    [House Hearing, 117 Congress]
    [From the U.S. Government Publishing Office]

                             [H.A.S.C. No. 117-73]

                      PATIENT SAFETY AND QUALITY OF CARE
                         IN THE MILITARY HEALTH SYSTEM

                                   __________

                                    HEARING

                                   BEFORE THE

                       SUBCOMMITTEE ON MILITARY PERSONNEL

                                     OF THE

                          COMMITTEE ON ARMED SERVICES

                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                  HEARING HELD

                                 MARCH 30, 2022

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                                    __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    51-196                    WASHINGTON : 2023

    -----------------------------------------------------------------------------------

                       SUBCOMMITTEE ON MILITARY PERSONNEL

                     JACKIE SPEIER, California, Chairwoman

    ANDY KIM, New Jersey                 MIKE GALLAGHER, Wisconsin
    CHRISSY HOULAHAN, Pennsylvania       STEPHANIE I. BICE, Oklahoma
    VERONICA ESCOBAR, Texas, Vice Chair  LISA C. McCLAIN, Michigan
    SARA JACOBS, California              RONNY JACKSON, Texas
    MARILYN STRICKLAND, Washington       JERRY L. CARL, Alabama
    MARC A. VEASEY, Texas                PAT FALLON, Texas

                     Ilka Regino, Professional Staff Member
                     Glen Diehl, Professional Staff Member
                               Sidney Faix, Clerk

                                C O N T E N T S

                                  ----------
                                                                       Page

                  STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

    Gallagher, Hon. Mike, a Representative from Wisconsin, Ranking
      Member, Subcommittee on Military Personnel.....................     3
    Speier, Hon. Jackie, a Representative from California,
      Chairwoman, Subcommittee on Military Personnel.................     1

                                   WITNESSES

    Del Barba, Dez, U.S. Army Veteran................................     4
    Dingle, LTG R. Scott, USA, Surgeon General of the Army, and
      Commanding General, United States Army Medical Command.........    25
    Gillingham, RADM Bruce L., USN, Surgeon General of the Navy, and
      Chief, Bureau of Medicine and Surgery..........................    26
    Luckey, Derrick, Father of U.S. Navy Seaman Danyelle Luckey......     6
    Miller, Lt Gen Robert I., USAF, Surgeon General of the Air Force.    27
    Place, LTG Ronald J., USA, Director, Defense Health Agency.......    23
    Silas, Sharon, Director, Government Accountability Office Health
      Care Team......................................................     8

                                    APPENDIX

    Prepared Statements:

        Del Barba, Dez...............................................    43
        Dingle, LTG. R. Scott........................................   114
        Gillingham, RADM Bruce L.....................................   120
        Luckey, Derrick..............................................    82
        Miller, Lt Gen Robert I......................................   128
        Place, LTG Ronald J..........................................   105
        Silas, Sharon................................................    89

    Documents Submitted for the Record:

        [There were no Documents submitted.]

    Witness Responses to Questions Asked During the Hearing:

        [There were no Questions submitted during the hearing.]

    Questions Submitted by Members Post Hearing:

        Mr. Carl.....................................................   146
        Ms. Escobar..................................................   139
        Dr. Jackson..................................................   145
        Ms. Jacobs...................................................   141
        Ms. Speier...................................................   139

    .
        PATIENT SAFETY AND QUALITY OF CARE IN THE MILITARY HEALTH SYSTEM

                                  ----------

                      House of Representatives,
                           Committee on Armed Services,
                            Subcommittee on Military Personnel,
                             Washington, DC, Wednesday, March 30, 2022.
        The subcommittee met, pursuant to call, at 2:00 p.m., in
    room 2118, Rayburn House Office Building, Hon. Jackie Speier
    (chairwoman of the subcommittee) presiding.

    OPENING STATEMENT OF HON. JACKIE SPEIER, A REPRESENTATIVE FROM
       CALIFORNIA, CHAIRWOMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

