayment Program (HPLRP), which offers
educational loan repayment up to $40,000 per year. Full-time Duty Under
Instruction (DUINS) further supports Navy recruitment and retention
objectives by encouraging higher levels of professional knowledge and
technical competence. Training requirements are selected on Navy
nursing needs for advanced skills in war-time critical subspecialties.
Seventy-six applicants were selected for DUINS through the fiscal year
2011 board.
We remain diligent in our efforts to grow and sustain our community
of mental health nurses. The Navy Nurse Corps is entering its fourth
year of officially recognizing the psychiatric mental health nurse
practitioner specialty. Restructuring this manpower shift has not been
without its challenges, but we are actively involved in building and
expanding the close network of advanced practice psychiatric mental
health nurses with their peers outside the mental health arena. We
currently have two mental health nurse practitioners assigned to the
U.S. Marine Corps at the 1st and 2d Marine Divisions, and a majority of
our mental health nurse deployments have been in support of Joint
Medical Task Force, Guantanamo Bay, Cuba. Many of our Navy psychiatric
mental health nurses remain fully integrated in one collaborative
mental healthcare approach and are active members of Wounded, Ill and
Injured programs.
NURSING KNOWLEDGE
Care for both service members and their families is the top
priority for Navy Nursing, Navy Medicine and the Department of Defense.
Nurses are a key component of Family and Patient Centered Care
initiatives, and I would like to share with you a few success stories
where Navy nurses are leading the charge.
Nurse Case Managers provide services to the Wounded Warrior that
span the entire care continuum from point of injury to either return to
active duty or medical separation from service. The journey from
theatre to stateside care is only the beginning of a long road of
recovery for returning Wounded, Ill and Injured warriors who are often
facing extensive care and rehabilitation for life-changing physical,
psychological and cognitive injuries. The complexity of medical
healthcare and military systems is often overwhelming to the Wounded,
Ill and Injured service members, thus driving a critical need for
someone to coordinate care and support services. Nurse case managers
are the ``SOS or 1-800'' contact for the patient and family throughout
the continuum of care. The nurse case managers, along with Navy Safe
Harbor and the U.S. Marine Corps Wounded Warrior Regiment, bring a more
holistic approach to transition of the Wounded, Ill and Injured into
the Veterans Affairs (VA) or civilian care by addressing the medical
and the non-medical needs concurrently. This collaboration is important
to reducing stress and confusion during transition. I am proud to
report that our Clinical Case Management Program has been recognized
nationally by being awarded the 2010 Platinum Award for the Best
Military Case Management Program. This award was presented by the Case
Management Society of America and was featured in their journal, Case
In Point in May 2010. Case management is at the heart of ensuring the
development of comprehensive plans of care and ensuring smooth
transitions for all Wounded, Ill and Injured service members and their
families.
In support of the Navy's efforts to develop resilience in Sailors,
Marines, families and commands, we have detailed a senior mental health
nurse to the Chief of Naval Personnel to implement the Navy's
Operational Stress Control (OSC) program. This comprehensive effort is
line-owned and led, integrating policies and initiatives under one
overarching umbrella. The program is designed to build resilience and
to increase the acceptance of seeking help for stress-related injuries
through education, training and communication. Twenty-three modules of
formal curriculum have been developed and are being taught at key nodes
in a Sailor's career--from boot camp to the Naval War College, with
more than 206,000 receiving training to date. We are working hard to
develop a culture that rewards preventive actions and recognizes that
seeking help is a sign of strength. Navy nurses are uniquely qualified
to function in this non-traditional role where the focus is on building
resilience and prevention vice treating injury or illness.
During the past year we completed a nurse led Navy Medicine
assessment of caregiver occupational stress. Not surprisingly, the
study found evidence of caregiver occupational stress. The study also
identified that meaningful work, good training, and engaged clinical
leaders all contribute to building caregiver resilience. Our future
efforts will continue to invest in strategies that enhance resilience
and performance while identifying and mitigating expected caregiver
demands.
Clinical excellence is the cornerstone of Navy Nursing. An
innovative program titled ``The Immersion in Critical Care and
Emergency Nursing'' (ICE) program at Naval Medical Center Portsmouth
has been designed to train and sustain skills essential to our critical
wartime specialties. This three-part program, consists first of
prerequisite training with introductory courses and modules available
to and within the Military treatment facility (MTF). The second phase
is the Simulation/Skills Lab which targets skills review and specific
patient scenarios for high risk situations encountered by the nurse.
The final phase involves a practicum with time spent delivering hands-
on patient care, focused on specific areas of the specialty. The first
nurses to attend this program are just weeks into their deployment
rotation at the Expeditionary Medical Facility in Kuwait, so feedback
has not been obtained post-deployment. However, we anticipate that ICE
will be of great value in introducing nurses to critical care and
emergency nursing situations prior to future deployments.
To promote clinical excellence for families of Sailors and Marines
we are preparing nurses for unexpected emergencies both stateside and
overseas. This year our nurses participated in Mobile Obstetric
Emergencies Simulator training at Madigan Army Medical Center, Fort
Lewis, along with health providers from all branches of the armed
forces. Additionally, we joined in community outreach by partnering
with Baby Connections, a care-giver and infant learning/play group
facilitated by the local county health department, providing
information to caregivers regarding development, infant care,
breastfeeding, and dental care for newborns to 3 year olds. Navy nurses
serve as members of breastfeeding coalitions and have established
lactation consultant presence in hospitals, clinics, and at fleet
commands, all in support of initiatives to meet the Healthy People 2020
goals. Nurses are involved in numerous programs which support family
centered care, including the Happiest Baby on the Block and parent-
infant bonding programs. Family centered care is the foundation of our
care delivery model in all treatment facilities.
Nurse Corps officers are actively involved in mentoring
baccalaureate and master's students at universities throughout Navy
Medicine. Naval Medical Center Portsmouth identified the need for a
Nurse Education Coordinator who has the responsibility of coordinating
the activities for over 30 local and distance learning schools of
nursing from the licensed practical nurse-level to the facilitation of
graduate-level clinical experiences. We realize that community
involvement with the future nursing workforce is key to both our
recruiting and retention efforts as well as to creating a multi-
talented, diverse workforce. We are committed to providing high quality
clinical experiences to students whenever possible.
For the third year, I am pleased to tell you that funding has
allowed us to continue support of the Graduate Program for Federal
Civilian Registered Nurses (GPFCRN). We recognize the challenges
associated with recruitment and retention of civilian nurses for
Federal service positions, and continue to see this program as a way to
cultivate clinical expertise and future nursing leaders from our
civilian workforce by offering graduate nursing education. In the fall
we will select another five nurses to attend programs across the
country to develop skills as a clinical nurse specialist. After
graduation, they will continue their Federal service, directing expert
clinical nursing practice across the enterprise.
Navy nurses are at the forefront of Navy Medicine leadership. There
are currently eight Nurse Corps Officers serving as commanding
officers. In addition, nurses are encouraged to assume leadership
positions as associate directors and directors, sometimes in non-
traditional nursing roles. Our operational nurses also serve in key
leadership roles while underway. This year, the first Nurse Corps
Officer held the position of Deputy Commander for the Joint Medical
Group with the Joint Task Force Guantanamo, Guantanamo Bay, Cuba.
Leaders in executive medicine positions showcase the versatility of our
Corps and pave the path for an expanded role for future Nurse Corps
leaders.
This year, 22 nurses aboard aircraft carriers and amphibious ships
earned the Surface Warfare Medical Department Officer qualification.
This qualification is earned by Medical Department officers who attain
extensive shipboard knowledge and experience outside of the medical
professions. This includes knowledge of engineering systems, navigation
methods, communication and weapon systems and offensive and defensive
capabilities. The qualification requires knowledge of watch standing
responsibilities on the Bridge and in the Combat Information Center and
culminates with a final qualifying oral board. Nurses also earn and
wear the Fleet Marine Force (FMF) Qualified Officer Insignia. The FMF
insignia is earned by Navy officers assigned to the Fleet Marine Force,
and it clearly makes a statement that the wearer is a key member of the
Marine Corps team. Earning this designation requires serving for 1 year
in a Marine Corps command, passing an arduous written test, completing
the Marine physical fitness test, and passing an oral board conducted
by FMF qualified officers. To date, we have 56 nurses holding this
qualification, from our junior lieutenant junior grades officers, to
officers holding the rank of captain.
Nurses are not just caregivers, but are a vital part of our
organizational structure as mentors to junior officers and our enlisted
personnel. Navy-wide, nurses are seen leading Junior Officer Career
Development seminars, speaking at local high schools, health fairs, and
community colleges. We are actively involved with Navy Nurse Corps
students at our Reserve Officer Training Corps (NROTC) programs,
frequently attending activities to support and mentor students during
their time in school. These experiences are mutually beneficial,
providing opportunities for junior nurses to be involved within our
community by establishing and maintaining professional relationships,
and allowing junior nurses and nurse candidates to seek guidance from
senior nurses.
Deployed nurses also serve as mentors and educators for other
officers and enlisted personnel. One Navy Nurse recently returned from
a 6-month deployment as an individual augmentee in Camp Bastion,
Helmand Province, Afghanistan. He was an integral part of the
Emergency/Trauma Department where they provided direct patient care to
4,000 combat and non-combat injured patients, delivering over 3,600
units of blood products. During his deployment, this officer conducted
TeamSTEPPS Essential training to the Emergency Department. The
Department of Defense, in collaboration with the Agency for Healthcare
Research and Quality (AHRQ), developed the TeamSTEPPS program to serve
as a powerful, evidence-based teamwork system to improve communication
and teamwork skills. I am proud this energetic Navy Nurse took this
training to the deck plate, recognizing that we demand excellence in
healthcare quality even at our most remote locations. It is this type
of engaged leadership that is the hallmark of Navy Nursing.
Mr. Chairman, I am privileged to provide an update to you and your
Committee on the progress of the Navy Nurse Corps initiative for
doctoral preparation of our nurse practitioners and nurse anesthetists.
As you recall, the 2009 National Defense Authorization Act (Senate
Report 111-74, page 275) provided direction from this committee,
describing your support of graduate nursing education through our Duty
Under Instruction (DUINS) program for training nurse practitioners. The
Committee directed the Service Surgeons General, in coordination with
the Nurse Corps Chiefs, to provide a report outlining a critical
analysis of emerging trends in graduate nurse practitioner education,
with an emphasis on the consideration of replacing Master's in Nursing
preparation with a Doctorate of Nursing Practice degree program. We
submitted that Report to Congress in March 2009, and I am pleased to
tell you we immediately identified top performers who were completing
their Masters degrees, selecting them to add additional time onto their
schooling to complete their Doctorate of Nursing Practice. This past
November, we selected seven additional nurses to either transition
their Master's program to a Doctorate of Nursing Practice, or to pursue
education which will take them from their Bachelor's nursing degree
directly into doctoral level work, bypassing the Masters degree. Staff
members from my office are diligently working on a promotion and
schooling plan to send newly trained nurse practitioners and nurse
anesthetists to study directly for their doctoral education.
NURSING RESEARCH
The National Institute of Health (NIH), through The National
Institute of Nursing Research (NINR), defines nursing research as the
development of knowledge to build a scientific foundation for clinical
nursing practice, prevent disease and disability, manage and eliminate
symptoms caused by illness, and enhance end-of-life and palliative
care. We have numerous Navy Nursing and joint research and evidence-
based projects in process, and continue to be extremely grateful for
your ongoing support of the TriService Nursing Research Program.
Research projects are currently being conducted by active and reserve
component nurses on clinical topics such as; heat illness, hemorrhagic
shock, development of Navy-wide evidence-based guidelines for wound
care management and pressure ulcers, ultrasound guided and peripheral
nerve stimulation techniques, catheter removal and motor function
recovery, the role of nursing in implementation of a Patient Centered
Medical Home (PCMH) in MTFs, virtual reality for stress inoculation,
clinical knowledge development and continuity of care for injured
service members, competency and work environments of perioperative
nurses, moral distress, and nurse-managed clinics.
One study of interest is a collaborative project Navy is leading
which includes nurse researchers from the Army, Air Force and the VA.
The purpose of this study is to gather first person experience-near
accounts of experiential learning of military and civilian nurses
caring for wounded service members, along with first person accounts of
service members' memories of all levels of care and transitions from
the combat zone to rehabilitation. The knowledge gained about their
wounded care journey is essential in order to develop and sustain
nursing competencies, and to examine the acute and rehabilitative
factors affecting reintegration of the wounded warrior. This study also
has critical utility for optimal functioning of service members
returning to the United States, transitioning into the military and
Veterans Affairs healthcare systems, and for developing training
programs with military healthcare personnel who work with service
members in acute and rehabilitation healthcare settings. Preliminary
data analysis is underway. Nurses have shared their expertise and
knowledge, and lessons learned are being formulated to improve patient
care throughout the Department of Defense and VA healthcare systems.
Nurse researchers are also actively conducting research to explore
retention of recalled reservists, psychometric evaluation of a triage
decisionmaking, and construction of learning experiences using clinical
simulations. Without your initial support of the TriService Nursing
Research Program in the early 1990's this would have been a very
difficult task to achieve. Ongoing support of military nursing research
as a unique and distinct entity is vital to the advancement of this
important niche of science to our Nation.
STRATEGIC PARTNERSHIPS
A collaborative approach between Services and Federal agencies has
never been more important than it is today. Navy nurses, find
themselves serving as individual augmentees (IAs) with sister Services,
working in Federal healthcare facilities such as the James Lovell
Federal Health Care Center in Great Lakes, supporting academia in
facilities such as the Uniformed Services University Graduate School of
Nursing and serving in Joint Commands.
The Captain James A. Lovell Federal Health Care Center (FHCC) is
the Nation's first fully integrated medical facility between the VA and
DOD. Established on October 1, 2010, the facility integrates all
medical care into a Federal healthcare center with a single combined VA
and Navy mission, serving military members, Veterans, military family
members and retirees. Integrating many ``types'' of nurses has been
rewarding, and had very few challenges. Combining the strengths of
active duty, DOD, VA nurses and contract nurses, we have formed one
orientation nursing program, increased the venues for active duty
nurses to obtain their clinical sustainment hours, and combined forces
for one Executive Committee of the Nursing staff, with Navy and VA
Nursing Executives as equal co-chairs.
Coordination of seamless care is a top priority for the ongoing
care of our Wounded Warriors. I am pleased to tell you about a joint
initiative between the Deputy Secretary of Veterans Affairs and the
Deputy Secretary of Defense to staff a Navy Nurse Corps officer
directly to a newly created position at the VA Headquarters in
Washington, DC. This nurse will work directly with the Federal Recovery
Coordinator Program to uncover process issues and craft solutions to
streamline care. The nurse will serve as a vital link between the
Veterans Affairs Federal Recovery Coordination Program and the MTFs to
assist severely Wounded, Ill and Injured patients and their family
members in the complex coordination of their care throughout the
rehabilitation continuum. I look forward to providing additional
information to you next year on this important role.
Our nurses in Guam have joined their civilian counterparts from
Guam Memorial Hospital and Air Force nurses from Anderson Air Force
Base to share their skills and experiences. Navy nurses provide the
Trauma Nursing Core Course both for providers and instructors. This
course has been instrumental in building the confidence and honing
assessment skills of nurses who normally do not work in an Emergency
Department setting. Naval Hospital Guam also included Joint Medical
Attendant Transport Team (JMATT) members in their Emergency Department,
allowing them to receive this training at no-cost.
The nurses in the Primary Care Clinic at Naval Health Clinic Corpus
Christi (NHCCC) collaborated with our Air Force Nursing counterparts at
Wilford Hall Medical Center Diabetes Center of Excellence in San
Antonio regarding Diabetes Education. The staff at Wilford Hall Medical
Center routinely travels to Naval Health Clinic Corpus Christi to
provide monthly diabetic education classes to our patients. In
addition, they provide ``train the trainer'' sessions so our staff can
assume the role as the trainer. Naval Health Clinic Corpus Christi also
established a collaborative relationship with Brooke Army Medical
Center for supplementary clinical experiences.
Naval Hospital Pensacola maintains a Memorandum of Understanding
with the local trauma center, allowing collaboration for training and
clinical sustainment in critical care, pediatrics, neonatal, and high
risk obstetrics. Additionally, the civilian community nurses provide
trainers for our specialty neonatal course that prepares staff in the
care of high acuity newborns needing transfer to a higher level of
care. Recognizing that our nurses must be operationally prepared for
deployment, but may have limited inpatient nursing care exposure while
working in the clinic environment similar arrangements with inpatient
facilities have been made in Hawaii at Tripler Army Medical Center and
Newport, Rhode Island with the Providence Veteran's Hospital. We remain
grateful to the Army, Air Force, Veterans Affairs and civilian
facilities for these partnerships.
Our RC nurses routinely participate in joint initiatives. Through
their reserve commands, Nurse Corps Officers take part in joint
training exercises with the Coast Guard, Seabee forces through Naval
Mobile Construction Battalions, and Air Force and Army medical teams.
Our Operational Hospital Support Units have agreements with Veterans
Affairs Medical Centers in several States to provide real time patient
treatment both for nurses and hospital corpsmen during drill weekends.
This not only supports their continued training and clinical
sustainment requirements, but provides additional resources for the VA
facility.
I am excited to tell you about our annual ``Host Nation Symposium''
event at Naval Hospital Rota, Spain, where healthcare providers in the
community and military gather to share education and best practices
between the two unique healthcare systems. It also provides an
opportunity for members of Navy Medicine to meet their counterparts and
build camaraderie. We are also partnering with the head of the Spanish
Nurse Corps in Rota to allow newly graduated Spanish military nurses to
work in our facility. Their graduates spend approximately 2 weeks at
our hospital shadowing fellow American nurses. In turn, select military
nurses then travel to a trauma course hosted in Madrid. Both the
Commanding Officer and Surgeon General from Spain are very optimistic,
seeing this exchange as an opportunity to provide diverse experiences
and better understand the diverse cultures and healthcare needs of our
allies.
INFORMATION MANAGEMENT
The sharing and quick dissemination of news, resources and
announcements is a top priority of the Navy Nurse Corps. From a needs
assessment, we know that nurses want rapid and easy online access to
information which can be accessed at work whether in a traditional or
deployed environment. Navy Knowledge Online serves as one platform for
that capability and we are working to maximize its utility while we
leverage other means of communication.
Last year we reported the launch of the active duty Nurse Corps
Career Planning Guide, a web-based mentoring tool for nurses at each
stage of their career. Informally the feedback received has been
overwhelmingly positive. Within the past several months we deployed
similar Career Planning Guides for Reserve Nurse Corps Officers and
Government Service Civilian nurses on Navy Knowledge Online. Both
groups play a critical role in contributing to the Nurse Corps and Navy
Medicine as we meet our peace and wartime missions. As ``One Team,''
our civilian nurses work with our military staff, providing continuity,
experience, and enabling our military nurses to deploy in support of
our warriors in the field. Navy Nursing is committed to providing all
of our nurses the opportunities to enhance their understanding of
operational medicine, grow professionally, and give them the tools to
be leaders in Navy Medicine. The web-based Career Planning Guides
(active, reserve and government service) provide a ``point and click''
list of resources to maximize career opportunities and knowledge for
all nurses commensurate with rank and time in service. For example,
under ``Operational Support,'' information on Navy War College Distant
Learning Courses are provided, plus numerous links, and articles to
enhance their operational skills & knowledge. To help nurses grow
professionally, all the Bureau of Medicine and Surgery training and
reimbursement opportunities are placed in a ``one stop'' shop. Finally,
civilian nurses serve in leadership positions as directors, department
heads and division officers. Our Civilian Career Planning Guide gives
them comprehensive information and links to help them manage their
military and civilian workforce, and grow as a leader in Navy Medicine.
We are able to meet our mission requirements because of our dedicated
civilian nurses, and it is an honor to work with them side-by-side in
today's Navy Medicine. We will formally evaluate all three Career
Planning guides and will to continue to adjust information based on
feedback from the end users.
FUTURE DIRECTION
In September 2010, I met with a core group of leaders to formulate
my 2011 Navy Nurse Corps Strategic Plan. Included in the discussions
were Specialty Leaders representing over 70 percent of all Nurse Corps
officers; headquarters staff; junior officers from Navy Medicine East,
West, and the National Capital Region; and the Army Deputy Commander
for Nursing Services from the National Naval Medical Center. During
this 2-day offsite meeting, five key goals were identified and Team
Champions named. Since then, the Strategic Goal teams--comprised of
nurses from around the world--have collaborated on projects to meet
identified objectives within the five areas of focus: Workforce
(maximizing human capital), Nursing Knowledge, Nursing Research,
Strategic Partnerships, and Information Management. I recently had my
first quarterly update, and I am confident the teams are on track to
make solid recommendations for action. I look forward to my next report
when I can share with you the accomplishments of Navy nurses throughout
2011 and update you on their initiatives in support of Navy Medicine.
CONCLUSION
Navy Nurse Corps officers are healers of mind, body and spirit;
ambassadors of hope; respected nursing professionals and commissioned
officers. Being in the military has its challenges, yet it is these
challenges that allow Navy nurses to excel both personally and
professionally. Mr. Chairman, Vice Chairman Cochran, and distinguished
members of the subcommittee, thank you for providing me this
opportunity to share the state and future direction of the Navy Nurse
Corps and our continuing efforts to meet Navy Medicine's mission. Our
Navy Medicine concept of care will remain patient and family focused;
never losing perspective in the care for those wounded, ill, or
injured, their families, our retirees and their families, and each
other. I am honored to be here today to represent the Navy nursing
team, and I look forward to continuing to serve as the 23d Director of
the Navy Nurse Corps.
Chairman Inouye. And now may I call upon General
Siniscalchi. General.
STATEMENT OF KIMBERLY SINISCALCHI, ASSISTANT SURGEON
GENERAL FOR NURSING SERVICES, DEPARTMENT OF
THE AIR FORCE
General Siniscalchi. Mr. Chairman, Mr. Vice Chairman, and
esteemed members of this subcommittee, it is my distinct honor
and privilege to once again represent over 18,000 men and women
of the Air Force Nurse Corps and share our successes and
challenges as we execute our strategic plan for global
operations, force development, force management, and patient-
centered care.
AEROMEDICAL CREWS SAVE LIVES
Across the globe, our Aeromedical Evacuation and Critical
Care Air Transport Teams continue to be a vital link in saving
lives.
In 2010, our Aeromedical Evacuation crews accomplished
26,000 patient movements on over 1,800 missions. David Brown,
from the Washington Post, reported on an Army sergeant from
California who was critically injured in Afghanistan in October
2010. In his article, Brown stated, ``In any U.S. hospital,
Sergeant Solorzano would be considered too sick to put on an
elevator and take to the CT-scan suite. Now, he's about to fly
across half of Asia and most of Europe. The U.S. military's
ability to take a critically ill soldier on the equivalent of a
7-hour elevator ride epitomizes an essential feature of the
doctrine for treating war wounds in the 21st century: Keep the
patient moving.''
Members of Congress, thank you for passing Resolution 1605
recognizing airmen who perform our aeromedical evacuation
mission.
Recently, I was afforded the opportunity to meet my nursing
colleague, Brigadier General Rahimi Razia of the Afghanistan
National Army. She expressed appreciation for the many
contributions our senior mentors and training teams are making
to advance nursing. They are helping her create a fundamental
nursing education program and a scope of practice.
NURSE TRANSITION PROGRAMS
Our outstanding success could not be possible without
investing in our future. We completely transformed our nurse
transition program for new graduates into four strategically
located centers of excellence in an effort to broaden clinical
training. Tampa General Hospital was recently approved as our
newest site, and a training affiliation agreement was signed in
February. This site will complement our other three sites at
Scottsdale, Arizona, University of Cincinnati, Ohio, and San
Antonio Military Health System, Texas. We also created a Phase
2 component enabling us to advance the National Council of
State Boards of Nursing Transition to Practice Model. Our pilot
program at the 59th Medical Wing in San Antonio is leading the
charge to deliberately develop our Nurse Transition Program
graduates through a comprehensive, 9-month mentoring program.
The American Association of Colleges of Nursing declared
entry for advanced practice nurses to be at the doctorate level
by 2015. Mr. Chairman, sir, your support of this initiative has
been instrumental in our progression from masters to doctorate
at the Uniformed Services University of the Health Sciences. We
are preparing to send students to this program in 2012 and have
three students starting the civilian programs in 2011.
ADVANCED IN MEDICAL TRAINING
We continue to advance enlisted training. A ribbon-cutting
was held in May 2010 at the new Medical Education and Training
Campus in San Antonio, where all services will train their new
enlisted medical personnel. This state-of-the-art training
platform will graduate technicians in 15 different specialties
to support the Department of Defense mission and optimize our
interoperability across services.
As we are developing our airmen, we are also developing our
civilians. In January 2011, we conducted our first Nurse
Civilian Developmental Board. This inaugural event served as a
benchmark to create a civilian force development model that
aligns with our officer and enlisted programs.
Our goal of force management is to design and resource our
nurse corps to sustain a world-class healthcare force. In 2010,
we achieved 102 percent of our recruiting goal. Consistent with
the line of the Air Force initiative to meet end strength
requirements, our recruiting goals were reduced in 2011.
However, we continue to work with the Office of Manpower
Personnel and Services to ensure we maintain a robust
recruiting program to preserve our quality force.
Our Nurse Enlisted Commissioning Program creates a legacy
career path in Air Force nursing. In 2010, 45 enlisted
graduates were commissioned into the Nurse Corps. As we enter
our third year of the Incentive Special Pay Program, we are
seeing positive impacts on professional satisfaction and
retention.
We recognize the value of keeping clinical experts at the
bedside, table side, and litter side. We developed a clinical
track for master clinicians and researchers through the rank of
colonel to foster a higher level of excellence within our
nursing practice. One of our critical care master clinicians,
Colonel McNeil, is currently deployed to Afghanistan and is
making a significant difference in trauma and critical care
outcomes.
As we aim to provide better health, better care, best
value, we are committed to the family health initiative, the
Air Force's Pathway to Patient-Centered Medical Home. Our
advanced practice nurses, clinical nurses, and technicians are
positively impacting access, quality of care, patient outcomes,
disease management, and case management. Within our patient-
centered care philosophy is the need to address resiliency and
mental health of our airmen and families. Last year, I reported
that a mental health nurse course was being developed at Travis
Air Force Base in California. I am pleased to announce our
first students started in February.
The psychiatric Mental Health Nurse Practitioner Program at
the Uniformed Services University of the Health Sciences is one
of the few in the country that includes psychopharmacology and
addresses behavioral techniques specific to the unique needs of
our military population. We currently have four students
enrolled in this program and four to start this summer.
PREPARED STATEMENT
Mr. Chairman and distinguished members of the subcommittee,
it is an honor to represent such a dedicated, strong nurse
corps. Your continued support as we execute our priorities to
advance military nursing is greatly appreciated. Our wounded
and their families deserve nothing less than educated, skilled
nurses and technicians who have mastered the art of caring. It
is through the medic's touch, compassion, and professionalism
that we answer our Nation's call to care for those who served
yesterday, today, and will serve tomorrow.
Thank you, and I welcome your questions.
Chairman Inouye. All right. Thank you very much, General.
[The statement follows:]
Prepared Statement of Major General Kimberly A. Siniscalchi
Mr. Chairman, and distinguished members of the committee, it is
again my honor to represent the over 18,000 members of our Total
Nursing Force (TNF). Together, with my senior advisors, Brigadier
General Catherine Lutz of the Air National Guard (ANG), and Colonel
Lisa Naftzger-Kang of the Air Force Reserve Command (AFRC), along with
my Aerospace Medical Service Career Field Manager, Chief Master
Sergeant Joseph Potts, we thank you for your continued support of our
many endeavors to advance military nursing. It is a privilege to report
on this year's achievements and future strategies.
We are a total force nursing team delivering evidence-based,
patient-centered care to meet global requirements. We have developed
four strategic priorities in consonance with those of the Secretary and
the Chief of Staff of the Air Force. They are: (1) Global Operations,
(2) Force Development, (3) Force Management, and (4) Patient-Centered
Care. These priorities are built on a foundation of education, training
and research. This testimony will reflect our successes and challenges
as we strive to execute our strategic priorities.
GLOBAL OPERATIONS
For over two decades, our TNF has been supporting humanitarian
missions and contingency operations that span the globe. We recognize
that our mission effectiveness is contingent upon medics who are
equipped, trained, and proficient at implementing Air Force
capabilities across the full spectrum of operational environments. Air
Force medics are truly expeditionary, and frequent deployments are a
part of our culture. The nature of our current operating environment
has reshaped the Air Force Medical Service (AFMS) and our Corps.
Together we have experienced amazing success in the global environment.
At a flight nurse and technician graduation ceremony at Brooks City
Base in San Antonio, Texas on January 29, 2011, the guest speaker, Army
Master Sergeant Todd Nelson, gave a poignant talk to our new flight
crews. Sergeant Nelson was the personal recipient of aeromedical care
after being injured by an Improvised Explosive Device blast during a
convoy in Afghanistan. The explosion and shrapnel caused massive head
and facial injuries; he was in grave status from the beginning. After
receiving initial life-saving surgeries, Sergeant Nelson started his
journey home, his condition still life-threatening. Despite the
severity of his injuries, Sergeant Nelson remembers the aeromedical
team as ``a phenomenal team of flight nurses and technicians who did
not see me as a statistic, but as someone for whom they would do
everything to ensure I survived and got home to my family. They didn't
just see me as another patient, but as a person.'' In his closing
comments to the class, he concluded, ``for those of you who are
starting out and who will be caring for warriors such as myself, I
thank you. It is because of you that I am standing here today. It is
not only I who thank you, but my wife and my children for enabling me
to continue to be a part of this family and their lives.''
Aeromedical Evacuation (AE) Crews and Critical Care Air Transport
Teams (CCATT) remain busy. In 2010, our Total Force Flight Nurses and
Technicians accomplished 26,000 patient movements on over 1,800
missions globally; approximately 11,500 of these patients originated in
Central Command. Nearly 10 percent of these missions were for
critically injured or ill patients who required a CCATT. While the
number of patients has not drastically changed, there has been a shift
of casualties from Iraq to Afghanistan. Battle injuries in Iraq have
decreased but patients continue to require evacuation for medical
illnesses and non-battle related injuries. We continue to see many
polytrauma and critically injured patients originating in Afghanistan.
Over 1,100 medics deploy each year supporting the AE mission.
Validating this success, a major research study from the Tri-
Service Nursing Research Program was concluded this year. This study
evaluated the care of over 2,500 critically ill and injured casualties
as they moved through the continuum of care from the battlefield to
home. As published in the July-September 2010 quarterly journal for the
American Association of Critical-Care Nurses, Colonel Elizabeth
Bridges, U.S. Air Force Reserves (USAFR), reported that despite having
higher acuity than civilian trauma patients, and undergoing a 7,000
mile transport in less than 7 days, the outcomes for critically injured
combat casualties are equal to, or better than, outcomes for patients
in the most sophisticated trauma systems in the United States.
Additionally, the results of this study, along with research which has
validated operational nursing competencies, has the potential to
standardize and advance evidence-based practices for nurses in all
Services, and to ensure training is focused on the highest priority
areas including blast injuries, head trauma, shock, amputations, pain
management, and patient transport.
David Brown from The Washington Post reported in November 2010 on
Army Sergeant Diego Solorzano, who was injured in Afghanistan, ``In any
U.S. hospital, Solorzano would be considered too sick to put on an
elevator and take to the CT-scan suite. Now he's about to fly across
half of Asia and most of Europe . . . the U.S. military's ability--not
to mention its willingness--to take a critically ill soldier on the
equivalent of a 7-hour elevator ride epitomizes an essential feature of
the doctrine for treating war wounds in the 21st century: Keep the
patient moving.'' Despite the noise, vibration, temperature extremes,
and pressure changes, AE and CCATT have truly been the critical link
providing world-class care across the continuum from the battlefield to
the United States.
On September 28, 2010, members of the U.S. House of Representatives
unanimously passed a resolution honoring the Airmen who support and
perform AE. House Resolution 1605 recognizes the service of the medical
crews and aircrews in helping our Wounded Warriors make an expeditious
and safe trip home to the United States, commending the personnel of
the Air Force for their commitment to the well-being of all our service
men and women who help to guarantee wounded service men and women are
quickly reunited with their families and given the best medical care.
During a press release, Congressman Mike Thompson stated ``These men
and women put their lives on the line on a regular basis to protect
their fellow Americans.'' The ability to rapidly move patients from
point of injury, to initial intervention, and then on through the
system to the United States in 3 days or less for definitive care
continues to sustain the lowest mortality rate of any war in United
States history.
While our AE crews and CCATT members are the most visible members
of our AE system, it is the men and women in our Patient Movement
Requirements Centers who work behind the scenes to coordinate all
patient movements. Be it a tactical or strategic transport, patient
movement requests are validated at the requirements center and then
passed through an AE Control Team to match patients to AE crews, air
crews, and aircraft. Personnel in these centers have knowledge in both
the challenges of AE and an understanding of clinical pathologies. They
use this combined knowledge to facilitate patient movement in the most
timely and efficient manner possible. These individuals are integral to
the extraordinary patient outcomes we are experiencing.
Within the Pacific Theater, we constantly battle the tyranny of
distance to meet patient movement requests. Our Theater Patient
Movement Requirements--Pacific created a Joint-Medical Attendant
Transport Team (JMATT) Training Program to augment our AE system. These
multi-service medical attendants move critically ill or injured
patients within and across the Pacific Command Theater of Operations.
Since 2008, 98 Joint Department of Defense, Hawaii's Disaster Medical
Assist Team, and international medics from Australia, India, Indonesia
and Singapore have been trained to move high-acuity patients to augment
our AE system. This permits us to optimize critical care resources for
expedited patient movement.
In addition to the over 100 AE flyers in the combat environment,
over 1,300 nursing personnel support ground missions to include theater
taskings such as trauma hospitals, provincial reconstruction and
teaching teams, and forward-deployed and convoy medical missions.
Working side-by-side with our sister Services and Coalition Partners
enables us to integrate into the Joint environment and support our
Secretary and the Chief of Staff's priorities to partner to win today's
fight.
Captain Denise Ross, who is currently deployed to Kandahar,
Afghanistan, is a member of an Air Force multidisciplinary Medical
Embedded Training Team (METT) which enables Afghan National Security
Force nurses to train within their own hospitals using their own
personnel and equipment resources. This program empowers the staff to
problem solve using available resources. The development of this
internal reliance is leading the creation of a self-sustaining program
in order to ensure its continued success after North Atlantic Treaty
Organization forces are no longer required.
During a recent visit to Afghanistan, Brigadier General Rahimi
Razia, Chief Nurse of the Afghanistan National Army, expressed her
deepest appreciation for the contributions the METTs and our Senior
Military Mentors have made to advance nursing for the Afghan National
Army. These teams are assisting General Razia in developing a
sustainable, 1 year basic nursing education program, and defining a
fundamental scope of practice. This elemental program is essential to
the evolution of nursing practice in Afghanistan. As we transition to
an advisory role in Iraq and support ongoing operations in Afghanistan,
we continue to educate and mentor the local national healthcare
providers as they evolve their own healthcare system.
Building partnerships is all about developing trust-based
relationships in the global environment. Across the globe our medics
collaborate with our Joint colleagues and National partners to advance
the practice of nursing. Under the direction of Colonel Elizabeth
Bridges, USAFR, the Defense Institute of Medical Operations initiated a
new international trauma course. The course, which is the first of its
kind, was developed to advance trauma nursing in developing nations.
Additionally, the course focuses on the leadership role of nurses in
developing trauma systems and in responding to disasters. Since May,
the course has been presented to over 120 nurses from five nations,
including Estonia, Latvia, Lithuania, Pakistan, and Nigeria, with a
future course to be presented in Iraq. Feedback from the participants
and the host nations has been positive, as exemplified by the feedback
from Brigadier General Raiz, Commandant of the Pakistani Military
Academy, who had glowing praise for the Trauma Nursing and First
Responder courses. With regards to the nursing course, he stated that
45 nurses have already returned to their home stations and are teaching
other nurses using the course materials provided by the team.
Another exciting area within this global spectrum is our
International Health Specialist Program. This program is comprised of
Total Force officers and enlisted members who focus on capacity
building efforts and forging medical partnerships through humanitarian,
civic assistance, and disaster response. One such example is Operation
Pacific Angel in the Philippines, which is aimed at improving military-
civilian cooperation. During this operation in February 2010, the
medical teams treated nearly 2,000 Filipino patients. This program
assists Philippine officials to build capacity within their cities,
focusing on basic life support, infectious disease prevention and
treatments, disaster readiness, and public health.
This year, officials from the United States and Republic of the
Philippines co-hosted the 4th annual Asia-Pacific Military Nursing
Symposium in Manila, Republic of the Philippines for more than 200
nurses from 13 countries. This annual conference ignites the spirit of
collaboration to focus on nursing education, career development, global
pandemic preparedness, and disaster management. Through this unique
symposium, participants learn about each other's healthcare systems,
infection control practices, and nursing services. Colonel Narbada
Thapa, the head delegate from the Nepalese Armed Forces, commented on
the opportunity to build relationships and acquire knowledge on nursing
from many armed forces from around the world, making the symposium a
memorable event for all.
FORCE DEVELOPMENT
Our outstanding success in mission support could not be possible
without a solid investment in developing our nursing force. Grounded in
education, training and research, we are generating new knowledge and
advancing evidence-based care necessary to enhance interoperability in
nursing operations. Stepping into the future, we are preparing our
Total Nursing Force to meet emerging challenges as we develop globally
minded medics capable of providing world-class healthcare on the
strategic battlefields of today and tomorrow.
Our Nurse Transition Program (NTP) continues to be an integral
component in developing our new nurses. We graduated 212 nurses in
fiscal year 2010 from eight military and two civilian locations. In
December 2010, we graduated the third class from Scottsdale Healtcare
System in Arizona. This outstanding civilian program has produced 56
nurses since its inception. As a Magnet facility, Scottsdale Healthcare
System is one of only 382 hospitals recognized world-wide for nursing
excellence. This program provides complex clinical training under a
preceptor-led transition model for new graduates. Under the supervision
of Lieutenant Colonel Deedra Zabokrtsky, NTP Course Director--
Scottsdale, our new nurses are clinically prepared and gaining the
confidence to take on their own clinical practice. Program excellence
can be noted in a diary entry from one NTP student who had just begun
her week in Obstetrics (OB). This student was assigned a patient who
was failing to progress in labor and was informed that a cesarean
section was believed inevitable. Based on current research, she decided
to take an evidence-based approach as encouraged by her preceptor.
Garnering support from her fellow nurses and agreement from her patient
to try a new approach, a unique plan of care was initiated, to include
rotation of the patient's position every 15-30 minutes. The final
result: a vaginal birth of a beautiful baby boy. As the student stated,
``This situation has affected the way I will educate my OB patients in
the future . . . the best we can do as nurses is make sure our patients
are well informed . . . this is true for all areas of nursing.'' This
exemplar highlights the critical thinking and sound, evidence-based
nursing practice needed from today's nurses.
Due to the resounding success of this military-civilian
collaboration, we decided to consolidate resources and create four NTP
Centers of Excellence. A civilian Magnet facility, Tampa General
Hospital, Florida, was recently approved as one of these sites and the
training agreement was signed February 24, 2011. The remaining three
Centers of Excellence will be in Scottsdale, Arizona; San Antonio,
Texas; and Cincinnati, Ohio; and will provide our new nurses with the
experiences so crucial to their professional development.
Our Nurse Enlisted Commissioning Program (NECP) continues to be a
balanced source of nurse accessions as we ``grow our own'' from our
highly trained enlisted medics. In fiscal year 2010 we enrolled 46,
students nearing our goal of 50 students per year. The graduates from
this program are commissioned as Second Lieutenants and will continue
their active duty service in the Nurse Corps.
As we strive to create full-spectrum leaders and nursing
professionals, our recently launched Project Lieutenant is designed to
improve skills and reinforce training with increased oversight and
mentoring during our new nurses' first year. Over the years, the
National Council of State Boards of Nursing (NCSBN) has researched the
issues of education, training, and retention of novice nurses and found
that the inability of new nurses to properly transition from student
into a new practice can have grave consequences. The NCSBN reported
that approximately 25 percent of new nurses leave a position within
their first year of practice. The increased turnover, consequently, has
a potentially negative effect on patient safety and healthcare
outcomes. The NCSBN's Transition to Practice Model provides a way to
empower and formalize the journey of newly licensed nurses from
education to practice. Project Lieutenant is our pilot program to
support our nurses' successful completion of the nurse residency
program and transition into new clinical practice areas. Established at
the 59th Medical Wing, Joint Base San Antonio, Texas, Project
Lieutenant is leading the charge to deliberately develop our newly
graduated NTP nurses through a comprehensive 9 month mentoring program.
The deliberate development of the novice nurse is in step with the
NCBSN's model and will be replicated at several sites to ensure
consistent quality of patient care and address the concerns of the new
nurse, ultimately promoting public safety and positive patient
outcomes.
As we aim to improve upon positive patient outcomes, we are
committed to serving our Wounded Warriors. As we enter our 10th year of
intensive combat operations, we are not only faced with the challenge
of caring for those with physiological wounds but also those with
psychological wounds as well. As Secretary Gates stated, there is ``no
higher priority in the Department of Defense, apart from the war
itself, than taking care of our men and women in uniform who have been
wounded, who have both visible and unseen wounds.'' The National
Defense Authorization Act 2010, Section 714, directed an increase in
the number of active duty mental health personnel and, to meet the
Secretary's priority of taking care of our Airmen and families, we are
launching a program to develop mental health nursing professionals from
within our Corps. Our pilot class started at Travis Air Force Base,
California, on February 14, 2011, and our next class is set to begin in
June 2011, projecting eight graduates this year.
The Uniformed Services University of Health Sciences (USUHS)
Graduate School of Nursing recently stood up a Psychiatric Mental
Health Nurse Practitioner Program (PMH-NP). This new program has
graduated two Air Force advance-practice nurses, with two Air Force
students currently enrolled and four more students planned for 2011.
The PMH-NP is one of the few programs in the country that includes
psycho-pharmacology and addresses behavioral techniques specifically
designed for clinical care of the military population. The program also
has specific training in the logistics of delivering healthcare in
military populations and education in Compassion Fatigue/Resiliency to
decrease the risk of mental health issues and burnout.