        Ms. Speier. Good afternoon, ladies and gentlemen. We are
    going to call to order the Military Personnel Subcommittee of
    the Armed Services Committee.
        We welcome our witnesses this afternoon.
        We will have some complications in this hearing because
    there will be a series of five votes that the House will be
    taking. So, we will recess for a period of time, and then, come
    back. Hopefully, we will be able to get through the first
    panel.
        The taxpayers spent more than $50 billion each year on the
    Military Health System [MHS], which provides healthcare
    services to 9.6 million beneficiaries, including service
    members, dependents, and retirees. This sizable investment
    should buy timely, safe, high quality care for our service
    members and their families. However, I am not convinced that
    the military is delivering on this sacred obligation.
        The 2017 NDAA [National Defense Authorization Act]
    reorganized the Military Health System and standardized
    clinical quality processes. Before the reform, the Army, Navy,
    and Air Force each operated separate healthcare systems and the
    military had 24 different policies on patient safety and
    quality. Now, the Defense Health Agency oversees all medical
    treatment facilities, and since 2019, DOD [Department of
    Defense] has a single policy on patient safety and quality.
        But, despite these changes, I have not seen evidence that
    real improvement has occurred. In fact, I hear too often about
    medical errors that cause grievous harm to patients and quality
    assurance investigations [QAIs] that drag on for years, while
    the suspect providers continue to practice.
        Our first witnesses include two families that have been
    irreparably and devastatingly harmed by inexcusably poor
    military health care. I want to thank you for coming forward
    and sharing your deeply personal stories. You are representing
    yourselves, your families, and countless others who could not
    be here today. I want to hear from you on how you and your
    families were treated during and after your medical ordeals.
        Our first witness is Dez Del Barba. He had a dream to
    follow his family in service to his country. Instead, he found
    a toxic environment in basic training, where he became very
    ill. The command repeatedly ignored his symptoms and shamed
    him. When he finally got medical treatment, misdiagnosis and
    inexplicable additional delays in treatment resulted in an
    unimaginable set of circumstances for what was a healthy 21-
    year-old--43 surgeries, loss of a leg, and loss of a dream for
    a career in the military. This injury didn't happen in combat.
    It didn't even happen during training. Instead, it happened
    because providers failed to act in a timely manner.
        I also want to recognize Mr. Derrick Luckey, whose 19-year-
    old daughter Danyelle died in 2016 after the Navy failed to
    diagnose her condition while she was aboard the aircraft
    carrier USS [United States Ship] Reagan. Her symptoms were also
    repeatedly ignored, and she paid the ultimate price.
        I cannot tell you how grateful I am that you are both here
    to share your stories. You two represent countless victims of
    poor quality medical care, and I thank you.
        Our GAO [Government Accountability Office] witness, Ms.
    Silas, will shed light on whether the Defense Health Agency is
    adhering to its own clinical quality management procedures,
    including provider credentialing, investigating medical errors,
    and holding accountable providers who fail to meet the
    standards of care.
        When our service members suffer from poor quality medical
    care, when doctors fail to provide the standard of care, or
    woefully ignore symptoms or conditions, we need to make sure
    that there is a system in place to both prevent the incident
    from happening again and hold the providers accountable. And
    that is what we want to hear about from the second panel.
        To Lieutenant General Place and the Surgeon General of the
    military departments, we want to know how you are holding
    incompetent and negligent providers accountable; how are you
    implementing changes to improve patient safety, both in the
    military hospitals and operational medical environments,
    including ships; how are you making sure the doctors and nurses
    have the appropriate credentials to provide health care.
        In our country, we rightfully revere service members for
    their bravery and their sacrifice. It is incomprehensible and
    shameful that we cannot ensure they have the quality medical
    care they deserve.
        I also want to point out that my efforts to allow service
    members to file claims against the military for instances of
    medical malpractice aren't only a matter of justice, they are
    about accountability. And I'm frustrated, to say the least,
    that the DOD has been so slow to implement the Stayskal Act
    that Congress included in the 2020 NDAA. There are few
    incentives better than the threat of legal action to push an
    organization to change its behavior.
        Before hearing from our first panel, we want to hear from
    Ranking Member Gallagher and give him an opportunity to make
    his opening remarks.

        STATEMENT OF HON. MIKE GALLAGHER, A REPRESENTATIVE FROM
     WISCONSIN, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