We also recognize our unique role in supporting the AE System
within the AFMS. In 2009, we developed an Air Force Institute of
Technology Master's degree in Flight Nursing with a concentration in
Disaster Preparedness. This program was developed in partnership with
Wright State University, the Miami Valley College of Nursing, Dayton,
Ohio, and the Health and National Center for Medical Readiness Tactical
Laboratory. Additionally, a disaster training facility, called
Calamityville, is being created and may be incorporated into civilian
and military training programs. Our first student started the flight
nurse graduate program in July of 2010 and another student is
programmed to begin this summer. Upon graduation, these individuals
will have been educated in emergency and disaster preparedness and they
will be eligible to take the Adult Health Clinical Nurse Specialist and
American Nurse Credentialing Center certification exams. This expertise
will be invaluable to our current and future operational environment.
A major movement in advanced practice nursing education was
stimulated by the American Association of Colleges of Nursing (AACN) as
they voted to move the current level of educational preparation from
the master's level to the doctorate level by 2015. To maintain
professional standards and remain competitive for high quality students
amongst military advanced practice nurses, Senator Inouye addressed
Congress in December to recognize the need to make this transition at
USUHS. Along with our sister Service nursing colleagues, we are working
with USUHS to develop the curriculum for a Doctorate of Nursing
Practice (DNP) with a transition plan to meet this goal. By 2015, all
students entering the nurse practitioner career path will graduate with
a DNP. This entry level to advanced practice will apply also to direct
advanced practice nurse accessions. The Health Professions Education
Requirements Board (HPERB) allocated nine DNP positions for an August
2011 start. Four of the candidates will go from a master's to doctorate
level and five will progress from the baccalaureate level to the
doctoral level to meet the new requirement.
In addition to our DNP programs, we continue to bolster our
evidence-based care through investment in nurse researchers. We
recently developed a nursing research fellowship and the first
candidate began in August 2010. This 1 year pre-doctoral research
fellowship focuses 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. Following the
fellowship, they will be assigned to work in Plans and Programs within
the Human Performance Wing of the Air Force Research Laboratory. This
direction also reflects the National Research Council of the National
Academies recommendation that those planning for careers with a heavy
concentration in research have doctoral preparation.
Major Candy Wilson and Major Jennifer Hatzfeld both received their
Ph.D.s in Nursing Science through the Air Force Institute of Technology
civilian institution program. The Air Force's investment in doctorally
prepared researchers equipped these nurses to deploy as integral
members of the Joint Combat Care Research Team with the clinical and
scientific expertise needed to make a difference for our Wounded
Warriors. The research and statistic expertise of these nurses in
conjunction with their clinical expertise was pivotal in projecting the
medical resources needed for casualties during the surge in combat
operations and assisting the Afghan government in evaluating the effect
of a Strong Food program supported by the U.S. Agency for International
Development. The investment in military nurse education is critical for
improving the lives of deployed U.S. military members, coalition
partners, and host nationals.
With a goal to advance cutting-edge, evidence-based nursing
practice, we have further developed the clinical career track for
Master Clinicians and Master Researchers through the rank of Colonel.
Master Clinicians are board certified nursing experts with a minimum
preparation of a master's degree and at least 10 years of clinical
experience in their professional specialty. They serve as the
functional expert and mentor to junior nurses. Our Master Researchers
are Ph.D. prepared and have demonstrated sustained excellence in the
research arena. Both of these highly respected positions facilitate
critical thinking and research skills, and foster the highest level of
excellence in care across our healthcare system. We currently have
eight Master Clinicians and three Master Researchers within designated
medical and research facilities.
In addition to training our newest nurses, we have realized the
efficiencies in Joint training for our enlisted medical technicians as
well. Teaming with our Joint partners, a ribbon cutting ceremony was
held in May 2010 at the new Joint Service Medical Education and
Training Campus (METC). This training campus will grow to be home to
nearly 8,000 students with an operating staff and faculty of over 1,400
civilian and Joint military personnel. In March 2011 a Memorandum of
Agreement and Board of Governers Charter was signed by all three
service Surgeon Generals. Creating this state-of-the-art training
platform will produce technicians in 15 different specialties to
support the DOD mission and optimize our interoperability amongst the
next generation of medics in the ever-growing Joint environment.
An ongoing effort in the development of our enlisted members is the
transition of our Independent Medical Technicians (IDMTs) and Aerospace
Medical Technicians (4NOs) to certified paramedics. This advancement
will continue to decrease our reliance on contract emergency response
systems and with an end goal of 700 paramedics. In 2010 we certified 46
paramedics, bringing our total over 200. To enhance the tremendous
capability of our IDMTs, our goal is to reach 100 percent within this
constrained career field over the next 5 years.
We believe this advancement in the development of our medics will
eliminate the stove pipe that has limited career opportunities within
the IDMT specialty field and over the long run enhance career
progression for these highly qualified medics. Additionally, our IDMTs
are eligible for the selective reenlistment bonus which has aided in
the recruitment and retention of these highly valuable assets. Our
IDMTs are enlisted professionals who serve as physician extenders and
force multipliers and who are capable of providing medical care, often
in isolated locations. Senior Master Sergeant Patrick McEneany, who is
just one of these valued medics, deployed for 7 months as an IDMT to
Iraq with a Joint Special Operations task force. As a provider in a
remote location, he supervised an urgent care medical clinic, serving a
camp of 1,200 individuals. His accomplishments during this deployment
included the resuscitation and stabilization of combat traumas and
emergencies and the treatment of 1,500 ill and injured patients.
Additionally, he evaluated multiple Combat Search and Rescue exercises
at forward operating bases to validate the care for Special Operations
Pararescuemen. For his efforts, Sergeant McEneany was awarded the
Bronze Star.
Further opportunities to maximize the potential of our Airman and
grow the next generation of Noncommissioned Officers are available
through the Air Force Institute of Technology (AFIT) for certain key
enlisted specialties. To date, we have three such positions identified;
one in education and training at the Air Force Medical Operations
Agency, another within our Modeling and Simulation program at Air
Education and Training Command, and the third within the research cell
at Wilford Hall Medical Center. Our most recent addition to the
research cell is Senior Master Sergeant Robert Corrigan, who just
arrived to Wilford Hall Medical Center.
Just as we are developing our Airmen, the development of our
civilians is critical to our overall mission success. We are
establishing a career path from novice to expert and offering
deliberate, balanced, and responsive career opportunities for our
civilians. Just as the career path for our military nurses and medics,
this career path will focus on the right experience, training, and
education, at the right time. In January 2011, we conducted our first
Civilian Developmental Board at the Air Force Personnel Center. The
goal of this board is to present the opportunity to our civilian nurses
for deliberate development and vectoring from the Force Development
team, similar to the feedback given to their military counterparts.
During this inaugural event, Level I and Level II Civilian Nurse
Supervisors volunteered their records for this formal review and career
counseling opportunity. This program will be a benchmark for the AFMS
as we continue to expand this vectoring process across all of our
Corps.
FORCE MANAGEMENT
The goal of Force Management is to design, develop, and resource
the Air Force Nurse Corps to sustain a world-class healthcare force in
support of our National Security Strategy and align our inventory and
requirements by specialty and grade. We must have the right number of
people to accomplish the mission. In fiscal year 2010, we recruited 170
fully qualified nurses and selected 126 new nursing graduates exceeding
our recruiting goal of 290. In line with initiatives to decrease Air
Force end-strength, Nurse Corps recruiting service goals were reduced
in 2011. As we face force shaping initiatives, it is critical that we
continue to develop programs that provide the clinical ability
essential to the sustainment of our nursing force.
In fiscal year 2008, the long-needed increase in colonel
authorizations for the Nurse Corps created a deficit to the grade
ceiling. With current personnel and year-group sizes, filling the
authorized grades at the senior level remains challenging. In an effort
to resolve the persistent grade level imbalances, nursing leadership
has been working closely with the Office of Deputy Chief of Staff,
Manpower, Personnel and Services to develop options, to include the
possibility of the Defense Officer Personnel Management Act relief.
This scenario would allow the colonel grade ceiling to reach allowable
guidelines by 2016. The Nurse Corps is continuing to pursue the optimal
solution in keeping with the Chief of Staff of the Air Force's
direction. These critical Nurse Corps positions are not affected by
current Air Force efforts to reduce its endstrength to authorized
levels.
In light of the significant limitations placed on direct
accessions, it is imperative that we focus on the retention of our
experienced nurses. As we enter our third year of the Incentive Special
Pay (ISP) program, we continue to see the positive impact this program
has on enhancing the professional satisfaction and retention of our
experienced clinical experts. This program, which incentivizes clinical
excellence at the bedside, tableside and litter-side, is crucial in
maintaining the needed staffing in career fields that are critically
manned.
Another incentive for our nursing force is the Health Professions
Loan Repayment Program targeted at those specialties with identified
shortages. Health professionals who qualify for the program are
eligible for up to $40,000 of school loan repayment in exchange for an
extended service agreement. In 2010, 53 nurses elected to use this
opportunity for financial relief in paying back school loans.
With Chief Master Sergeant Joseph Potts leading our enlisted force,
he is pleased to report success in securing a Selective Reenlistment
Bonus (SRB) for the 4N enlisted career field fiscal year 2010. As
mentioned, our IDMTs, along with medical technicians in several other
critically manned career fields such as the surgical sub-specialties,
Ear Nose and Throat, urology and orthopedics, are eligible for this
bonus. The SRB allows us to focus our resources in areas where we can
best retain medics in our critically needed specialties.
The Graduate School of Nursing (GSN) at 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. The GSN helps to
ensure the Services meet essential mission requirements and has a
history of rapidly responding to Service needs that is not possible in
civilian institutions. For example, the GSN established the
Perioperative Clinical Nurse Specialist and Psychiatric Mental Health
Nurse Practitioner Program; as well as focusing research and evidence-
based practice initiatives on pain management, traumatic brain injury,
and the care of deployed and Wounded Warriors.
PATIENT CENTERED CARE
As we mold our nursing force today, we are shaping our capabilities
for tomorrow's fight. Our success will be measured continuously through
conscious and deliberate planning and development. We strive to
establish leadership and professional development opportunities to meet
current and future Joint and Air Force requirements while building
trust through continuity and patient centered care. ``Trusted Care
Anywhere'' is the mantra of the Air Force Medical Service.
Understanding the value of patient-centered care, the AFMS is focusing
on ``Better Health, Better Care, Best Value'' through the Family Health
Initiative.
Across the globe, our healthcare teams are focused on building
patient-centered platforms able to perform the full scope of medical
and preventive care to our patients at home and abroad. We are
committed to the execution of the Family Health Initiative (FHI), the
Air Force's pathway to Patient-Centered Medical Home, which provides
continuity of care, team work and fosters improved communication; all
maximizing patient outcomes. Our Disease Managers and Clinical Case
Managers (CCMs) play an integral part in this process. At several
locations, our telephone consults have decreased by 21 percent from
2009, and our network referrals to an Urgent Care Clinic have decreased
by 50 percent since the FHI was started. This decrease in urgent care
referrals has saved over $174,000 for Joint Base Elmendorf Richardson
in Alaska. As well, a set of performance measures developed by the
National Committee for Quality Assurance, Healthcare Effectiveness Data
and Information Set (HEDIS), is used to measure clinical outcomes since
FHI inception. The HEDIS results demonstrated an overall improvement in
diabetic screening results and reporting. F.E. Warren Air Force Base,
Wyoming reports patient satisfaction is at an all time high of 96
percent for 2010. Additionally, many other sites are reporting similar
experiences as a result of this modification in how we care for our DOD
beneficiaries.
Alongside our Disease Managers, our CCMs are helping patients
receive safe, timely, cost-effective healthcare. The Air Force has 113
CCMs and in fiscal year 2010 there were 47,000 CCM encounters, a 50
percent increase over fiscal year 2009. Additionally, 4,000 of these
encounters were with Wounded Warriors, a 100 percent increase over
fiscal year 2009. Based on Air Force Audit projections, CCMs have
generated over $300,000 in savings compared to fiscal year 2009. The
CCM is integral to patient care coordination and the FHI, ensuring our
patients see the right provider, at the right time, and at the right
place. The goal of the Medical Home Model is to strengthen the
partnership between the patient and the healthcare team, and continue
to look at ways to provide timely, cost-effective care while focusing
on patient safety, and decreasing variance at every point of healthcare
delivery.
Patient safety remains paramount. For AE, the rate of patient
safety incident reports was less than 5 percent of patient moves. Of
note, most of these events were near-miss, meaning the event was
prevented and never reached the patient. To strengthen our Patient
Safety Program, Air Mobility Command has created an Aeromedical
Evacuation Patient Safety Course modeled on the principles of the
Department of Defense's Patient Safety Program. Ms. Lyn Bell, a retired
Lieutenant Colonel flight nurse and Chief, Aeromedical Evacuation
Patient Safety, taught the first class in December 2010. She trained 17
safety monitors from 10 total force agencies including AE Squadrons,
the Patient Movement Requirements Center and Staging Facilities. This
new program focuses on accurately capturing and documenting actual and
potential patient safety concerns. It teaches units how to incorporate
patient safety into their training scenarios and prepare the units for
the high operations tempo in the combat theater. With these continued
efforts, we hope to further enhance our culture that protects patients
and advances process improvements.
Beginning November 2010 through June 2011, the Air Force Medical
Operations Agency (AFMOA), in conjunction with the DOD, is implementing
the Patient Safety Reporting (PSR) System in Air Force military
treatment facilities worldwide. The PSR provides staff with a simple
process for reporting patient safety events using DOD standard
taxonomies, which enhance consistency and timely event reviews. The PSR
event data will be analyzed for trends and assist in identifying
targets for process improvement, both at Air Force and DOD levels.
A final note on patient safety: We have initiated a 1 year
fellowship in Patient Safety incorporating all areas within the AFMS,
to include the clinical, logistical, financial, and environment aspects
of care. This fellowship includes education on patient safety event
reporting, sentinel and adverse events, root cause analysis, proactive
risk assessment, and risk management. The fellow will also become
knowledgeable in patient safety database systems and strategic
communication to allow them to engage with Air Force and DOD
leadership.
We also recognize our responsibility in caring for victims of
sexual assault within our military healthcare system. Medical treatment
facilities team with installation Sexual Assault Response Coordinators
to deliver care to victims via coordination with Victim Advocates and
Medical Specialists. To ensure the integrity of forensic evidence and
guarantee access to care, most sexual assault exams are done off-base
via a memorandum of understanding with local treatment facilities. In
the deployed environment, seven of eight medical treatment facilities
perform exams on-site while one location uses a co-located Army
hospital. Upgraded First Responder training has been implemented to
increase training efficiency; over 6,000 medics completed First
Responder Training in fiscal year 2010.
At the root of patient care is nursing research yielding evidence
based practices. In fiscal year 2010, the Tri-Service Nursing Research
Program (TSNRP) awarded 18 research grants, including five awards
totaling $1,015,045 to Air Force nurse scientists. These investigators
are now studying military unique and military relevant topics such as
positive emotion gratitude, the resilience of active duty Air Force
enlisted personnel, and military medics' insight into providing women's
health services in a deployed setting.
Under Colonel Marla De Jong's leadership, and for the first time in
its history, TSNRP offered research grant awards to nurses at all
stages of their careers--from novice nurse clinician to expert nurse
scientist. The Military Clinician-Initiated Research Award is targeted
to nurse clinicians who are well-positioned to identify clinically
important research questions and conduct research to answer these
questions under the guidance of a mentor. The Graduate Evidence-Based
Practice Award is intended for DNP students who will implement the
principles of evidence-based practice and translate research evidence
into clinical practice, policy, and/or military doctrine. It is
critical that funded researchers disseminate the results of their
studies so that leaders, educators, and clinicians can apply findings
to practice, policy, education, and military doctrine as appropriate.
This grant will enhance this dissemination and uptake of evidence.
This year, Air Force nurses authored more than 10 peer-reviewed
publications and delivered numerous presentations at nursing and
medical conferences. Also in 2010, the TSNRP's Battlefield and Disaster
Nursing Pocket Guide and clinical practice guidelines were established
as the primary performance criteria for the Air Force Nurse Corps
readiness skills verification program. The integration of these
evidence-based recommendations will ensure that all nurses are prepared
and provide the highest quality, state-of-the-art care under
operational conditions.
We are also leveraging data gained from the Joint Theater Trauma
Registry to create innovative solutions for the battlefields of
tomorrow, today. In summer of 2011, in collaboration with our Joint and
Coalition Partners, we are establishing an enroute critical care
patient movement system to augment our existing tactical transport.
Once wounded, a patient is transferred as quickly as possible to a
forward surgical team, normally within 1 hour. These patients may
undergo life-saving damage control resuscitation and surgery.
Most often these patients are then transferred via helicopter to a
trauma center where their wounds can be treated more extensively by
medical specialists. These seriously and critically injured patients
receive en-route care by an Emergency Medical Technician with basic or
intermediate clinical skills or a facility must provide an attendant to
accompany the patient. This latter option limits the availability of
these skilled clinicians who may be needed for other incoming patients.
Neither solution was considered optimal in terms of ensuring
clinicians with the right skill sets are available while not reducing
the availability of care providers. As a result, of these challenges,
the Air Force developed Tactical Critical Care Evacuation Team, or
TCCET, to augment these inter-hospital transfers. The current TCCET
composition consists of two certified registered nurse anesthetists and
an emergency room physician. This team possesses advanced clinical
skills to support ventilated patients as well as patients who are
hemodynamically unstable. The team can function as a whole or each
provider can perform separately to meet the patient or mission needs.
The TCCET will augment the Army flight medic, or Air Force
pararescuemen on missions, and will also be able to support AE missions
or augment the CCATT, if needed.
Prior to deployment, these providers will hone their critical care
skills by attending our Centers for Sustainment of Trauma and Readiness
Skills (CSTARS) program at University of Cincinnati, Ohio. They will
attend the Joint Enroute Care Course at Fort Rucker, Alabama to become
familiar with rotary wing operations. The team will carry backpack
sized equipment packs to support most critical care patients, to
include pediatric patients. By inserting this higher level of
specialized care at the earliest juncture in the injury spectrum, we
hope to improve overall outcomes for the Wounded Warrior.
In the area of skills sustainment, our partnerships with high
volume civilian trauma centers continue to thrive. Our CSTARS platforms
provide invaluable opportunities to hone war-readiness skills. In 2010,
907 doctors, nurses, and medical technicians completed vital training
at one of these three centers located in Baltimore, Maryland;
Cincinnati, Ohio; and St. Louis, Missouri. Another example of our
skills sustainment initiatives lies within the 88th Medical Group at
Wright Patterson AFB, Ohio. The Medical Group stood up a state-of-the-
art Human Patient Simulation Center for providing realistic training
opportunities for healthcare personnel in 2009 with completion of the
center in 2010.
The Center has incorporated simulation into various training
courses including Advanced Cardiac Life Support, Pediatric Advanced
Life Support, and the Neonatal Resuscitation Programs as well as the
Aerospace Medical Service Apprentice Phase II and III program, and the
Nurse Transition Program. The Simulation Center also initiated monthly
Mock Code drills using human patient simulators and implemented Team
Strategies and Tools to Enhance Performance and Patient Safety
(TEAMSTEPPS) into simulation training scenarios. This center is also
the primary pediatric simulation site for military and civilian medical
students attending the region's Dayton Area Graduate Medical Education
Consortium.
Because of their efforts, the 88th Medical Group won the Air Force
Modeling and Simulation Annual Innovative Program Team Award for their
live training via a remote presence robot on the care of burn
casualties. The team connects via laptop with a robot at Brooke Army
Medical Center's burn unit during interventional patient care, and an
on-site facilitator describes the treatment procedure in real time. The
program was coordinated through the Army Institute of Surgical
Research.
Within our patient-centered care philosophy is the recognition of
the need to address the resiliency of our Airmen and families as well
as to care for the caregiver. As an experienced critical care nurse,
Lieutenant Colonel Mary Carlisle thought she could handle anything on
deployment to Iraq. But the casualties she saw daily took a toll on her
psychological health. When Colonel Carlisle returned home, her war
wounds were invisible. She became increasingly lost in sorrow, becoming
absorbed and distracted by thinking ``What if?'' and ``Why?'' She
sought solace at the National Mall in Washington, DC, studying the
faces of the Vietnam Women's Memorial monument, identifying with each
of the women depicted in the monument. During her 2010 Memorial Day
speech at the Vietnam War Memorial she reflected how she was, during
different times of her deployment, each one of those women. She states
``I was the woman kneeling, looking down, defeated, holding the helmet
that will never be worn again. I was the woman cradling the Wounded
Warrior, fighting with everything I had to save his life. And, I was
the woman gazing skyward; grasping the arm of my colleague,
anticipating whatever was to come.''
Colonel Carlisle found the courage to seek help for her wounds and
hidden trauma. She further states ``now I am at peace knowing I--we--
did the best we could, and the fallen angels were not lost in vain, and
America's freedom still reigns.'' Colonel Carlisle became a spokeswoman
for nurses and other medical personnel with post-traumatic stress or
other war-related adjustment issues. Instead of being rebuked by her
upper command for openly talking about her experiences, Colonel
Carlisle is praised for her efforts to encourage other troubled nurses
and medical technicians to see help. Colonel Carlisle helps to show our
Airmen that she is a senior officer who has experienced the same
feelings they may be having and they should feel comfortable talking
about their experiences and feelings. We are changing our culture to
promote the building of resilience, facilitate recovery, and support
reintegration of returning Service members.
WAY AHEAD
The United States Air Force Nurse Corps consistently achieves
excellence in all that we do. The use of professional clinical judgment
in delivering evidence-based care is essential in enabling our Airman
and their families to improve, maintain, or recover health, and achieve
the best possible quality of life. By partnering with our civilian
institutions, Joint, and Coalition partners we are building the next
generation of care and capability. As we step into the 21st century, we
are forging our future by addressing our stressors, embracing our
professional diversity, and fortifying our Total Nursing Force with
education, training and research.
Mr. Chairman, and distinguished members of the Subcommittee, it is
an honor to be here with you today and represent a dedicated, strong
Total Nursing Force. Our Wounded Warriors and their families deserve
nothing less than educated and skilled nurses and technicians who have
mastered the art of caring. It is through the medic's character,
compassion and touch that we answer our nations call to care for those
who served yesterday, today and tomorrow.
Chairman Inouye. And now, if I may, I was in the Army about
69 years ago. That is a long time ago. And at that time, the
highest-ranking nurse, I believe, was a colonel--one colonel.
And in the hospital that I spent 2 months in Italy, the
highest-ranking nurse was a major. The theater commander of the
nurse corps was a lieutenant colonel. In the hospital in
Atlantic City and Michigan, the highest-ranking nurse was a
lieutenant colonel.
As we all know, in 2003, we made nurses two stars. Now I
have been told that the Secretary of Defense has come up with
efficiencies, and he recommends a reduction from two stars to
one star.
I would just like to have your views, General Horoho.
General Horoho. Yes, sir.
First, sir, I would like to thank you very much for the
support because I would not be sitting here as a two-star
general without your support. So, thank you.
We used the launching of the rank of two star to actually
leader develop across all of our corps across Army medicine. We
have right now nurses that are commanding at the level 2
command within the theaters of operation. We also have them
commanding across Army medicine. We have nurses that have
strategic input into decisionmaking at the strategic level, and
so we now have I think a very competitive field for our nurses
to be able to be competitive for branch materiel one star and
then also at the two-star level.
Chairman Inouye. So, you are not in favor of the
Department's recommendation?
General Horoho. Sir, I will support the Secretary of
Defense and his efficiencies, and I----
Chairman Inouye. You are a good soldier.
General Horoho [continuing]. Am very, very grateful for the
rank of two star. Thank you.
Chairman Inouye. Well, I will make certain you keep your
two stars. I think it is about time we recognize the value of
nurses. When I was in the hospital, other than the time spent
on the operating table, in the wards I saw the doctor about
once a week, nurses 24 hours per day. She is the one who
provided minor surgery, all the medicine, all the care. But she
was a second lieutenant. I think it is about time we recognize
their value, and I think if a man gets two stars for commanding
10,000 troops, I think a nurse should get two stars for
commanding 18,000 troops.
Senator Mikulski. Hear hear.
Chairman Inouye. That is how I get my votes.
Does the Navy support----
Admiral Niemyer. Well, sir, I want to extend our grateful
appreciation for the support you have provided to military
nurses. It has enabled us to achieve both civilian nursing and
military medicine respect commensurate with the rank of a two
star, and the scope of responsibility of a two star as well.
I have had the unique opportunity of being able to be
selected as a one star and work in a very challenging joint
position, which I believe enabled me to better lead the Nurse
Corps today. We are extremely grateful, and I, too, would not
be sitting here as a two star without your support and this
subcommittee's support.
Thank you.
Chairman Inouye. General, does the Air Force support two
stars or one star?
MILITARY NURSING LEADERSHIP
General Siniscalchi. Sir, military nurses will continue to
provide the best patient care possible and will continue to
lead at whatever rank we are asked to lead at. But having
served as a two star, and I thank you for your continued
advocacy for military nursing and for the support that military
nursing received in 2003, to have the leadership position
raised to a two star. And when you look at our scope of
leadership and our scope of responsibility and for the Air
Force having to include our total force Active, Guard, Reserve,
officer, enlisted, and civilian, we are close to 19,000. And to
provide policy and directives for a total nursing force of that
size, the two star rank has served us very well. And it is
commensurate given our total nursing force engagement in global
operations. But we will continue to support whatever decision
is made, sir. Thank you.
Chairman Inouye. Today's war has much trauma, brain
injuries, multiple amputations, and it is a bloody war, much
more severe than World War II. Are the nurses getting
specialized training for this type of service?
General Horoho. Mr. Chairman, we are looking at the Joint
Trauma Tracking Registry System to get lessons learned, and we
have changed, over these last several years, our training
platform in the area of trauma nursing. We also made a decision
with--over the last couple of years that every single nurse
needs to be a trauma nurse. It is at our core competency. So,
we have the combat trauma tactical course that our medics focus
on. Everyone who deploys gets trauma training prior to their
deployment, whether that is in San Antonio or it is in Florida
at the University of Miami. And then we are constantly refining
and looking out at what is occurring in the civilian sector,
which is part of what develops our Virtual Leader Academy, is
that we looked at competencies and capabilities, and we
redesigned all of our training programs to better support the
complexity of the wounds that we are seeing in this war.
Chairman Inouye. Before I call upon Senator Cochran,
listening to our two ladies, I could not help but think about
the trauma that families have to go through. For example, today
a spouse can call her husband in Afghanistan every day----
General Horoho. Yes, sir.
Chairman Inouye [continuing]. On a telephone that is not
censored. Every evening she can watch CNN or whatever it is and
see her husband's unit in action, and she has to sweat it out
until the next day, and she does not hear from him. And you
wonder why someone gets stress disorders. In my time, I made a
telephone call before I left Hawaii. The next telephone call I
made to Hawaii was 3 years later on my way home. The letters
that I wrote to my family were all censored. All I could say
was the food is terrific, Italy is a wonderful place, I love
France and Paris--nothing about action or injuries.
I can understand why there are more suicides today. I can
imagine coming back, getting together with your family and 6
months later have to ship off again. That is not the way to
serve. We will have to do something about this.
What are the nurses thinking about stress disorder and
suicides?
MENTAL HEALTH ISSUES
General Horoho. I will let you, and then we will just kind
of go down the line.
Admiral Niemyer. Thank you, Senator.
The issue of families and our service members with post-
traumatic stress and mental health is a concern for all of us.
We have tried to build resilience programs, not just for the
service members themselves, but for our families as well. I
know we have FOCUS, which is Families Overcoming Under Stress
for our Navy personnel and Marine Corps personnel, and use that
as a training platform to discuss those issues proactively. The
goal currently is to build resilience and strengthen our
soldiers, sailors, airmen, and marines, as well as each other.
And that is just one type of program that we are using to
address the families.
We have also looked at building stigma reducing portals for
our service members and their families to access mental health.
An area where mental health psychiatric nurse practitioners are
making a difference, as well as all of our mental health
personnel, is to embed them in primary care areas where they
are accessible to those that need them in an attempt to ward
off and address those issues before they become problematic.
Any one suicide is one too many, so building that resilience
and looking proactively is one of the ways that we are trying
to address that.
General Horoho. Mr. Chairman and the subcommittee, part of
what we learned over the last 10 years of supporting a Nation
at war is that we cannot just treat the warrior, that we
absolutely have to treat the family. And where social
networking came in, which you mentioned, is that because of
that, it connects the home to the battlefield, and all of the
stressors that are at home are felt by the soldiers, and
sailors, airmen, and marines, and Coast Guards that are
deployed, as well as what is going on in theater is also known
by the families.
A couple of things that we have done: We have implemented
in nursing as part of all of this--we have implemented the
Comprehensive Behavioral System of Care, which has five touch
points. And we evaluate 100 percent, so to try to reduce the
stigma, it is mandatory from our privates to our general
officers to be evaluated by either a psychologist, a
psychiatrist, a psych nurse practitioner, or a social worker,
and then primary care that are trained in behavior health. That
evaluation then allows us to get them help as soon as possible
if it is needed. We have also embedded our behavior health into
primary care because what we found is a lot of our patients
come in for healthcare, and it is a low back pain or maybe a
headache when it really is something that has to do with stress
or anxiety. Then when they are in the deployed theater and we
have our nurses as part of the combat support teams, 100
percent are evaluated prior to them redeploying back. That
information of whether they are high risk, moderate, or a low
risk is then sent back to the installation that is going to
receive them. And we have behavior health and nursing as part
of that team. When we talk behavior health, it is the entire
complement from our medics, our nurses, psychiatrists,
psychologists, and social workers, so when I use that, that is
the team that I am talking about. They evaluate at each one of
those touch points.
We also found that we needed to leverage virtual behavior
health when we talked about how difficult it is to be able to
get a--national shortage of resources--how do we get that? So
we leveraged virtual behavioral health, and we have over hired,
and we have platforms in Europe as well as at Fort Louis,
Washington, Walter Reed, and Brooke Army Medical Center, and
then Eisenhower. And we use those electrons to be able to get
healthcare to those that are needed. And when we marry the
family up, what we are testing right now is using virtual
behavior health and counseling of a family of children and the
wife with a service member that is deployed to be able to keep
continuity of care and look at trying to reduce the stressors
of healthcare if we can deal with those issues now instead of
delaying that till they redeploy back.
And then on the children's side, we are also working, and
actually all of our services are working with us and Department
of Defense, to embed behavior health into the school system so
that we can help with the young children that are stressed
because of either multiple deployments of their parents. And so
that is part of our school-based programs that we are using as
pilots across, and we are starting to see whether or not that
impacts by being proactive.
Thank you, sir.
Chairman Inouye. Thank you very much.
General.
TIERED-BASED MODEL OF RESILIENCY
General Siniscalchi. Sir, it is a very stressful time for
our military members and their families. But what we are
finding is that prevention is key, and it has to start from the
very beginning and continue throughout their entire
professional career.
We are looking at a tiered-based model of resiliency that
incorporates multi-dimensions of human wellness from the
physical to the social to the psychological and the spiritual.
And our tier-based resiliency model begins from the beginning,
whether it be in basic military training, technical training,
and officer training. And we instill a culture of resiliency,
recognizing signs and symptoms of post-traumatic stress, de-
stigmatizing behavioral care, and encouraging our military
members, their families, to seek behavioral health when
necessary.
And as we continue throughout the professional career, we
look at multiple points throughout the career to introduce
training, whether it be through professional military education
or through leadership training. And then as we identify groups
that are at high risk for post-traumatic stress, for
depression, for suicide, then the training and the education is
tailored to them and their families to help minimize and help
to moderate their risk.
We have used a Mortuary Affairs Model from Dover Air Force
Base that has incorporated strength-based training and
resiliency, and we incorporated that model throughout our
different levels of command-based resiliency programs.
We have targeted pre- and post-deployment training, and
while in theater, those individuals who have been serving
outside the wire or have been exposed to multiple trauma, then
as they pass through Germany, they go through our Deployment
Transition Center, and that helps to prepare them as they go
back to their families and to their bases. And it better
enables them to reintegrate and rejuvenate as they come back
from deployment.
We have reached out to our senior leaders, who have
deployed and have experienced post-traumatic stress. And we
have two of our senior leader nurse officers--critical care
nurses, Lieutenant Colonel Mary Carlisle and Lieutenant Colonel
Blackledge. And they came back from multiple deployments and
recognized that they were experiencing signs of post-traumatic
stress. And in our effort to incorporate behavioral health into
our family home model and to de-stigmatize behavioral health,
both of these senior nurses sought behavioral healthcare, and
then decided to take their message forward. And they have
produced videos in multiple forums. They have shared their
experiences that not only they went through individually, but
what their families also went through when it came to post-
traumatic stress.
We recently had a nursing conference last week in Dallas,
and Lieutenant Colonel Blackledge came and shared her message
to close to 500 nurses and technicians. And we also had a
social worker on site who met in small groups with our nurses
and technicians recently coming back from deployment who
experienced post-traumatic stress.
I think the best approach that we can take is the tiered
model for resiliency, targeting those groups that are at high
risk, de-stigmatizing mental health, encouraging all of our
members to openly communicate when they are recognizing signs
of stress, to focus pre-deployment, during deployment, and
post-deployment, and then looking at success stories out there,
which have been the Mortuary Affairs Group at Dover, and then
emulating programs that they have put in place.
Chairman Inouye. Thank you very much.
General Siniscalchi. Thank you, sir.
Chairman Inouye. Senator Cochran.
Senator Cochran. Mr. Chairman, I have been impressed with
the comments that I have read and the testimony that you
prepared for our subcommittee before the hearing. And we thank
you for that. I was particularly impressed with the training
programs, and I was looking at the Air Force experience as
defined in your testimony that you prepared, General
Siniscalchi.
We appreciate the fact that it does not just happen on
instinct or spontaneous judgment, but a lot of people spend a
lot of time drawing on their experiences and presenting it to
others who would be confronted with long flight times coming
back from combat areas, critically injured soldiers and sailors
who have to have special care and treatment. And the scope and
involvement of so many people in the success of these
operations is really quite awesome. I cannot imagine any
military force in the world being able to come close to what
our military, and particularly the Nursing Corps in all of our
services, have done to help make it such a successful and
caring, lifesaving experience for many men and women.
Do you have any comments about that, and is there funding
available in the request for funding that will continue these
programs and help support what you have designed as the best
that you know, the state of the art?
FUNDING TO SUPPORT AN INCENTIVE SPECIAL PAY PROGRAM
General Siniscalchi. Sir, funding is available. Our
Incentive Special Pay Program, first and foremost, is helping
us to retain our clinical experts. So, being able to have
funding to support an Incentive Special Pay Program is helping
us to retain seasoned clinicians.
Our strength in the care that we are to provide and to have
the successes that we--that you have just mentioned comes
through our ability to build partnerships. As we continue to
partner with our sister services in critical care training, as
we continue to partner with academic institutions for our nurse
transition program, we currently have partnerships at
Baltimore, at St. Louis, University of Cincinnati for our C-
Stars, our critical skills sustainment training. We have,
again, academic partnerships and partnerships with civilian
trauma centers that allow us to send our nurses into their
facilities for sustained training. So our goal is to ensure
that if we do not have robust training platforms within our
military treatment facilities, that we establish robust
partnerships with our sister services, with academic
institutions, academic--or civilian trauma centers, and the VA
so that we have a ready force with sustainment training, that
we have platforms in place for going out the door so they can
hone their critical care and trauma skills, so that we can
continue to provide the care that we provide. But we do that
through training affiliation agreements and robust
partnerships.
Senator Cochran. Thank you.
Mr. Chairman, thank you.
Chairman Inouye. Thank you.
Senator Mikulski.
Senator Mikulski. Mr. Chairman.
First of all, I would like to say to the entire nursing
leadership of all the services, we just want to thank you for
what you do every day. Every day in every way, you do high tech
and high touch patient-centered healthcare, and I just want you
to know I think all the Members of the Congress, they do not
thank you every week--we cannot thank you enough for what you
do.
And, Admiral Niemyer, I understand you are a graduate of
the University of Maryland. Is that right?
Admiral Niemyer. Yes, ma'am. I am in your State. I am a
home grown Annapolis girl.
Senator Mikulski. I know. I have got the accent, you know.
We both have the same accent, and I graduated from the
University of Maryland School of Social Work.
NAVAL BETHESDA--WALTER REED NURSE STAFFING
Admiral Niemyer. Yes, ma'am, I saw that.
Senator Mikulski. I think we were a couple of yearbooks
away from each other, but nevertheless, we were at the downtown
campus.
I have two questions, one related to acute care, and then
the other to this more chronic behavioral post-deployment care.
Admiral, we are going to be opening a Naval Bethesda Walter
Reed, and my question is, number one, as we gear up, first of
all, who is going to actually be in charge of the nursing
clinical services? It is an unusual governance mechanism. We
are looking forward to it. I am really excited about it. And,
perhaps, General, you could help. Who is going to be in charge?
And then the second question: Do you feel that as we are
gearing up, that there will be adequacy for both nursing care
as well as the very important Allied Health Services?
Admiral Niemyer. Yes, ma'am. The current Director of
Nursing Services at the now National Naval Medical Center, soon
to be Walter Reed Military Medical Center, is Colonel Ellen
Forster, she is an Army colonel. The nurses there, and at Fort
Belvoir and Walter Reed, have blended nicely to create an
executive nursing staff to work together. So, to answer your
question, the governance and who is in charge of the nurses at
Bethesda, it will be Colonel Ellen Forster. I believe she is
here in the room today as well.
Senator Mikulski. Is she here? Could she hold up her hand?
Well, we are glad to see you, and we will be out to see you.
Tell me about adequacy. Thank you.
Admiral Niemyer. In terms of adequacy, from my
understanding, yes. As we move the patients over, we have the
nursing staff and the facility support to take care of the
patients there. So, in terms of adequacy, I do not see any
issues in bringing our patients and combining our patient force
there.
Senator Mikulski. General.
General Horoho. Ma'am, one of the things is looking a
little bit broader than Walter Reed Military Medical Center is
actually looking at Belvoir, because both Belvoir and Walter
Reed are Tri-Service-based hospitals, and looking at an
integrated healthcare system. And so, with that, one of the
things that we did on the nursing side is we have already sent
Army, Navy, and Air Force nurses to Champion training to
support the Patient CareTouch System, to really look at
providing one standard of nursing care, decreasing variance,
and really focusing on the patient being in the center, and
improving the health of the patient and their family members.
So, I think adequacy of training is going to be just fine, and
I actually think it may be expanded as we learn from each of
our services what we offer the best in a large beneficiary
population in the National Capital Area.
Senator Mikulski. First of all, that is so heartening to
hear. I go back, again, to the awful times of Walter Reed in
2007. And now we are looking ahead, and part of the looking
ahead was not only the immediate treatment of acute care, which
I think everybody says is actually stunning, stunning in the
annals of medicine, military or civilian. It is truly stunning
in battlefield to back home.
But I want to hear, if I could just for a minute, this
Patient CareTouch System, because I think that was what I was
trying to get at with General Schoomaker. It says patient
advocacy, enhanced care team communication, clinical capacity,
and evidence-based, which we want, and healthy environment.
Could you describe for me, from the patient standpoint, what
does that mean, because we hear touch tones, benchmarks, yadda
yadda.
General Horoho. Yes, ma'am. If I can back up first and just
explain how we even came to develop the Patient CareTouch
System. We actually looked across Army, Navy, and Air Force,
and looked at what were the common elements of high-performing
systems. We also then looked across the civilian sector to see
the magnet hospitals and what did they have in common. And then
we realized that there was not one system out there that put
all of those elements together. So we developed that and we
piloted it at Fort Campbell, Kentucky. And what we found is
that we actually had an increase in patient satisfaction. We
had an increase in communication between our clinicians and the
ancillary staff and the physicians. We had patient involvement
with the family members and positive feedback. We had a
decrease in left without being seen in our emergency rooms. We
had a decrease in medical errors. We had an increase in
critical lab value reporting. So, all of our nurse-centric and
nurse-sensitive measures we saw very positive outcomes. So,
after we piloted that for about 9 months and made some
adjustments is when we then developed the training program to
support that.
And the Patient CareTouch System, what it does is it
actually focuses on having the patient in the center of every
touch point--every place, whether it is in the ambulatory arena
or whether it is inpatient, that we make sure that the patient
is involved in decisionmaking. We do hourly nursing rounds. We
actually use white boards to communicate so that if family
members come in, instead of the patient having to say, this is
what the physician just told me, this is what the nurse just
did, these are the reports we are waiting for, we take that
burden off of our patient, and it is the clinical team working
together, better communicating that information.
We also identified data mechanisms and data that we wanted
to track that really led to positive outcomes in healthcare,
because we needed to be able to say what is the value of nurses
providing patient care, whether it is inpatient or outpatient?
And how do I know, as the Chief of the Army Nurse Corps,
whether or not we are making improvements in patient care? So,
we have a database now that looks at the health of our
patients, that the head nurse or the clinical officer in charge
can look at their patient and see how they are doing in patient
care performance. That is rolled up to the Deputy Commander of
Nursing, and then I across the Corps can then look at the
health of our patients.
We also added a peer review, so if you look at our officer
evaluation----
Senator Mikulski. My time is going to run out.
General Horoho. I am sorry.
Senator Mikulski. But that is the evaluation.
General Horoho. There is a lot. There is a lot----
Senator Mikulski. I am going to stick to--well, what I
would appreciate, because the chairman has been generous with
my time, though I know he is very passionate about this because
it is the follow through. As nurses, social workers, we say
this. It is not only when they are in the ER or the OR, it is
the rest of the R; it is rehabilitation, it is follow through,
it is the management of chronic pain, etc.
What I would like is a white paper actually, or any color--
a paper describing really what it is and what it does, and
perhaps some casing samples, I think in case examples, which I
think you do, too, in addition to this epidemiology and all you
are looking at. So, I really would follow this through because
I think you are on to something, and I think you are on to
exactly what I am on to, that you need a patient advocate and
all the way through inside. So, let us work together.
[The information follows:]
A top to bottom review of Army Nursing revealed that high
quality care was being delivered but that it varied from
facility to facility. The variability challenged patients,
their families, and the nurses providing care. Notable in this
review was the impact that the high technology environment had
on patient care and a shift from those things that are
considered unique to the art of nursing.
The Patient CaringTouch System was developed in order to
optimize care delivery. A pilot program was conducted at
Blanchfield Army Medical Center in 2008 and this pilot revealed
performance improvement across multiple dimensions within 6
months of implementation, and suggested that broad
implementation of the Patient CaringTouch System can create
real value for Army Medicine. The following areas showed
statistically significant improvement: (1) Decreased medication
errors, (2) decreased risk management events, (3) decreased
left without being seen from the emergency department, (4)
increased pain reassessment, (5) increased critical lab
reporting, (6) increased nurse retention and intent to stay
The Patient CaringTouch System is what Army Nursing (AN)
believes and values about the profession of nursing, delineates
AN professional practice, articulates a capability-building and
talent management strategy to ensure the right quantity and
quality of AN leaders, and describes how AN delivers evidence-
based care in accordance with best practice standards across
care environments.