        Mr. Gallagher. I thank the chairwoman.
        And I want to thank both of our panels for being with us
    today. And a special thank you to Mr. Luckey and Mr. Del Barba
    for your willingness to share your personal stories and
    experiences in an effort to help us make the system better.
        In preparing for this hearing, I looked at some statistics
    from the National Institutes of Health and found that
    approximately 400,000 hospitalized patients experience some
    type of preventable harm each year, and that medical errors
    cost approximately $20 billion a year; and that medical errors,
    furthermore, in hospitals and clinics result in approximately
    100,000 people dying each year.
        Within the Department of Defense, a 2014 review found that,
    quote, ``While the Military Health System delivers safe,
    timely, and quality care that is largely comparable to care
    delivered in the civilian sector, the MHS demonstrated wide
    performance variability with some areas better than civilian
    counterparts and other areas below national and DOD
    benchmarks.''
        I understand that reforms in the NDAA, as well as the
    internal process improvements of DOD, are making a positive
    impact, but the bottom line is that the Military Health System
    is not where we need it to be. One thing that I believe can be
    done is to attack that variation at every turn, whether it is
    in the operating room, in the clinic, or on the battlefield.
    There are many examples within the military of high reliability
    organizations that focus on eliminating variation and planning
    until service members can't get it wrong.
        These organizations empower meritocratic ideals that teach
    us that every person has an important role on the team, based
    on their performance and their professional acumen. Some
    examples include military aviation, nuclear propulsion, and
    special warfare communities.
        I would also like to add, although not the focus of today's
    hearing, that wargaming is actually another way to evolve our
    military culture in eliminating variation in the never-ending
    quest to defeat our adversaries, and sometimes we focus so much
    on the high-end weapons system, we forget that health care is
    part of our ability to be ready to deter and, if necessary, win
    our Nation's wars.
        So, I am really looking forward to better understanding the
    challenges the Military Health System has today; how we can
    embrace that high reliability organizational culture, and any
    recommendations that we should be thinking of, as we gear up
    for another NDAA cycle, in order to ensure that our outcomes
    are better than they are today.
        Thank you.
        Ms. Speier. Thank you, Mr. Gallagher.
        I ask unanimous consent to allow members not on the
    subcommittee to participate in today's hearing and be allowed
    to ask questions after all subcommittee members have been
    recognized. And we welcome Mr. DeSaulnier, and I believe Dr.
    Wenstrup is here as well.
        I ask unanimous consent that the chair be authorized to
    declare a recess at any time. Is there objection?
        Without objection, it is ordered.
        Each witness will have the opportunity to present his or
    her testimony, and each member will have an opportunity to
    question the witnesses for 5 minutes.
        We respectfully ask the witnesses to summarize their
    testimony in as close to 5 minutes as you can. Your written
    comments and statements will be made part of the hearing
    record.
        With that, Mr. Dez Del Barba, you may make your opening
    statement.
        You have to push that little button there to turn on the
    microphone. I don't think it is on yet.