Senator Murkowski. I worked with your predecessors on the
nursing shortage. We want to continue that. And we have a real
champion in Senator Inouye. We all--we are all in love with
Senator Inouye. And--but we want to thank you again for your
service and look forward to working with you.
General Horoho. Thank you.
Admiral Niemyer. Thank you, Senator.
Chairman Inouye. Thank you very much.
Senator Murkowski.
SEXUAL ASSAULT
Senator Murkowski. Thank you, Mr. Chairman. And I
appreciate the time that the subcommittee has given to this
very important testimony here today. Thank you all again for
your service.
I want to ask a question this morning about military sexual
trauma. The fact that the three of you, this panel, is all
female has nothing to do with my question. I had actually hoped
to ask it to panel one, but I ran out of time. So, but it is
equally applicable from the nursing perspective as well.
As you are aware, the Women's Veterans Health Care
Improvement Act put these new responsibilities on the VA to
care for our discharged members of the armed forces who are
suffering from military sexual trauma. The question to you all
is, are we doing enough within the military medicine field here
to identify, to treat these cases of military sexual trauma at
the time that the service member has been victimized, or is
this going to be a situation where the treatment for these
individuals will be at the end when the service member is now
part of the VA system and then discharged? And then, in
addition to answering that question, if you will, are we doing
okay, I guess, in terms of maintaining the records that we will
need in determining the incidence of military sexual trauma and
the outcomes in treating these victims? Is the process set up
to work, and then, again, are we tending to the situation at
the time that the sexual trauma has occurred, or are we waiting
until this individual is part of the VA system? So, if you
could just very quickly--and I recognize that this is an issue
of time here this afternoon, but this is a very important
issue, I think, as we know within all branches of our service
right now. And I will throw it out to anyone who wants to
start.
Admiral Niemyer. I would be happy to just make a comment. I
think the issue is so much broader than the medical parts, and
although I cannot speak directly to your question about the
records at this point, I would be happy to provide that back as
a Navy response.
The issue is so much broader than medical, and even today,
I read this morning a white paper on sexual trauma. We have not
progressed where we need to be. It is still a prevalent issue,
and despite much of the training that we have done and the
focus, it still remains an issue.
That being said, I think we are doing a great deal in the
military today with our line leadership to highlight this very
prevalent issue and to focus on decoupling the alcohol
incidence that at times accompanies sexual assault. We have a
zero tolerance in the Navy, and I know for the other services
as well.
So, I can speak on the broad sense and would be happy to
provide a more detailed medical response on that. But like
suicide, any assault, and any particularly when it is our own
folks, it is something that we clearly have zero tolerance for.
Senator Murkowski. Oh, I would welcome a follow-up from you
from the Navy's perspective if I could.
Admiral Niemyer. Yes, ma'am.
[The information follows:]
Senator, Navy Medicine has taken an active role in
supporting victims of sexual assault through the provision of
medical care and the ability to support legal action by the
completion of a sexual assault forensic examination when a
victim presents to our facilities after an assault. Specific
Navy Bureau of Medicine and Surgery (BUMED) initiatives include
the establishment of a training program on the sexual assault
forensic examination for medical providers stationed at
overseas (OCONUS) commands. Not all of our medical treatment
facilities (MTFs) within the United States offer in-house
forensic evidence exams after an assault, but great care has
been taken to establish Memorandums of Understanding (MOUs) at
high-quality civilian facilities to meet this need. In
addition, BUMED has initiated a study with the Center for Naval
Analysis to gain understanding why some victims are choosing
not to seek medical care or have a forensic examination at the
time the assault occurs. Interventions will be initiated based
on the finding of the study.
The incidence and tracking of sexual assaults is reported
via two sources. Naval Criminal Investigative Services reports
and tracks unrestricted cases and the Sexual Assault Response
Coordinators monitor and track the cases for victims who choose
a restricted report. The challenge of accurate record keeping
in the Navy is two pronged. First is the issue of under
reported data. As many victims of sexual assault, both in the
military and our society in general, continue to be concerned
with the stigma associated with the crime and the fear of
privacy breaches. Second, and specific to Navy Medicine, is the
electronic medical record. Currently the required documentation
for the forensic medical exam is Defense Form 2911 (per the
DOD-I 6495.02). This form is not in electronic format but
requires a scanned entry to be maintained in the electronic
medical record, which is happening.
Navy Medicine has an important and specialized role in
caring for sexual assault victims. Our care for sexual assault
victims encompasses the full scope of medical and psychological
care with a priority on care that includes access to personnel
trained to perform forensic examinations and psychological care
aimed at providing the means to resume a healthy lifestyle. We
realize that sexual assault affects more than just our Sailors
and Marines. Sexual assault erodes unit cohesion, denigrates
Navy core values and can adversely affect fleet readiness and
retention. We allow victims of sexual assault the right to
choose the option for care that is best for them, allowing them
time to regain control of normal life functions. Our leaders
are highly encouraged to use Sexual Assault Awareness Month to
further educate sailors about the Navy sexual assault
prevention and response program to include the role of medical
personnel. Posters, educational leadership guides and other
materials are readily available for download to assist in
providing quality educational programs, encouraging an emphasis
on a climate that values responsible behavior and active
intervention. Navy Medicine, along with all Navy leaders stands
ready to meet the challenge of eliminating sexual assault from
our ranks.
Senator Murkowski. General.
General Horoho. Ma'am, we started about 2 years ago with
Secretary Geren of having a campaign to increase awareness,
that it really was an affront to our warrior ethos, whether it
is a female being assaulted, or if it is a male being
assaulted. So we looked at it with both demographics.
I believe we have enough trained counselors to provide that
level of care. Part of it, though, is creating that safe
environment for people to feel comfortable coming forward,
which is what you are talking about, the early intervention.
And I think that is a work in progress, to be perfectly honest.
We have also worked very closely with the VA. We have a
midwife, Colonel Carol Hage, who actually works at the Office
of the Surgeon General that has established a partnership with
the VA to look at women's health issues, and this is one piece
of that, because the demographics of the VA have changed, and
then the impact of deployment with behavioral health and other
issues, we wanted to make sure that we had the right programs
in place to support. So we are evolving as time goes on.
Senator Murkowski. Are you satisfied with the records that
are being kept at this point, or do you know?
General Horoho. Ma'am, if they come in and it gets into our
electronic health record, then absolutely it is being
documented and it is being kept in the system. And then we have
got a lot of work that is being done right now with DOD
partnering with the VA so that we have one electronic health
record sharing that information. So, I think once it is in the
system, it is absolutely in the system and is being maintained.
INCIDENCE OF SEXUAL ASSAULT IN THE MILITARY
Senator Murkowski. We've got to get in the system.
General Horoho. Yes, ma'am.
Senator Murkowski. General.
General Siniscalchi. Thank you, ma'am, for your question.
And we all are concerned about the incidence of sexual assault
in the military.
In 2004, General Casey McLean from the Air Force was
charged to stand up a task force, and did a remarkable amount
of work to advance training and prevention regarding sexual
assault. As a result of the work done by the group that she
led, we moved to restricted and unrestricted reporting of
sexual assault. There had been numerous years from this initial
task force where the Air Force focused on various training
programs, various approaches to reduce sexual assault, and ways
to advance treatment when sexual assault did occur, and then
focusing on restricted and unrestricted reporting.
Now in 2010, there was a Gallup survey that the Air Force
did to establish a baseline looking at the incidence of sexual
assault. When the results of that Gallup survey came out, there
was a Sexual Assault Prevention Council that was stood up, and
I was asked to represent the medical--surgeon general--on this
council. So, this group of senior leaders did a very in-depth
analysis of this Gallup survey, the result. And what we found
was that once a sexual assault occurs, that across 100 percent
of our military treatment facilities within the United States,
overseas, and at deployed locations, that we have the
appropriate response teams in place, whether they be sexual
assault forensic examiners, sexual assault trained nurses, or
sexual assault examiners, that they are either within the
facilities or that we have memorandums of understanding
established with a civilian facility to provide that level of
response.
And so, the response to a sexual assault, we have made
tremendous strides. When it occurs, the care--the immediate
care--we found that one of our longest treatment lines to
response was at one of our overseas locations, and that
treatment was still under 2 hours. We have really made great
strides in treating sexual assault.
However, what the Gallup report showed is that there still
is significant improvement that needs to be made when it comes
to prevention and training. Our working group is now looking at
ways to enhance training and areas that were identified focused
on leadership. We are looking at training programs, whether
they be through, you know, modular training, distance learning
programs, face-to-face training, to enhance awareness and
sexual assault training, and then put better programs in place
that focus on prevention.
Senator Murkowski. Well, I appreciate what you have
provided me. If there is any follow-up that you can offer, I
would be interested in that as well. I often wonder whether the
same stigma that attaches to just the need for services for
behavioral health might also attach when it comes to issues as
they relate to sexual trauma, sexual harassment, because that
is also part of what we deal with within the definition of
military sexual trauma. And it is something that as we think
then as to the treatments beyond, again, it is not just the
physical, but it is as we deal with those mental health issues
that may last for considerable periods of time. So, this is an
issue that I appreciate your attention to and to the surgeon
generals that I know are all still here. I thank you for that.
But any efforts that we can make to improve this is greatly
appreciated.
With that, I thank the chairman and the vice chairman.
Chairman Inouye. Thank you very much.
ADDITIONAL COMMITTEE QUESTIONS
General Schoomaker, Admiral Robinson, General Green,
General Horoho, Admiral Niemyer, and General Siniscalchi, thank
you very much for your testimony, and, above all, thank you for
your service to our Nation.
[The following questions were not asked at the hearing, but
were submitted to the Department of response subsequent to the
hearing:]
Questions Submitted to Lieutenant General Eric B. Schoomaker and Major
General Patricia Horoho
Questions Submitted by Chairman Daniel K. Inouye
SOURCES OF HELP FOR SERVICEMEMBERS AND THEIR FAMILIES
Question. General Schoomaker, are there efforts within the
Department of Defense and amongst the Surgeons General to coordinate
their approach on access to psychological healthcare needs and work
towards one dedicated DOD Web site and phone line for all services?
Answer. The Defense Centers of Excellence for Psychological Health
and Traumatic Brain Injury (DCoE) is the Department of Defense (DOD)
effort to coordinate psychological healthcare needs for servicemembers
and their families across all services. The DCoE was established to
assess, validate, and oversee prevention while facilitating the
resilience, recovery and reintegration of servicemembers and their
families needing help with psychological health and traumatic brain
injury. The DCoE Web site (www.dcoe.health.mil) has a wealth of
information to include information on the 24/7 outreach center. This
center can be reached via phone at 866-966-1020, email at
[email protected], or via live chat.
Military One Source is a single virtual portal to behavioral health
(BH) care to meet the needs of all servicemembers and their families,
including Guard and Reserve, regardless of activation status. This DOD
level resource serves as an extension of installation services to
improve access to BH care while reducing stigma.
PSYCHOLOGICAL HEALTH
Question. General Schoomaker, there has been an effort to expand
psychological treatment options across the Army healthcare system. How
is the Army providing expanded access to these services, both for
soldiers and their families?
Answer. In the past year the Army implemented the Comprehensive
Behavioral Health System of Care Campaign Plan. This initiative is
nested under the Army Campaign Plan for Health Promotion, Risk
Reduction and Suicide Prevention. The Comprehensive Behavioral Health
System of Care is intended to further standardize and optimize the vast
array of behavioral health policies and procedures across the Medical
Command to ensure seamless continuity of care to better identify,
prevent, treat and track behavioral health issues that affect soldiers
and families during every phase of the Army Force Generation cycle.
The U.S. Army Medical Command currently supports over 90 behavioral
health programs. The ``Virtual Behavioral Health program for
Redeploying Soldiers'' (VBH) was established to maximize behavioral
health assets and modern communications technology to provide uniform
contact with all redeploying soldiers. VBH is meant to provide a
positive experience for soldiers, so that they are more likely to seek
behavioral health assistance in the future if needed. Additionally, the
Army is enhancing behavioral health services provided to its Family
members through Child, Adolescent and Family Assistance Centers and the
School Behavioral Health Programs.
In theater there has been a robust Combat and Operational Stress
Control presence since the beginning of the war, with deployed
behavioral health assets supporting both Operation Enduring Freedom and
Operation New Dawn. Beginning in fiscal year 2012, the Army will
increase behavioral health teams assigned to all its brigade size
operational units. The increase will provide two behavioral health
providers and two behavioral health technicians assigned to every
Brigade Combat Team, Support Brigade and Sustainment Brigade in the
Active, Reserve and National Guard Army inventory. The process will be
complete by fiscal year 2017 and increase the total available uniformed
behavioral health force by over 1,000 additional personnel.
PATIENT CENTERED MEDICAL HOMES
Question. General Schoomaker, the Army's new community-based
medical homes are located off-post in communities in order to provide
increased capacity for primary care. How is the Army expanding this
program and when will it be available service-wide?
Answer. By the end of fiscal year 2011 the Army will have opened 17
Community Based Medical Homes (CBMHs) in 11 markets. Two additional
CBMHs will open in early 2012 bringing the total to 19 clinics in 13
markets and complete phase 1 of the project. Phase 1 focused on meeting
the primary care needs of our active duty family members. Once our
CBMHs are proven to achieve desired results (improved access,
satisfaction and health, and reduced utilization and cost), the Army
plans to expand our community based presence. Phase 2 of the project
will move some primary care services off-post to generate on-post space
for specialty services and Warrior care. By doing so we will be able to
better leverage our advanced on-post medical infrastructure,
consolidate on-post services, and achieve the advantages of CBMHs.
Phase 2 will begin in late 2012. Phase 3 of the project will explore
opening additional services such as physical therapy, obstetrics,
pediatrics, imaging, and refill pharmacy in community-based settings to
generate positive value for DOD. Phase 3 planning will begin in late
2011 with clinic expansion possible by 2013.
RECRUITMENT AND RETENTION
Question. General Horoho, as the United States enters our tenth
year of intensive combat operations, nurses have been heavily engaged
in both wartime and humanitarian missions. How has the deployment tempo
of nurses serving in critical nursing career fields affected the
ability of the Army to recruit and retain nurses in these particular
high demand fields?
Answer. Six month deployments were initiated in summer of 2008
which has had a positive effect on improving and maintaining the
resiliency among Army critical care nurses. These deployments are
better for the nurses and their Families. The critical care nurses as a
group are very resilient and the majority do well post-deployment. In
fiscal year 2010, the Army was able to recruit 642 nurses, meeting 105
percent of its active duty need and 94 percent for the reserve. This
includes some precision recruiting of experienced critical care nurses.
NURSING RESEARCH
Question. General Horoho, I understand that the Army Nurse Corps
has realigned nursing research assets, has embraced evidence based
practice, and is an active participant in the TriService Nursing
Research Program. How has this impacted nursing research opportunities
in the Army?
Answer. Army Nursing follows the American Nurses Association
research participation guidelines that it is the expectation that
nurses at every level participate in research activities appropriate to
their educational preparation. Every nurse is involved in Evidence
Based Practice (EBP) of which, research is one component.
We are building a culture in all nurses at all levels that evidence
drives practice. The goal is to have a core group of champions at all
levels to sustain the application of research and use of evidence. EBP
is built into curriculum at every level for Army professional nursing
courses. This includes EBP and research lectures to the Clinical
Transition Program, hospital or facility orientation, all specialty
courses (Intensive Care Unit, Perioperative) and preceptor training.
Army nursing has the support of Tri-Service Nursing Research Program in
EBP and research grant camps.
NURSING ISSUES
Question. General Horoho, are Army military treatment facilities
staffed to the actual patient load or to the number of beds?
Answer. The Army staffs to nursing care hours, the same as both the
civilian community and Veterans Administration, using a research-based
workload management system which adjusts for complexity of patient care
and type of nursing care provider required.
Question. General Horoho, nurses working in patient care areas
often voice concerns that there are not enough nurses performing
patient care duties. What is the ratio of Army nurses delivering
traditional hands on nursing care to those conducting research,
performing administrative duties or involved in functions that are not
directly involved in the delivery of patient care?
Answer. The ratio of nurses delivering direct patient care vs.
research and administrative duties is approximately 5:1 or 83 percent.
______
Questions Submitted by Senator Patty Murray
MEDICAL COMMUNITY
Question. General Schoomaker, when the Army made the decision to
``Grow the Force,'' did it factor the size of its medical community
into its billet needs? Was military construction for medical facilities
factored into this process?
Answer. Yes, the U.S. Army Medical Command (MEDCOM) participates in
the Total Army Analysis (TAA) which is a phased force structure
analysis process. Furthermore, MEDCOM employed a multi-factorial
process in determining specific needs to support Grow the Army that
included population changes, access to care challenges, network
availability, the inability to hire civilian staff, medical treatment
facility productivity and new operational requirements. Military
construction of medical facilities was factored into the process.
Question. How has the Army evaluated the capacity of its medical
community against the current and future structure?
Answer. The Army evaluates capacity annually using the enrollment
capacity model (ECM). Inputs to the ECM are current and expected force
structure, productivity benchmarks, and expert clinical input. The ECM
allows the Army to project needed or unused capacity for all Army
military treatment facilities to meet the needs of its beneficiaries.
MENTAL HEALTH
Question. Does the Army have enough mental health providers to meet
soldier and family member needs?
Answer. While the Army has increased its behavioral health
inventory by 90 percent since 2007, we still do not have enough
providers and continue to work toward hiring more. As of February 2011,
the Army had 4,998 behavioral healthcare providers. The current
estimated active component Army behavioral health requirement is 6,107
providers, which represents an unmet requirement of 1,109 providers.
Question. If there is a gap in mental health providers, what
efforts are being taken to get more providers in the system?
Answer. The Army is using numerous mechanisms to recruit and retain
both civilian and uniformed behavioral health (BH) providers including
bonuses, scholarships, and an expansion in training programs. The U.S.
Army Medical Command has increased funding for scholarships and bonuses
to support expansion of our provider inventory and provided centrally
funded reimbursement of recruiting, relocation, and retention bonuses
for civilian BH providers to enhance recruitment of potential
candidates and retention of staff. The Army expanded the use of the
Active Duty Health Professions Loan Repayment Program and offers a
$20,000 accessions bonus for Medical and Dental Corps health
professions scholarship applicants; has allowed recruitment of legal
non-resident healthcare personnel to fill critical shortages; used a
one-time Critical Skills Retention Bonus (CSRB) for social workers and
BH nurses and the Army Medicine CSRB for clinical psychologists; and
implemented an officer accessions pilot program that allows older
healthcare providers to enter the Army, serve 2 years, and return to
their communities.
Additionally, in partnership with Fayetteville State University,
MEDCOM developed a Masters of Social Work program which graduated 19 in
the first class in 2009. The program has a current capacity of 30
candidates. This program is fully funded by the Army with all graduates
incurring a 62 month service obligation. To improve the accession of
Clinical Psychologists, MEDCOM increased the number of Health
Professions Scholarship Allocations dedicated to Clinical Psychology
and the number of seats available in the Clinical Psychology Internship
Program.
Question. What programs are being undertaken to address the mental
health needs of spouses and dependent children?
Answer. The Army has an extensive array of behavioral health (BH)
services and resources that have long been available to address the
strain on military Families. These services include but are not limited
to routine BH care, Chaplains, Military One Source, Comprehensive
Soldier Fitness, Psychological School Programs and Army Community
Service (ACS), Family Assistance for Maintaining Excellence (FAME), and
the Warrior Resiliency Program (WRP). New initiatives include the
Comprehensive Behavioral Health System of Care Campaign (CBHSOC) and
our Child and Family programs available through the Child, Adolescent
and Family Behavioral Health Office (CAF-BHO).
The CAF-BHO is the lead office within the Army Medical Command
(MEDCOM) for integrating and coordinating Child and Family BH programs.
CAF-BHO promotes optimal military readiness and wellness in Army
Children and Families through the Child and Family Assistance Centers
(CAFAC), School Behavioral Health (SBH) and Medical Home BH support.
Plans are being considered to implement CAFACs and SBHs across the Army
to meet the goals of the Army's CBHSOC Plan.
CAFACs provide cost-effective, comprehensive, integrated BH system
of care to support military Children, their Families, and the Army
Community throughout the Army Force Generation (ARFORGEN) and Family
Life Cycle. CAFACs focus on coordinating, integrating, and
synchronizing available BH and related services on an installation, and
filling identified service gaps. The programs use a Public Health Model
continuum of care, focusing on prevention and early intervention to
promote wellness and resilience, and providing a higher level of BH
care when needed.
SBH programs provide cost-effective, comprehensive BH services to
support military children, their families, and the Army community in
schools. The overarching goal is to facilitate access to care by
embedding BH within the school setting, and to provide state of the art
prevention, evaluation, and treatment through standardization of SBH
services and programs. Services are directed at improving student
academic achievement, maximizing wellness and resilience of Army
children and families, and ultimately promoting optimal military
readiness.
ALTERNATIVE TREATMENT
Question. What efforts are being taken to provide for alternate
sources of pain management? Has the Army looked at civilian best
practices? What are their plans for incorporating them?
Answer. The U.S. Army Medical Command (MEDCOM) Comprehensive Pain
Management Campaign Plan (CPMCP) is a phased effort that has been
working to standardize pain care across MEDCOM, establish
interdisciplinary pain centers in each Regional Medical Command, de-
emphasizing medication-only treatment of pain, address the challenge of
poly-pharmacy with improved oversight of those on multiple medications,
and improve access to non-medication pain treatments--complementary and
alternative medicine (such as acupuncture, massage therapy, and
movement therapies such as yoga.
Expanding the availability of non-medication approaches for pain
management has been an area of special emphasis and careful execution.
The Army has continued to reach out to civilian experts who have had
experience and success in incorporating integrative medicine into their
medical practices and healthcare systems. Clinical practice and
research initiatives with Samuelli Institute and Bravewell
Collaborative are two examples of the MEDCOM's ongoing collaboration
with civilian experts.
MEDCOM has also been developing a model for MEDCOM/Veterans
Affairs/civilian academic medicine pain management consortiums. These
collaborative efforts have been developed to share clinical expertise,
best practices, and education/training opportunities across these
organizations. The first of these consortiums is located in the
Seattle, Washington area and involves Madigan Army Medical Center,
Puget Sound Veterans Affairs Hospital, and University of Washington
Center for Pain Relief.
TASK FORCE TREATMENT
Question. I am concerned about the increasing amputation rates
among servicemembers and understand there was a task force recently
established with experts in trauma, orthopedic surgery, wound patterns
and analysis and rehabilitation specialists.
What is the status of this task force?
What best practices have been identified with treating these
casualties?
What do these trends mean for future combat care?
Is there any applicability to civilian trauma care? Has the Army
looked at public-private ventures to create more training opportunities
for state-side medical personnel?
Have any additional methods been identified to prevent, protect
and reduce the impact of these injuries?
Answer. The Dismounted Complex Blast Injury Task Force was
established in early February 2011 and recently completed an analysis
of trauma data that addresses many of these concerns. The Task Force
report is nearly complete and will include recommendations on the best
clinical practices to care for these soldiers and their families from
the point of injury and throughout the evacuation, care, and
rehabilitation continuum. The report will also include recommendations
for future combat care and protection of our Warriors, and strategies
for the mitigation of injury severity.
These injuries represent the extreme of combat injuries, and go far
beyond the most severe injuries ever encountered in civilian trauma.
Our surgeons and rehabilitation experts have the most current
experience in these uncommon injuries. Where we rely upon civilian
expertise and cooperation is in the area of regenerative medicine
approaches, skin and muscle reconstruction and associated
rehabilitation.
MEDICAL TRAINING
Question. The Army is producing medics with a wealth of experience
in a variety of medical specialties like trauma care. Has there been
any effort to align training programs with civilian training
requirements? If no, then why not?
Answer. The Army aligns training programs with civilian training
requirements in areas where civilian requirements match military
medicine mission. Applying civilian trauma care principles without
adapting them to the tactical environment is not only frequently
ineffective but may lead to more casualties. In October 2001, evidence
based research drove the Army to incorporate the National Registry of
Emergency Medical Technicians--Basic (EMT-B) as the necessary baseline
for all students of the U.S. Army Combat Medic course. This program
emphasizes increased trauma training by incorporating a standardized,
externally validated civilian curriculum into the Army's program.
National certification is a Combat Medic (68W) graduation and
sustainment requirement. The basic skills of the Combat Medic overlap
with competencies of the EMT-B; however, the Combat Medic has been
trained to be more uniquely skilled and capable of providing advanced
combat casualty care. Care in combat is focused not just on injuries
suffered by the soldier but on the tactical situation surrounding the
event. The Department of Combat Medic Training holds annual curriculum
committee meetings to assess training needs, considering civilian
training requirements, evidence-based research, and lessons learned.
ACQUISITION COMMUNITY INTERACTION
Question. How well does your medical community interact with your
acquisition community? As different injuries are identified as
prevalent within your service, what are the procedures to work with the
acquisition community to acquire equipment, tools, or clothing to limit
or prevent these injuries?
Answer. The U.S. Army Medical Department (AMEDD) is fully
integrated with the Acquisition community under the DOD 5000 process
which governs and implements policies of the defense acquisition
system. The U.S. AMEDD Center and School serves as the Combat Developer
defining requirements and the U.S. Army Medical Research and Materiel
Command (USAMRMC) serves as the Materiel Developer providing materiel
solutions. The Commanding General, USAMRMC, serves as the Deputy for
Medical Systems to the Assistant Secretary of the Army for Acquisition,
Logistics, and Technology (ASA(ALT)). In this role the Commanding
General, USAMRMC, is the senior medical officer providing information
to the ASA(ALT) regarding medical acquisition initiatives and the
medical implications of non-medical acquisition initiatives.
There are multiple ways that the needs identified on the
battlefield are incorporated into the acquisition process to include
working with the Rapid Equipping Force, the Army Materiel Command's
Forward Area Support Team--which is deployed in Theater and includes at
least one medical representative, the Combatant Command Technology
Assessment and Requirements Analysis, the other services, and the
operational needs statement process to name a few. In each initiative
mentioned above, personnel closely affiliated with the acquisition
community are intimately involved with every step of the process from
capturing the Warfighter's requirements, through fielding a potential
solution. Each of these initiatives complements the traditional
acquisition process and allows the AMEDD to respond to Warfighter
identified needs in a timely and controlled fashion. The Army utilizes
the Joint Theater Trauma Registry to analyze the types and trends of
injuries and the causes to inform the developers on improving
operational approaches and materiel solutions.
______
Questions Submitted by Senator Tim Johnson
ELECTRONIC HEALTH RECORD
Question. Secretary Gates and Secretary Shinseki recently announced
that the Department of Defense and the Department of Veterans Affairs
will develop a joint electronic health record. On April 1, 2011, the
Department of Veterans Affairs also announced that it will form an open
architecture community around the VA's electronic health record, VISTA.
Are these the same thing or will each Department still keep its own
version of VISTA and AHLTA?
Answer. Yes, these are the same. Secretary Gates and Secretary
Shinseki met in March and agreed to a joint electronic health record
called iEHR (integrated electronic health record) that will replace
VISTA and AHLTA.
Question. Do the Departments envision the joint electronic health
record replacing VISTA and AHLTA?
Answer. Yes, Secretary Gates and Secretary Shinseki met in March
and agreed to a joint electronic health record called iEHR (integrated
electronic health record) that will replace VISTA and AHLTA.
Question. When will the Departments release details and a
comprehensive plan forward on the joint electronic health record?
Answer. The two Departments will meet over the coming months to
develop a comprehensive implementation plan. Once complete, we envision
the plan and details will be released by the Departments.
______
Questions Submitted to Vice Admiral Adam M. Robinson, Jr.
Questions Submitted by Chairman Daniel K. Inouye
SOURCES OF HELP FOR SERVICEMEMBERS AND THEIR FAMILIES
Question. Each service has taken a different approach to address
the psychological health needs of their service members and their
families. In addition, the Department of Defense and the Tricare
contractors have also instituted programs to help provide this type of
care. Rather than streamlining those services, new Web sites and phone
lines are created. On top of those efforts, the private sector, the
Department of Veteran's Affairs, and non-profits are all trying to
address these issues. This is all well intended but more often than not
it is challenging for servicemembers and family members to guide their
way through a maze of avenues to seek for sources to help.
On one Navy pamphlet to combat operational stress there are 16
different Web sites and phone numbers and on another there eight. Each
one has very little information associated with them, forcing the
individual to access each Web site to decipher if that meets their
needs. One Air Force pamphlet has 13 and on one Army pamphlet there are
19. People seeking help should not have to go through a maze like this.
Admiral Robinson, as I mentioned in my opening statement it can be
quite confusing for a servicemember who is seeking help to deal with
combat stress or other psychological health needs. On one Navy pamphlet
provided to me there is a list of 16 different Web sites or phone
numbers for sources of help. It takes so much to get someone to seek
the help they need, we don't want to discourage them by making it
difficult to find the appropriate help. Could you explain how you are
attempting to consolidate these efforts and make the process less
confusing for those that need it?
Answer. The Navy is committed to fostering a culture that promotes
resilience and wellness, and that empowers leaders to ensure the health
and readiness of service members and their families. We concur that
there have been a proliferation of services available to service men
and women affected by post traumatic stress and traumatic brain injury.
We must balance the desire to provide service members with options;
understanding that one size does not fit all, with the possibility of
creating confusion by providing too many alternatives.
To address this issue we are working with the Naval Center for
Combat and Operational Stress Control (NCCOSC) to develop consolidated
strategic communications for psychological health initiatives across
the Department of the Navy. Similarly we are working with the Defense
Center of Excellence to consolidate resources and Web sites supported
by the Military Health System and Department of Defense.
Furthermore, across DOD strides are being taken to address
effecencies within the multiple programs offered to our wounded, ill
and injured service members. The Department of Defense (DOD) Task Force
on the Care, Management and Transition of Recovering Wounded Ill and
Injured Members of the Armed Forces, also known as the Recovering
Warrior Task Force (RWTF) provides DOD with advice and recommendations
on matters related to the effectiveness of the policies and programs
developed and implemented by DOD, and by each of the military services
in caring for our wounded, ill and injured service members. The goal of
this task for is to look at best practices and various ways in which
DOD can more effectively address matters relating to the care,
management, and transition of these warriors.
RECRUITING AND RETENTION
Question. The Air Force is short surgeons, family practitioners,
clinical psychologists, and technicians. In addition to compensation,
the Air Force identifies the lengthy hiring process for both officers
and civil service health professionals as a top recruiting challenge.
The Army faces personnel shortages in numerous healthcare
specialties including: neurosurgeons, nurse anesthetists, behavioral
health experts, physical therapists, oral surgeons, and others. Some of
these areas are staffed at less than 50 percent of need. The Army is
seeking to increase compensation for critical skills to reduce the gap
between civilian and military pay, as well as leverage its Health
Professions Scholarship Program.
Overall, the Navy has somewhat improved recruitment and retention
of medical officers over the last 3 years. The greatest challenges
remain in the areas of general surgery, family medicine, oral surgeons,
general dentists, and psychiatry. The problem is more severe in the
reserve component.
Admiral Robinson, some medical specialties are severely
understaffed, particularly in the reserve component. For example, less
than one-quarter of critical care medicine and cardiology positions are
filled. How is the Navy ensuring that it has the number of reserve
physicians it needs?
Answer. Direct appointment recruiting of physicians and dentists
remains a challenge, primarily because these healthcare professionals
have well-established medical practices and are very well compensated
in the civilian market. Interrupting their civilian medical careers is
often personally and financially unattractive to many private medical
providers. Additionally, retention has improved in the active forces,
reducing Navy Veterans available for Reserve appointments.
We are developing incentives within budgetary constraints to target
specific communities that are, and will remain, critical to our
mission. A credible recruiting bonus is critical and remains the
primary incentive to attracting these professionals.
We have collaborated with Navy Recruiting Command at a recently
held Medical Stakeholders Conference and have developed a Medical
Professionals Task Force Charter group in an effort to improve access
and to collaboratively market targeted specialties to achieve
recruiting goals. Working closely with Navy Recruiting Command, we have
also restructured the Training Medical Specialties Drilling option (one
of the most successful Physician recruiting options) to ensure the
program is meeting the needs of Navy Medicine as well as attracting
candidates.
Despite these Reserve shortages, Navy Medicine continues to meet
its global commitments in support of all contingency operations.
MILITARY MEDICINE
Question. Since fiscal year 2010, the Department of Defense (DOD)
has requested funds for the advancement of military medicine. Prior to
that, the majority of these funds were provided to the Department
through earmarks and nationally competed programs added to the Defense
budget by Congress. In the fiscal year 2012 budget request the
Department is requesting $438 million through the Defense Health
Program and the Defense Advanced Research Projects Agency (DARPA) to
further these efforts.
Admiral Robinson, we are currently investing in medical research
applicable to the needs of our current warfighter but what do we know
about the issues we might face in the future and how are we attempting
to stay ahead of that curve?
Answer. In my testimony, I outlined a strategic vision for Navy
Medicine that keeps us as a world leader in patient and family centered
medical care. We manage the spectrum of current needs, while ensuring
that the urgencies of the present do not diminish the intensity of our
focus on the future. That focus is a critical element of our RDT&E and
medical education vision and mission.
One-third of our research portfolio of over 1,200 individual
research studies is focused on the delivery of technologies to the
Warfighter in the near-term through advanced development. Another third
targets the next 10 to 20 years (technology development), with the
balance addressing technology innovation for 20 to 50 years out (basic
research). Where appropriate, this research is executed both at our
research and development facilities in CONUS and overseas as well as in
our Medical Treatment Facilities (MTF) by our experienced clinicians
and our most promising graduate trainees, where appropriate. Navy
Medicine demonstrates excellence in research in each domain. While our
research focuses on Navy and Marine Corps requirements, our efforts
complement and are closely coordinated with our sister services, the
Defense Health Program, and DARPA.
We are expanding the envelope of the possible, providing
technologies, procedures, and practices that promote reintegration of
our wounded warriors into productive roles in the services and in
society. We will continue to expand on our progress in the areas of
rehabilitative and regenerative medicine. The revolutionary advances we
have made in wound management are a prelude to upcoming developments in
prosthetics, transplantation, and regeneration.
We recognize the critical role personalized medicine will play in
maintaining the capabilities of our Fleet and Marine Forces. With small
unit, agile forces on the ground and reduced manned ships at sea, the
importance of each individual is magnified. Our progress in
individualized medical care, personalized health maintenance and
promotion, and enhanced individual and unit readiness will play a
critical role in the future effectiveness of the DOD.
History tells us that during peace-time and during armed conflict,
more of our service members are rendered less than fully operational by
disease than by bullets and bombs. As we evolve our global military
presence, Navy Medicine is enhancing our capabilities through global
health initiatives with our international partners and through a global
presence. We are at the forward edge of battle in combating emerging
diseases and solving health problems worldwide.
Every day, the CONUS and OCONUS Navy Medical Research labs and the
MTF-based Clinical Investigation Programs conduct cutting edge research
to answer issues, both current and projected to arise. These facilities
are necessarily lean and our researchers are few in number, but they
have made significant contributions to the men and women who wear the
cloth of our Nation and for the world. We will continue to develop
innovative technologies to save the life and limb and to expand the
operational envelope of our Navy and Marine Corps Warfighters.
PSYCHOLOGICAL HEALTH
Question. There has been a significant expansion of psychological
healthcare across the military health system. This includes increasing
the number of specialists in psychiatry, psychology, mental health, and
social work, to provide more services at a greater number of locations.
Psychological treatment options are also being integrated into primary
care to provide more comprehensive and holistic support.
Early identification and treatment of psychological health issues
can accelerate healing and improve long-term outcomes. This is
supported by numerous campaigns to train service members to identify
warning signs of excessive stress, suicidal tendencies, depression, or
other mental health concerns. Given the stress of combat operations and
repeated deployments, the services are striving to place more
psychological health providers in theater, as well as continued
screening for symptoms long after service members return.
Admiral Robinson, the services are seeking to provide early
identification and treatment of psychological health needs in theater
by deploying additional psychological health professionals to forward
operating bases. Since the Marines are sometimes located in remote
locations with limited access to even basic services, how can the Navy
ensure this care reaches them?
Answer. Within the Marine Corps, we continue to see the
effectiveness of the Operational Stress Control and Readiness (OSCAR)
program, as well as the OSCAR Extender program. OSCAR embeds full-time
mental health personnel with deploying Marines and uses existing
medical and chaplain personnel as OSCAR Extenders together with trained
senior and junior Marines as mentors to provide support at all levels
to reduce stigma and break down barriers to seeking help. Embedded
mental health providers can provide coordinated, comprehensive primary
and secondary prevention efforts throughout the deployment cycle,
focusing on resilience training, stress reduction efforts, and when
necessary, timely access to a known provider with reduced stigma
associated with mental health intervention. Our priority remains
ensuring we have the service and support capabilities for prevention
and early intervention available where and when it is needed. OSCAR is
allowing us to make progress in this important area.
PATIENT CENTERED MEDICAL HOMES
Question. The fiscal year 2012 budget request supports the phased
implementation of the Patient Centered Medical Home concept for
delivering primary care for all three services. This concept,
originating in the private sector, seeks to improve quality of care and
the patient experience by integrating primary care into a comprehensive
service. Patients will have an ongoing relationship with a personal
physician leading a team of professionals that collectively takes
responsibility for the individual's or family's healthcare needs.
The Army is beginning with Community Based Medical Homes, which are
Army-run clinics located off-post. They function as extensions of the
Army hospital and are staffed by civil servants. Seventeen are
currently underway in communities which needed increased access to
primary care, including one in Hawaii.
The Air Force was the first service to implement the concept, which
it termed the Family Health Initiative, beginning in 2008. It will soon
be expanding the concept across all the clinics service-wide. The Navy
is also ramping up its program to convert its facilities, started in
May 2010, called Medical Home Port. Over 200,000 sailors and family
members are already enrolled.
Admiral Robinson, as the Navy creates additional Medical Home
Ports, how will this new reorganization lead to more comprehensive
service to patients and better continuity of care?
Answer. Medical Home Port is Navy Medicine's Patient-Centered
Medical Home (PCMH) model, an important initiative that will
significantly impact how we provide care to our beneficiaries. In
alignment with my strategic goal for patient and family centered care,
Medical Home Port emphasizes team-based, comprehensive care and focuses
on the relationship between the patient, their provider and the
healthcare team. The Medical Home Port team is responsible for managing
all healthcare for empanelled patients, including specialist referrals
when needed. Patients see familiar faces with every visit, assuring
continuity of care. Appointments and tests get scheduled promptly and
care is delivered face-to-face or when appropriate, using secure
electronic communication.
It is important to realize that Medical Home Port (MHP) is not
brick and mortar; but rather a philosophy and commitment as to how you
deliver the highest quality care. A critical success factor is
leveraging all our providers, and supporting information technology
systems, into a cohesive team that will not only provide primary care,
but integrate specialty care as well. We continue to move forward with
the phased implementation of Medical Home Port at our medical centers
and family medicine teaching hospitals, and initial response from our
patients is very encouraging. To date, there are 68 MHP teams across
seven Navy Medical Treatment Facilities with over 225,000 beneficiaries
enrolled.
______
Questions Submitted by Senator Patty Murray
MEDICAL FORCE STRUCTURE
Question. Has the Navy evaluated the capacity of its medical
community against the current and future structure?
Answer. Navy Medicine evaluates annually and as needed our current
and future total force structure in response to changing requirements
to ensure that the correct mix of medical, dental, medical service,
nurse and hospital corps professions are available to support our
Nation's needs. Included in these analyses are our total force of
active, reserve, civilian and contract professional to meet the
operational and beneficiary missions.
MENTAL HEALTH FORCE STRUCTURE
Question. Does the Navy have enough mental health providers to meet
soldier and dependent needs? If there is a gap in mental health
providers, what efforts are being taken to get more providers in the
system? What programs are being undertaken to address the mental health
needs of spouses and dependent children?
Answer. We are committed to improving the psychological health,
resiliency and well-being of our Sailors, Marines and their family
members and ensuring they have access to the programs and services they
need. We recognize that shortfalls within the market of qualified
mental health providers has led to challenges in contracting and
filling provider and support staff positions; however, recruitment and
retention of uniformed personnel have improved. Current Navy inventory
for mental health professionals (February 2011) is as follows:
--Psychiatrist: 73 percent--projected to be at 86 percent end of
fiscal year 2012.
--Psychologist: 75 percent--projected to be at 93 percent end of
fiscal year 2012.
--Clinical Social Worker: 48 percent--projected to be at 44 percent
end of fiscal year 2012. This is due to significant billet
growth, from 35 billets in fiscal year 2010 to 86 billets in
fiscal year 2012.
--Mental Health Nurse Practitioner: 57 percent--projected to be 100
percent end of fiscal year 2012.
--Mental Health Nurse: 111 percent.
Mental Health Professional recruiting remains a top priority. Navy
uses numerous accession and retention bonuses to attract and retain
mental health professionals. Medical Special and Incentive Pays are
critical to attracting and retaining Navy medicine professional staff
inventory.
--Psychiatrists.--In fiscal year 2011 there is a $272,000 critical
wartime skills accession bonus available to Psychiatrists
entering the Navy. In addition, up to $63,000/year is available
through Incentive Special Pay/Multi-Year Special Pay for
current Navy psychiatrists who qualify.
--Psychologists & Clinical Social Workers.--The Accession Health
Professionals Loan Repayment Program pays out up to $40,000 to
qualified licensed clinical social workers up to $80,000 to
clinical psychologists. The Health Professions Scholarship
Program is available to attract and train clinical
psychologists by paying for tuition, books, fees and a stipend.
The Health Services Collegiate Program is available to attract
and train licensed clinical social workers paying E6 salary and
benefits while candidates are in training. In addition, a
clinical psychologist accession bonus pays up to $60,000 for a
4 year obligation, and clinical psychologist incentive pay is
$5,000/year. The clinical psychologist retention bonus pays up
to $80,000 for a 4 year obligation, and the licensed clinical
social worker accession bonus pays up to $30,000 for a 4 year
obligation. Board certification pay of $6,000/year for both
specialties is also available to these mental health
professionals. A retention bonus for clinical social workers
has recently been submitted and is pending review and approval.
--Mental Health Nurse Practitioner & Mental Health Nurse.--In fiscal
year 2011 there is up to $30,000 available through the Nurse
Corps accession bonus for nurses entering the Navy. In addition
up to $20,000/year is available through Registered Nurse
Incentive Special Pay.
When our Sailors and Marines deploy, families are their foothold.
Family readiness is force readiness and the physical, mental,
emotional, spiritual health and fitness of each individual is critical
to maintaining an effective fighting force. A vital aspect of caring
for our service members is also caring for their families. FOCUS is a
family centered resiliency training program based on evidenced-based
interventions that enhances 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.
The program provides community outreach and education, resiliency skill
building workshops and at the center of the program a 8-week, skill-
based, trainer-led intervention that addresses difficulties that
families may have when facing the challenges of multiple deployments
and parental combat related psychological and physical health problems.
It has demonstrated that a strength-based approach to building child
and family resiliency skills is well received by servicemembers and
their family members. 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. To date
over 200,000 Service members, families and community providers have
received FOCUS services.
In addition to FOCUS, the Reserve Psychological Health Outreach
Program (RPHOP) identifies Navy and Marine Corps Reservists and their
families who may be at risk for stress injuries and provides outreach,
support and resources to assist with issue resolution and psychological
resilience. An effective tool at the RPHOP Coordinator's disposal is
the Returning Warrior Workshop (RWW), a 2-day weekend program designed
specifically to support the reintegration of returning Reservists and
their families following mobilization.
The Naval Special Warfare (NSW) Family Resiliency Enterprise (FRE)
program was designed toward enhancing the performance and readiness of
the force by increasing resilience of the service member and his or her
family--and thus the team, squadron, group and overall NSW community.
To date, each NSW SEAL Team has conducted seven or more consecutive
combat deployments resulting in cumulative exposure to wartime events
and extensive familial separations. The goal has been to build
resilience by collecting baseline information (seven main areas:
psychological, neuropsychological, physiological, relationships,
spirituality, finances, and lifestyle) about service members and their
spouses/significant others; identifying areas of concern and providing
training as indicated; and providing forums (overnight retreats) for
family members to network to build support during deployments, as well
as celebrate return from deployment and facilitate reintegration. To
date, about 5,500 participants have attended NSW FRE retreats.
MEDICAL TRAINING PROGRAMS
Question. The Navy is producing medics with a wealth of experience
in a variety of medical specialties like trauma care. Has there been
any effort to align training programs with civilian training
requirements? If no, then why not?
Answer. Yes, our enlisted training programs are aligned and often
exceed civilian training programs. Similar to civilian medical
training, military medical training is nationally accredited by the
American Council on Education and the Council on Occupational
Education, representing higher education and quality for the U.S.
Government. The academic programs for enlisted medic training are under
the auspices of the National License Practical Nursing guidelines for
our basic hospital course and the National Emergency Medical Technical
for field training.
The Navy Credentialing Opportunity Online (COOL) program provides
expanded opportunities to earn civilian occupational licenses and
certifications. The program promotes recruiting and retention and
further enhances the Sailor's ability to make a smooth transition to
the civilian workforce. The Navy's credentialing program has two key
components--dissemination of information on civilian licensure and
certification opportunities and payment of credentialing exam fees.
Community College of Air Force (CCAF) is a multi-campus community
college accredited through the Southern Association of Colleges and
awards course college credits to the enlisted personnel of the Air
Force (AF) Medical Program. Navy corpsman participating in consolidated
courses with the Air Force (AF), such as those offered at Medical
Enlisted Training Campus (METC) in San Antonio, Texas or Sheppard AFB,
are awarded college credits for training (i. e. emergency medicine,
biomed tech, surgical tech, radiology, etc.) in both hospital corpsman
basic and technical medical course work.
In addition, Navy Medicine is formally affiliated with the LA
County Trauma Center, California, approved by American College of
Surgeons and sends medical teams (nurses, physicians and corpsman) to
train in level 1 trauma care. This training opportunity allows for
integration of knowledge and skill performances of civilian and
military working side by side in trauma teams.
MEDICAL ACQUISITION PROGRAMS
Question. How well does your medical community interact with your
acquisition community? As different injuries are identified as
prevalent within your service, what are the procedures to work with the
acquisition community to acquire equipment, tools, or clothing to limit
or prevent these injuries?
Answer. Let me share how various aspects of Navy Medicine work
together to improve medical care for Wounded Warriors.
In the scenario you describe, surgeons at a forward operating base
would note a change in the type or severity of injuries being treated.
The change might be caused by new weapons or tactics employed by the
enemy. The surgeons at the forward operating base would describe the
new injuries and define a new medical capability needed to meet the
threat. In this scenario, this information would go to the Navy
Medicine Specialty Leader for Surgery. This senior surgeon represents
the entire surgical community to Navy Medicine at large. There are
specialty leaders for all aspects of clinical care.
The Surgical Specialty Leader validates the new capability that is
needed and determines whether the new capability can be satisfied by
using a new surgical protocol or through the use of new or additional
equipment not currently in theater. If the new capability can be
achieved through the use of new surgical protocols, the Surgical
Specialty Leader initiates the change in procedure.
If the Surgical Specialty Leader determines new or additional
medical equipment is needed, Navy Medicine's clinical engineers will
write the specifications for the new equipment and our acquisition
office will purchase it. These three groups--specialty leaders,
clinical engineers, and acquisition professionals--have established
procedures to validate, define, and procure medical supplies and
equipment for our forward deployed providers.
If the Surgical Specialty Leader determines that the new and needed
medical capability cannot be satisfied using existing equipment or
techniques, then the requirement is turned over to the Navy Medicine
Research Center. These skilled and dedicated researchers work with
colleagues in academia and industry to put new medical capability into
the hands of our clinicians.
______
Questions Submitted by Senator Tim Johnson
ELECTRONIC HEALTH RECORDS
Question. Secretary Gates and Secretary Shinseki recently announced
that the Department of Defense and the Department of Veterans Affairs
will develop a joint electronic health record. On April 1, 2011, the
Department of Veterans Affairs also announced that it will form an open
architecture community around the VA's electronic health record, VISTA.
Are these the same thing or will each Department still keep its own
version of VISTA and AHLTA?
Do the Departments envision the joint electronic health record
(EHR) replacing VISTA and AHLTA?
When will the Departments release details and a comprehensive plan
forward on the joint electronic health record?
Answer. Department of Defense (DOD) is leading the way forward on
Electronic Health Records (EHR) and Navy Medicine is providing support
for this mission.
DOD and Veterans Affairs (VA) will continue to synchronize EHR
planning activities for a joint approach to EHR modernization. The
Departments have already identified many synergies and common business
processes, including common data standards and data center
consolidation, common clinical applications, and a common user
interface. The VA has released a request For proposal to evaluate open
source management options, and DOD is working with the VA to identify
opportunities to contribute and participate in the open source
collaboration. As the open source communities mature, DOD and VA will
continue to analyze open source components that fit the architectural
construct for use in the future EHR.
The following excerpt from the April 6, 2011 testimony of Ms. Beth
McGrath, DOD Deputy Chief Management Officer, before the House Armed
Services Subcommittee on Emerging Threats and Capabilities additionally
supports the commitment by both the DOD and VA to develop a joint
approach to EHR modernization.
``In the field of health IT, DOD and the Department of Veterans
Affairs (VA) have committed to a full and seamless electronic exchange
and record portability of healthcare information in a secure and
private format, wherever needed, to ensure the highest quality and
effective delivery of healthcare services for our military
servicemembers and Veterans, from their accession into service and
throughout the rest of their lives. To this end, the Departments are
collaborating on a common framework and approach to modernize our
Electronic Health Record (EHR) applications. On March 17, the Secretary
of Defense and Secretary of Veterans Affairs affirmed we will continue
to synchronize our EHR planning activities to accommodate the rapid
evolution of healthcare practices and data sharing needs, and to speed
fielding of new capabilities. The Departments have already identified
many synergies and common business processes, including common data
standards and data center consolidation, common clinical applications
and a common user interface.''
VISION CENTER OF EXCELLENCE
Question. As Chairman of the Military Construction and VA
Appropriations Subcommittee, I have closely followed the development of
the Vision Center of Excellence and pressed for better cooperation
between the Department of Defense and the VA. I have been frustrated
with the delays in funding, full military staffing, and operational
support for this important project.
Admiral Robinson, what are the Navy's budgetary plans for fiscal
year 2012-fiscal year 2015 for the Vision Center of Excellence? Where
is the Navy currently at with staffing the Vision Center of Excellence?
What staffing levels--military, Federal, and contractor support--are
necessary to be fully operational and when do you anticipate reaching
that point?
Answer. The Joint DOD/VA Vision Center of Excellence (VCE) is a
demonstration of a high level of cooperation between the DOD and VA. It
continues to advance the coordination of vision care and research
across both Departments and the VCE's work on the Joint Defense and
Veterans Eye Injury and Vision Registry is an excellent example of how
the two Departments can integrate processes. Further, the VCE has an
integrated staff and is funded by both Departments.
Oversight and direction of the VCE is accomplished jointly,
specifically by the VA/DOD Health Executive Council (HEC) and the Joint
Executive Council (JEC). The VCE is included in the VA/DOD JEC Joint
Strategic Plan reported to Congress annually.
The Navy has operational authority for the VCE, and the Assistant
Secretary of Defense for Health Affairs has funding responsibility. The
Navy is developing a transition plan for the transfer of funding and
staffing responsibility from Health Affairs to the Navy.
My office works closely with Health Affairs to adequately fund the
VCE. Most of the leadership is in place now and additional key staff
will be on board in fiscal year 2012. The VCE is funded at $17.9
million in fiscal year 2012, which will support requisite operations,
registry development, contractors, and DOD civilians (an increase of 18
from the current 6 DOD civilian staff). Additionally, there are a total
of 13 Federal staff members at the VCE, including 5 VA and 2 military.
Our estimate is 111 staff will be required to achieve full operating
capability by fiscal year 2017. We will continue to work with the VCE
the requirements, as well as continue to evaluate all of our
organizations to support DOD efficiency initiatives.
JOINT VETERANS EYE INJURY AND VISION REGISTRY
Question. Admiral Robinson, what is the status of the
implementation of the Joint Defense Veterans Eye Injury and Vision
Registry? How soon will this become fully operational? Does the Navy
have the funding necessary for full implementation?
Answer. Development of the Defense and Veterans Eye Injury and
Vision Registry is progressing very well and is 6 months ahead of
schedule. During the first year of operations of the Vision Registry,
the Joint Department of Defense (DOD) and Department of Veterans
Affairs (VA) Vision Center of Excellence (VCE) will validate the
registry capabilities; collect and enter ocular data of Service Members
and Veterans with ocular injuries into the registry; and identify
future registry requirements and capabilities. We expect the Vision
Registry to be fully operational by first quarter fiscal year 2013.
The VCE is developing the Vision Registry to be a dynamic tool. As
the first central repository of DOD and VA clinical ocular related
data, the Vision Registry will provide the quantitative data necessary
to perform longitudinal analyses for the development of preventative
measures and for recognition of best practices for treatment and
rehabilitation of injuries and disorders of the visual system.
Personnel and operational costs for the Vision Registry sustainment
and continued development are included in the proposed VCE fiscal year
2013-17 POM.
______
Questions Submitted to Lieutenant General Charles B. Green
Questions Submitted by Chairman Daniel K. Inouye
SOURCES OF HELP FOR SERVICEMEMBERS AND THEIR FAMILIES
Question. General Green, what role do you see the private sector
playing in your efforts to reach out to servicemembers and their
families to provide access to psychological health services?
Each Service has taken a different approach to address the
psychological health needs of their servicemembers and their families.
In addition, the Department of Defense and the Tricare contractors have
also instituted programs to help provide this type of care. Rather than
streamlining those services, new Web sites and phone lines are created.
On top of those efforts, the private sector, the Department of
Veteran's Affairs, and non-profits are all trying to address these
issues. This is all well intended but more often than not it is
challenging for servicemembers and family members to guide their way
through a maze of avenues to seek for sources to help.
On one Navy pamphlet to combat operational stress there are 16
different Web sites and phone numbers and on another there eight. Each
one has very little information associated with them, forcing the
individual to access each Web site to decipher if that meets their
needs. One Air Force pamphlet has 13 and on one Army pamphlet there are
19. People seeking help should not have to go through a maze like this.
Answer. Private sector organizations and individual providers play
a critical role in the delivery of psychological health services to
service members and families. TRICARE providers, community resources
and non-medical counseling options supplement the direct military
medical care system. They also offer options which may be perceived as
bearing lower stigma for military families.
In the Air Force, most formal mental healthcare for family members
is provided by TRICARE providers or through other community agencies.
Unfortunately, anecdotal reports from geographically remote bases
particularly indicate that child and adolescent mental health services
may be hard to find. There is a nation-wide shortage of qualified
mental health providers. This situation becomes more problematic in
remote locations or where there are low numbers of providers accepting
TRICARE.
While not providing formal mental healthcare, Military One Source
counselors available through on-line or toll-free call referral, or
Military and family life consultants and child and youth behavioral
consultants working out of base Airman and Family Readiness Centers
provide confidential, non-medical, short term counseling services to
address issues common in the military community, with no medical
documentation.
Case management and referral management occurs both through private
and military offices. Medical treatment facilities assist in locating
specialty care for their enrolled patients and TRICARE regional
contractors offer this service as well. Additionally, there are
numerous private and local advocacy groups and offices that aid with
access to services. The Defense Veterans Brain Injury Center provides
coordination of care for individuals suffering from a Traumatic Brain
Injury (TBI).
Indeed there are many Web sites, agencies and advocacy groups
providing resources for individuals and families with needs in the area
of mental health. There are DOD/VA workgroups in place which are
working to further consolidate and simplify these resources and
establish one site for patients to seek medical information regarding
psychological health. The breadth of resources is reflective of the
wide array of topics being addressed: from type of problem (post
traumatic stress disorder, depression, suicide, deployment related
issues, TBI) to demographic or beneficiary issues (Guard/Reserve,
Active Duty, family/individual, and age). Fortunately, in the military
medical system, each patient has his/her own primary care physician as
the first and best advocate to assist in the management of services.
Because of the importance of the relationship with a primary care
manager, the Air Force is placing behavioral health providers in
primary care clinics. Where this is in place, patients see mental
health providers for targeted, brief care in the primary care clinic
avoiding the stigma of making a mental health clinic appointment. When
further care is required the provider can refer the patient to the
community to see a private sector or TRICARE provider or other
appropriate resources.
MILITARY MEDICINE
Question. General Green, a key element to the improvement of care
is how fast we are able to transport servicemembers from the point of
injury to the care they need. Can you detail some of the advancements
in our aeromedical evacuations and what areas you are researching to
further these efforts?
Since fiscal year 2010, the Department of Defense has requested
funds for the advancement of military medicine. Prior to that, the
majority of these funds were provided to the Department through
earmarks and nationally competed programs added to the Defense budget
by Congress. In the fiscal year 2012 budget request the Department is
requesting $438 million through the Defense Health Program and the
Defense Advanced Research Projects Agency to further these efforts.
Answer. Evolutionary advancements in technology, and improvements
in clinical interventions enable movement of the most severely injured
or ill patients. Recent technology advancements introduced by the Air
Force include: advanced ventilators, video assisted intubation devices,
improved aircraft configuration equipment for litter patients, improved
aircraft lighting systems, an extracorporeal membrane oxygenation
device for adult patients, and improved virtual training for medical
personnel to name a few.
Aeromedical evacuation today is done flawlessly but must always be
focused on continuous improvement to care for ever more complex
patients. Based on operational outcomes, effects, and well defined
capability gaps, the major focus areas for enroute care research are:
patient stabilization; patient preparation for movement; patient
staging; impacts of in-transit environment on patient physiology and
medical crew/attendant performance; occupational concerns for medical
staff; human factors and patient safety; medical personnel training and
equipment; environmental health issues; infectious disease and cabin
infection control; burn and pain management; resuscitation; life saving
interventions; nutrition; alternative medicine; and a wide variety of
organ system effects (neurologic, psychologic, orthopedic, pulmonary,
cardiovascular, gastrointestinal, renal, and respiratory). Air Force,
Army, Navy, public and private academia, and industry partners are
engaged in research in these focus areas.
PATIENT CENTERED MEDICAL HOMES
Question. General Green, the Air Force continues to transition its
clinics to the patient centered medical home model. This concept
organizes health professionals into teams able to provide more
comprehensive primary care. Each patient's personal physician leads the
team and serves as a continuous point of contact for care. Has the Air
Force seen improvements in patient satisfaction or cost control with
this initiative?
The fiscal year 2012 budget request supports the phased
implementation the Patient Centered Medical Home concept for delivering
primary care for all three services. This concept, originating in the
private sector, seeks to improve quality of care and the patient
experience by integrating primary care into a comprehensive service.
Patients will have an ongoing relationship with a personal physician
leading a team of professionals that collectively takes responsibility
for the individual's or family's healthcare needs.
The Army is beginning with community based medical homes, which are
Army-run clinics located off-post. They function as extensions of the
Army hospital and are staffed by civil servants. Seventeen are
currently underway in communities which needed increased access to
primary care, including one in Hawaii.
The Air Force was the first service to implement the concept, which
it termed the Family Health Initiative, beginning in 2008. It will soon
be expanding the concept across all the clinics service-wide. The Navy
is also ramping up its program to convert its facilities, started in
May 2010, called Medical Home Port. Over 200,000 sailors and family
members are already enrolled.
Answer. The Air Force Medical Service has seen improvement in
patient satisfaction and access at locations that have implemented FHI.
Early data from the RAND (Research and Development) evaluation of the
Air Force Medical Home Model (RPN PA06R-R190) study show a 1.3 percent
increase in patient satisfaction. Additionally, continuity between
patients and their providers is on the rise changing from an average of
40 percent of patients seen by their assigned clinical to 60 percent
following FHI implementation. Continuity with the assigned team is even
higher averaging greater than 80 percent of the time seeing either the
physician or the extender on the health team. A secondary effect of
this improved continuity is decreased demand for acute appointments and
improved access to care. Patients have shown less need for follow-up
appointments as their assigned providers are able to provide more
comprehensive care to patients they know, driving down the total number
of overall healthcare visits. Provider satisfaction with this model of
care has also led to a 5 percent reduction in attrition of our family
physicians.
We are also monitoring Emergency Department (ED)/Urgent Care Clinic
utilization to see if the increased continuity can reduce high cost ED
visits. As continuity increases patients learn that visits to their
assigned provider, who are familiar with their medical history, offer
advantages over convenience of acute care clinics. The roll out of
Relay Health secure patient messaging over the next year will allow
simpler communication with patients electronically and further enhance
continuity.
Disease management and case management programs built into PCMH are
maturing and health indicators (such as diabetes compliance) are
improving. The patient linked as partner with a specific healthcare
team allows our extensive informatics network to provide decision
support to both patients and the care team. Aggregating patient data
into the informatics network will allow better care to populations as
we tie specialty consultants and analytic experts together to improve
care. It all starts with the partnership between patient and the
healthcare team in PCMH.
______
Questions Submitted by Senator Patty Murray
Question. Has the Air Force evaluated the capacity of its medical
community against the current and future structure?
Answer. Yes, the Air Force uses current and projected mission
changes to align resources where most appropriate. Beginning with Base
Realignment and Closure 2005, and continuing in subsequent program
objective memorandum (POM), the Air Force Medical Service (AFMS) has
realigned manpower and medical facility capability based on changing
mission requirements, including those mission changes associated with
BRAC decisions or other Department of Defense mission movements or
beneficiary changes.
We continue to use staffing models, beneficiary population, and
projected mission changes from the Air Force and the Office of the
Secretary of Defense communities to place resources where they can be
most effective, and where our deploying medics can receive the most
current, diverse case-mix. Beginning in the fiscal year 2010 POM, and
continuing today, the AFMS is aligning resources back into our
inpatient platforms, with plans to increase enrollment by 35,000 and
increasing inpatient capability at several of our larger Military
Treatment Facilities. Specifically, the AFMS increased Joint Base
Elmendorf by 200 personnel to account for force structure changes,
beneficiary recapture opportunity, and to improve currency. Similar
initiatives are in progress at Joint Base Langley-Eustis, and Eglin and
Nellis Air Force Bases in response to mission changes. These efforts
will result in medical personnel being better prepared for deployment
to the area of responsibility), and will bring care back into the
Direct Care System, a critical long-term goal to reduce costs and
improve efficiency.
The AFMS reviews current and future healthcare needs and directs
changes within the assigned force structure (specialties) of each
Corps. Under direction of the National Defense Authorization Act 2010,
Section 714, the AFMS is increasing the active duty mental health
authorizations by 25 percent to better address the needs of our service
members and their families. These additional authorizations are built
based both on the identified needs of our beneficiaries as well as our
projected ability to recruit and retain professionals in these
specialties. Although all active duty mental health professions will
increase in the next 5 years, the largest growth will be in social
workers, who we have had recent success in recruiting. We will also
increase both psychiatrists and psychiatric nurse practitioners to
increase our ability to provide psychiatric medication management
services. We recently reviewed our current force structure to realign
mental health resources and support the needs of our beneficiary
population while maintaining manning levels within the current Air
Force manpower constraints. Additionally, the AFMS is adding more
contract mental health professionals as a gap-fill measure until the
added active duty manpower needs are filled. This increase in mental
health manning does not increase the overall manning numbers of the
AFMS, but realigns the mix of specialty resources of our current
medical program to more effectively recapture costs and provide
expanded mental health services of these essential programs.
Question. Does the Air Force have enough mental health providers to
meet soldier and dependent needs?
Answer. Through the TRICARE network and community organizations,
the Air Force Medical Service (AFMS) has the mental health staffing to
meet the treatment needs for Airmen and family members. The
availability of resources varies depending on geographical region and
catchment area but it is adequate to provide for mental health needs in
a manner equal to other types of insurance.
Question. If there is a gap in mental health providers, what
efforts are being taken to get more providers in the system?
Answer. There is a nationwide shortage of mental health providers
which the AFMS confronts in a three-pronged approach addressing: (a)
educational programs and scholarships, (b) direct compensation, and (c)
quality of life (QOL) initiatives.
(a) Due to historical difficulties recruiting fully qualified
specialists, the AFMS places emphasis and funding into educational
scholarships.
(b) We use accession bonuses to recruit fully qualified specialists
into the Air Force and retain them through the use of retention
bonuses.
(c) The AFMS addresses QOL initiatives such as family services,
medical practice, educational or leadership opportunities, or frequency
of moves and deployments to recruit and retain our health
professionals.
Question. What programs are being undertaken to address the mental
health needs of spouses and dependent children?
Answer. A variety of programs provide support for the mental health
needs of spouses and dependent children. Each installation has a Family
Advocacy Program (FAP) that provides outreach and prevention services
to families. One novel FAP approach is the New Parent Support Program
(NPSP), which provides support and guidance in the home to parents
screened as high risk for family maltreatment. Educational and
Development Intervention Services (EDIS) are provided by a child
psychologist for special education children in DOD schools. Other
programs provide education on common family issues like good parenting,
couples communication, or redeployment integration. Counseling for
families is also available. Military One Source is a DOD program using
a civilian network that provides face-to-face, telephonic, or online
counseling/consultation to service members and families for up to
twelve sessions. Also providing nonmedical counseling, Airman and
Family Readiness Centers have Military and family life consultants and
child and youth behavioral consultants. These provide confidential,
non-medical, short term counseling services to address issues common in
military families such as deployment stresses and relocation. Other
nonmedical counseling alternatives for family members not able to be
seen at military medical treatment facilities have access to services
through community TRICARE providers. These providers offer an array of
services from individual counseling and group therapy, to inpatient
behavioral healthcare.
Question. The Air Force is producing medics with a wealth of
experience in a variety of medical specialties like trauma care. Has
there been any effort to align training programs with civilian training
requirements? If no, then why not?
Answer. We have established multiple training affiliations with our
civilian counterparts in numerous settings aimed at providing mutual
exchange of education. The purpose is not to align our training
programs with civilian requirements, but to optimize the respective
programs for both military and civilian students for the best outcomes.
We have military instructors embedded in civilian institutions where we
have military students for both GME (Graduate Medical Education) and
sustainment training. In turn, several civilian schools use our medical
facilities for student training with experiences unique to the
military.
Many of our surgical trauma experts are now in faculty positions in
different private sector university hospitals. Our Centers for
Sustainment of Trauma and Resuscitation Skills share expertise at
University of Maryland, University of Cincinnati and St Louis
University. Our Sustainment of Trauma and Resuscitation Skills Programs
also share expertise with Tampa General Hospital, University of
California--Davis, Scottsdale Medical Center, Miami Valley Medical
Center, and University of Texas-San Antonio. We also have surgeons
working closely with the Veterans Administration Hospitals, University
of Alabama-Birmingham and University of Pittsburgh Medical Centers.
Three of the four Centers of Excellence for the Nursing Transition
Program are civilian medical centers, two having achieved Magnate
status. These institutions provide a rich environment for our new nurse
graduates as they transition from new nurse graduate to military nurse.
Our military instructors and students provide our civilian colleagues
with unique training opportunities as experiences with the phenomenal
care we give our wounded warriors, establishing a collaborative process
of information sharing for optimal patient outcomes.
Question. How well does your medical community interact with your
acquisition community? As different injuries are identified as
prevalent within your service, what are the procedures to work with the
acquisition community to acquire equipment, tools, or clothing to limit
or prevent these injuries?
Answer. The medical community and acquisitions community work
closely together. Human Systems Integration has been a focus of the Air
Force Medical Service and the Vice Chief of Staff of the Air Force for
over 7 years to ensure new high cost military equipment addresses the
needs of the human that will operate it. There are continuous efforts
with Air Force logistics and the Army to mitigate the impact of combat
injuries by evaluating protective equipment and improving it. Once
protective equipment is identified as needed, our Air Force Medical
Service Medical Logistics Division at Fort Detrick, Maryland, works
with the acquisition community to contract for needed medical supplies,
equipment and services based on clinically identified requirements and
specific items are obtained as needed.
______
Question Submitted by Senator Tim Johnson
Question. Secretary Gates and Secretary Shinseki recently announced
that the Department of Defense and the Department of Veterans Affairs
will develop a joint electronic health record. On April 1, 2011, the
Department of Veterans Affairs also announced that it will form an open
architecture community around the VA's electronic health record, VISTA.
Are these the same thing or will each Department still keep its own
version of VISTA and AHLTA?
Do the Departments envision the joint electronic health record
replacing VISTA and AHLTA?
When will the Departments release details and a comprehensive plan
forward on the joint electronic health record?
Answer. The Department of Veterans Affairs and the Department of
Defense are collaborating on the Integrated Electronic Health Record
(iEHR) program which will operate in the future as a common EHR. Given
the iEHR is a complex, multi-year development program, a DOD-VA
Integrated Program Office is being created to coordinate the
development and deployment of the iEHR and then the sun-setting of
VISTA and AHLTA. During the initial planning, the Departments have
identified common business processes and practices, including common
data standards, data center consolidation, common clinical
applications, and a common user interface. Coordinating the efforts
between the Departments sets the course toward a seamless electronic
health record exchange and portability of health information in a
secure and private format.
The EHR Senior Working Group and various subgroups are currently
assembling the information needed to put together a comprehensive plan.
The plan is considering the budget, architecture, security, policies,
and business processes. A high level project plan is being constructed
that includes cost models, proposed timelines, and joint assumptions.
The Secretary of Defense and the Secretary of the Veterans Affairs are
scheduled to receive a status brief on cost, schedule and performance
on May 2, 2011.
______
Questions Submitted to Rear Admiral Elizabeth S. Niemyer
Questions Submitted by Chairman Daniel K. Inouye
PEDIATRIC INJURIES ON THE BATTLEFIELD
Question. Since 2002, DOD hospitals in Iraq and Afghanistan have
treated over 2,000 injured children with over 1,000 of these children
having suffered from blast injuries. Children have unique physiological
responses to illness and injury. Therefore, the treatment of children
demands specific training, equipment and approaches that are different
than those required for adults. Children injured in war zones are
sometimes treated as ``little adults'', and the healthcare
professionals do not have the experience or training necessary to
appropriately care for pediatric trauma injuries.
Admiral Niemyer, our military medical personnel in theater are
treating a wide array of civilian cases in addition to caring for our
servicemembers. As a result, they are seeing numerous pediatric
injuries similar to injuries sustained by adults. Has the Navy
implemented any pre-deployment training for nurses to address the
unique needs of pediatric casualties of war?
Answer. In 2002, the Navy established the Navy Trauma Training
Center (NTTC), a joint cooperative medical venture with the Los Angeles
County-University of Southern California Medical Center, to train our
nurses, doctors, and corpsmen in real world trauma medicine skills and
experiences. Staff teaching this course solicit feedback from students
who have completed the course and deployed. Over time our personnel
noted a change in the demographic population of those injured in
Afghanistan to include children. This feedback was used to begin
incorporating a more robust training module highlighting the
physiologic differences and responses to pediatric trauma, injury
patterns, and pediatric specific treatments. Furthermore, because of
this feedback clinical rotations in the Pediatric Intensive Care Unit
and Pediatric Trauma Emergency Department have increased. Approximately
75 percent of NTTC students deploy with Marine units.
One of our pediatricians, Captain Jon Woods, was involved with
extensive pediatric trauma in Afghanistan. He identified the
requirement for qualified nurses trained specifically in military
transport of pediatric patients. Staff at Naval Medical Center San
Diego took this information and are in the process of creating a
certified training program using their extensive simulation resources.
The plan is to create a simulated space equivalent to that found inside
a Blackhawk transport helicopter, where students in full battle gear
will have pediatric trauma simulation experiences in which care is
affected by significant limitations in visibility, communication, and
movement.
RECRUITMENT AND RETENTION
Question. Despite well known shortages in the nursing profession,
the three services have continued to do well in recruiting nurses into
the military. Last year, the Air Force testified that one of the
challenges the nurse corps faced was the development of new flight
nurses and technicians in the pipeline to meet the needs of the ever
growing aeromedical evacuation mission. Flight nurses remain the lowest
manned specialty in the nurse corps (78 percent), and have one of the
highest demands. For the fifth consecutive year the Navy has achieved
their active component nursing goal (92 percent manning) and they have
2,852 nurses currently serving around the world. In fiscal year 2010,
the Army was able to recruit 642 nurses, meeting 105 percent of its
active duty need and 94 percent for the reserve.
Admiral Niemyer, how are deployments affecting the Navy nurse
corps' ability to retain experienced nurses, particularly those working
in high demand, low occupancy nursing career fields?
Answer. With the ongoing war efforts, we are keenly aware of the
need to grow and retain nurses in our critical war-time subspecialties.
Though loss rates have improved overall, there remains a gap in the
inventory to authorized billets for junior nurses with 5 to 10 years of
commissioned service.
Key efforts which have positively impacted retention include
Registered Nurse Incentive Special Pay (RN-ISP), which targets bonuses
to undermanned clinical nursing specialties, and the Health
Professional Loan Repayment Program (HPLRP), which offers educational
loan repayment up to $40,000. Full-time Duty Under Instruction (DUINS)
further supports Navy recruitment and retention objectives by
encouraging higher levels of professional knowledge and technical
competence through graduate education. Training requirements are
selected based on Navy nursing needs for advanced skills in war-time
critical subspecialties. Seventy-six applicants were selected for DUINS
through the fiscal year 2011 board.
Tracking specific reasons for losses is complex, but currently the
Center for Naval Analysis is completing a follow-up study where intent
to leave is one of the outcome variables. As the economy improves and
civilian nursing opportunities expand through the Affordable Care Act,
we might once again be faced with recruiting and retention challenges.
In anticipation of these challenges, we are inviting nursing students
and new graduate nurses to participate as American Red Cross volunteers
at our hospitals and clinics to enhance exposure to the military.
Additionally, we assigned a Nurse Corps Fellow to my staff to monitor
recruitment and retention, and to ensure that both remain a priority.
NURSING RESEARCH
Question. Scientific inquiry, planned and conducted by nurses, is a
vital part of improving the health and healthcare of Americans. Nursing
research has been a long time catalyst for many of the positive changes
that we have seen in patient care over the years. The National
Institute of Nursing Research defines nursing research as the
development of knowledge to build a scientific foundation for clinical
nursing practice, prevent disease and disability, manage and eliminate
symptoms caused by illness, and enhance end-of-life and palliative
care. The TriService Nursing Research Program (TSNRP) is one such venue
to help ensure nursing care remains evidence based.
Admiral Niemyer, nurses have a long history of promoting quality
healthcare that is not only focused on the needs of the patient but
also on the needs of their families. Nursing research has played a big
part in how we take care of patients today. How are you ensuring that
Navy nurses at all levels in the organization understand the research
process and are given opportunities to participate in nursing research
efforts?
Answer. The Navy Nurse Corps has aligned nursing research
priorities with military relevant Surgeon General's priorities and has
embraced evidence based practice. ``Invigorating Nursing Research'' is
a priority and one of the five Navy Nurse Corps' Strategic Goals for
2011. It is aligned with the Navy Medicine Goal of Research and
Development and Clinical Investigation programs. Also an active
participant in the Tri-Service Nursing Research Program (TSNRP), the
Navy Nurse Corps' aim is to continually increase the interest,
submission, and subsequent selection of military relevant funded
research projects to improve the health of our patients and/or add to
the body of nursing knowledge.
Our Nursing Research assets are aligned regionally and are aimed at
providing guidance, communication, and mentoring to nurses at all
levels of the organization. These assets actively advertise and provide
TSNRP and other educational research and evidence based practice course
offerings through presentations, site visit training, postings on the
Navy Knowledge Online Navy Nurse Corps Web site, and enterprise-wide
emails. Due to the efforts of the Strategic Goal Team and the synergy
of the research assets in the region (both active component and reserve
component), an overwhelming successful number of nurses have applied to
participate in the TSNRP Research Development Course offered in San
Diego in May 2011. Twenty-one Navy Nurses were selected to fill 25 Tri-
Service seats.
______
Questions Submitted to Kimberly Siniscalchi
Questions Submitted by Chairman Daniel K. Inouye
RECRUITMENT AND RETENTION
Question. General Siniscalchi, last year you testified that one of
the challenges the nurse corps faced was the development of new flight
nurses and technicians in the pipeline to meet the needs of the ever
growing aeromedical evacuation mission. Would you please provide us
with an update on the status of those initiatives to increase this
career field?
Despite well known shortages in the nursing profession, the three
services have continued to do well in recruiting nurses into the
military.
Last year, the Air Force testified that one of the challenges the
nurse corps faced was the development of new flight nurses and
technicians in the pipeline to meet the needs of the ever growing
aeromedical evacuation mission. Flight nurses remain the lowest manned
specialty in the nurse corps (78 percent), and have one of the highest
demands.
For the fifth consecutive year the Navy has achieved their active
component nursing goal (92 percent manning) and they have 2,852 nurses
currently serving around the world.
In fiscal year 2010, the Army was able to recruit 642 nurses,
meeting 105 percent of its active duty need and 94 percent for the
reserve.
Answer. Despite this critically manned, high demand specialty,
Aeromedical Evacuation (AE) nurses and technicians continue to perform
superbly with a 100 percent mission success. In fiscal year 2010, AE
authorizations increased and as a result, the percentage of staffed
versus authorized dropped significantly. At the same time, we relocated
the Air Force School of Aerospace Science from Brooks City-Base, San
Antonio to Wright-Patterson AFB, Ohio, which temporarily affected our
training pipeline.
Several initiatives are now underway to fill AE requirements. To
improve retention, flight nurses are now offered Incentive Special Pay
(ISP). The ISP program is making a positive impact on professional
satisfaction and retention. To maximize our training investment in both
AE nurses and technicians, the Air Force Personnel Center initiated
several changes to allow nurses and technicians to complete a full 3-
year tour with the option to extend. An AE force development model was
developed to allow nurses and technicians to weave in and out of flying
assignments throughout their career. Developmental leadership positions
were also established so nurses and technicians can return to AE and
provide the much needed leadership and clinical mentorship for our
junior AE nurses and technicians. Previous flyers are being asked to
volunteer to return to flying assignments and many are eager to have
the opportunity to return to flying. We project filling 100 percent of
our allocated training seats this year.
In addition, we are currently working on AE training
transformation. We scheduled a utilization and training workgroup in
fiscal year 2011 to streamline training by leveraging distance learning
and creating modular training. The new format will increase the volume
of Phase I students and decrease training time needed for Phase II
students with a flying assignment pending. Our partnership with Wright
State University in Dayton, Ohio is progressing well as we continue to
refine the new graduate program in Flight Nursing. This new program
offers didactic and clinical training in flight nursing, disaster
preparedness/homeland defense, and adult health clinical nurse
specialist. Our first student graduates in May 2012.
NURSING RESEARCH
Question. General Siniscalchi, how are you fostering nurse
researchers in the Air Force?
Scientific inquiry, planned and conducted by nurses, is a vital
part of improving the health and healthcare of Americans. Nursing
research has been a long time catalyst for many of the positive changes
that we have seen in patient care over the years. The National
Institute of Nursing Research defines nursing research as the
development of knowledge to build a scientific foundation for clinical
nursing practice, prevent disease and disability, manage and eliminate
symptoms caused by illness, and enhance end-of-life and palliative
care. The TriService Nursing Research Program (TSNRP) is one such venue
to help ensure nursing care remains evidence based.
Answer. In addition to our Master Clinician's and Master Research
career paths, we recently developed a nursing research fellowship and
the first nurse started in August 2010. This 1 year, pre-doctoral
research fellowship, focuses 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. Following
the fellowship, they will be assigned to work in Plans and Programs
within the Human Performance Wing of the Air Force Research Laboratory.
This direction is consistent with the National Research Council of the
National Academies recommendations for research career paths.
Under Air Force Colonel Marla De Jong's leadership, and for the
first time in its history, TSNRP offered research grant awards to
nurses at all stages of their careers--from novice nurse clinician to
expert nurse scientist. The Military Clinician-Initiated Research Award
is targeted to nurse clinicians who are well-positioned to identify
clinically important research questions and conduct research to answer
these questions under the guidance of a mentor. The Graduate Evidence-
Based Practice Award is intended for Doctor of Nursing Practice
students who will implement the principles of evidence-based practice
and translate research evidence into clinical practice, policy, and/or
military doctrine. It is critical that funded researchers disseminate
the results of their studies so that leaders, educators, and clinicians
can apply findings to practice, policy, education, and military
doctrine as appropriate. This grant will enhance this dissemination and
uptake of evidence.
Further opportunities to maximize the potential of our Airman and
grow the next generation of noncommissioned officers are available
through the Air Force Institute of Technology for certain key enlisted
specialties. To date, we have three such positions identified; one in
education and training at the Air Force Medical Operations Agency,
another within our Modeling and Simulation program at Air Education and
Training Command, and the third within the research cell at Wilford
Hall Medical Center. Our most recent addition to the research cell is
Senior Master Sergeant Robert Corrigan, who just arrived to Wilford
Hall Medical Center.
NURSING ISSUES
Question. General Siniscalchi, the acuity of patients, level of
experience of nursing staff, layout of the unit, and level of ancillary
support are all key components in establishing the ``right'' nurse-
patient ratio for any unit. This year I reintroduced The Registered
Nurse Safe Staffing Act which addresses those concerns. How does the
Air Force ensure adequate nurse staffing levels on inpatient units?
A new study published in the New England Journal of Medicine shows
that inadequate staffing is tied to higher patient mortality rates
which supports the principles that call for nurse staffing to be
flexible and continually adjusted based on patients' needs and other
factors.
Answer. A workload data review is conducted on a facility's patient
census and acuity to establish a workload average over a 4 year period.
From this data review, staffing levels are set at 15 to 20 percent
greater than the average census to cover the anticipated patient load.
Through the Tri-Service Patient Acuity and Staff Scheduling System
Working Group, a model is being developed to staff according to patient
need, nurse experience, and acuity versus a fixed nurse to patient
ratio. Currently, there is no national standard for nurse staffing,
however, the American Nurses Association provides a compilation of
State regulated requirements which are taken into consideration for the
current Air Force manpower model.
In step with our manpower and staffing initiatives, our Air Force
Medical Operations Agency in conjunction with the Department of Defense
(DOD), implemented the Patient Safety Reporting (PSR) System in Air
Force Military Treatment Facilities worldwide. The PSR provides staff
with a simple process for reporting patient safety events using DOD
standard taxonomies, which enhance consistency and timely event
reviews. The PSR event data will be analyzed for trends and assist in
identifying targets for process improvement, both at Air Force and DOD
levels.
Question. General Siniscalchi, how many nursing positions does the
Air Force have for senior nurses to remain in direct patient care?
Answer. We have developed a career track for Master Clinicians and
Master Research positions through the rank of Colonel. This career
track will allow our expert clinicians and researchers to stay within
their realm of expertise without sacrificing promotion opportunity.
Master Clinicians are board certified nursing experts with a
minimum preparation of a master's degree and at least 10 years of
clinical experience in their professional specialty. They serve as the
functional expert and mentor to junior nurses. Our Master Researchers
are Ph.D. prepared and have demonstrated sustained excellence in the
research arena.
Both of these highly respected positions are critical in the
advancement of nursing practice and to the mentoring of our novice
nurses. Currently we have 19 Master Clinician and 3 Master Researcher
positions established at designated areas. In addition to our Master
Clinicians, 3,073 of our 3,355 nurses or 92 percent of our nurses are
in direct patient care positions.
Question. General Siniscalchi, how many nursing positions does the
Air Force have for senior nurses to remain in direct patient care?
A new study published in the New England Journal of Medicine shows
that inadequate staffing is tied to higher patient mortality rates
which supports the principles that call for nurse staffing to be
flexible and continually adjusted based on patients' needs and other
factors.
Answer. We have developed a career track for Master Clinicians and
Master Research positions through the rank of colonel. This career
track will allow our expert clinicians and researchers to stay within
their realm of expertise without sacrificing promotion opportunity.
Master Clinicians are board certified nursing experts with a
minimum preparation of a master's degree and at least 10 years of
clinical experience in their professional specialty. They serve as the
functional expert and mentor to junior nurses. Our Master Researchers
are Ph.D. prepared and have demonstrated sustained excellence in the
research arena.
Both of these highly respected positions are critical in the
advancement of nursing practice and to the mentoring of our novice
nurses. Currently we have 19 Master Clinician and 3 Master Researcher
positions established at designated areas. In addition to our Master
Clinicians, 3,073 of our 3,355 nurses or 92 percent of our nurses are
in direct patient care positions.
SUBCOMMITTEE RECESS
Chairman Inouye. The subcommittee will reconvene on
Wednesday, April 13 at 10:30 for a classified briefing with the
Commander of the United States Pacific Command. Until then, we
stand in recess.
[Whereupon, at 12:34 p.m., Wednesday, April 6, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]