             STATEMENT OF DEZ DEL BARBA, U.S. ARMY VETERAN

        Mr. Del Barba. Hello? Okay. I apologize.
        Ms. Speier. That is all right.
        Mr. Del Barba. Thank you, Congresswoman Speier.
        My name is Dez Del Barba.
        Before I begin, I'd first like to thank Chairwoman Jackie
    Speier and everyone on the subcommittee for allowing me to
    speak before you all today and tell my story.
        I would also like to thank my parents, Kamni and Mark Del
    Barba, and my girlfriend, Julie Ruiz, for being here with me
    today from the very beginning. I would also like to thank my
    sister, Drisa Del Barba, who is unable to attend, and lastly,
    my legal team, Daniel Maharaj and Elizabeth Zweibel, for
    supporting me throughout this journey.
        Many people have dreams and aspirations of having a career
    in tech, medicine, engineering, and law. I had dreams and
    aspirations of having a career in the U.S. military, and it was
    something I knew I always wanted to do from a very young age. I
    wanted to join the military right out of high school. However,
    I was guided to pursue a bachelor's degree first, before
    getting commissioned as an officer.
        I was an extremely health and athletic 21-year-old man
    before I enlisted in the U.S. Army. I had never had any health
    issues besides an ACL [anterior cruciate ligament] tear on my
    right knee.
        The Army is the only branch that makes it a requirement for
    their officers to complete basic combat training before they
    can attend Officer Candidate School [OCS]. I was accepted into
    the OCS program as I had a few semesters of college left to
    finish before obtaining my degree. I decided to take a leave of
    absence from college to complete basic combat training, return
    to school, then upon graduation from college, attend OCS.
        I shipped out to Fort Benning on January 7th, 2019, and
    like many young men and women, I was excited, energetic,
    enthusiastic, and even anxious for this new adventure in my
    life. I was assigned to Bravo Company, 1st Battalion, 46th
    Infantry Regiment.
        However, it only took 35 days for the military to destroy
    my life. I was left grossly neglected by the U.S. military
    healthcare system and by my basic training leadership at Fort
    Benning, Georgia.
        As a result of the neglect I experienced, I physically
    endured a total of 43 surgeries. Over half of my right glute
    has been debrided and skin-grafted. Both of my underarms have
    undergone debridement and skin-grafting. I have an above-knee
    amputation on my left leg, and my right leg has been severely
    debrided and skin-grafted, leaving me with 70 percent muscle
    and tissue damage.
        In order to somewhat restore these five major areas of my
    body, I had skin donor sites on my chest and back. Mentally, I
    am now diagnosed with severe PTSD [post-traumatic stress
    disorder] and depression.
        Today, as I sit in front of you all, 3 years and 19 days
    have passed since I had answers about what has happened since I
    contracted necrotizing fasciitis at Fort Benning. It has been
    1,143 days, and I still have no clear answers on the status of
    any quality assurance investigation that may or may not have
    been initiated promptly.
        What happened to me did not have to happen. This was
    preventable. I can sit here and speak all day about what
    happened to me, but my pictures will put my words into
    perspective of the damage that has been done to my body and my
    mind. Please see the attached photos for a better understanding
    of what I went through and what could have been avoided, had
    the medical providers at Fort Benning given me adequate medical
    attention.
        If I was your son, if I was your brother, if I was your
    loved one, would you sit stagnant waiting for answers? I would
    hope not. You would fight for their rights and you would never
    stop until the questions are answered and the responsible
    people are held accountable.
        I understand that the medical quality assurance is managed
    by the military medical community. I understand that this takes
    time and patience. However, my medical records from Fort
    Benning total less than 100 pages, and I cannot seem to
    understand or comprehend how the Army has taken over 3 years,
    and still has not concluded the QAI in my case.
        I have enclosed with my statement all the correspondence I
    have received from the Army command regarding the status of my
    QAI for the committee to see how convoluted this process has
    been and how inconsistent the Army is when responding to
    inquiries made.
        I would pose the question: How can the military say it is
    adequately providing medical quality assurance for service
    members like myself? I am here today not only fighting for
    myself, but for all other service members that have been
    subjected to an adverse event at a military treatment facility
    center and have never had a proper or an appropriate quality
    assurance investigation. This is a grave injustice for our
    service members, and this is the least that they deserve, given
    that some of them are no longer here as a result.
        I cannot stress the negative emotional impact this has
    caused on myself. Not only did I lose a limb, I also lost my
    identity, my self-esteem, and my confidence along with it.
    Activities that are supposed to be fun and enjoyable for
    someone in their twenties became a mental burden. Hiding behind
    a fake smile every time I am around others, while having
    feelings of true unhappiness on the inside, became normal.
    Having thoughts of ``it would be better if I just went to sleep
    and never woke up'' was something I was hoping would happen to
    me every single night before bed.
        As the saying, ``Life goes on,'' my life will go on. I will
    eventually find the strength, mentally and physically, to work
    past this horrendous time in my life. However, this has
    reshaped my identity as a human being. Daily things that you
    all take for granted, such as putting on your shoes before
    work, taking a walk around your neighborhood, going for a dip
    in the pool when it's too hot outside, these are all things
    that I am not able to do, either at all or as easily anymore,
    as a 24-year-old man.
        I would never wish what I went through upon anyone, but,
    unfortunately, that may not be possible, seeing that those
    responsible for the poor medical care I received are still
    employed by the Army to treat more service members.
        I ask you to take away the feeling of motivation from what
    I have shared here with you today--the motivation to want a
    better system that should be at its finest for its men and
    women who want to serve this country.
        Thank you for your time and attention, and please see my
    written statement for a full accounting and timeline of what
    happened to me. I am happy to answer any questions.
        [The prepared statement of Mr. Del Barba can be found in
    the Appendix on page 43. Enclosure 1 photos are retained in
    committee files.]
        Ms. Speier. Thank you, Mr. Del Barba. It is extraordinary
    courage that you have shown.
        I want my colleagues to know that in your binders are
    pictures of his injuries, and they are truly shocking.
        Mr. Luckey, you are recognized.

        STATEMENT OF DERRICK LUCKEY, FATHER OF U.S. NAVY SEAMAN
                            DANYELLE LUCKEY

        Mr. Luckey. Good afternoon.
        Ms. Speier. Could you make sure your microphone is on?
        Mr. Luckey. Good afternoon.
        Ms. Speier. Maybe put the microphone a little bit closer.
    Yes, there you go.
        Mr. Luckey. Good afternoon, Chairwoman Speier and members
    of the committee.
        My name is Derrick Luckey. I am from Pittsburg, California.
    I am joined today by my wife Annette. We are the parents of the
    late Seaman Danyelle Luckey, who died October 10, 2016, from
    sepsis while serving on the USS Ronald Reagan. We were invited
    to appear today to share what happened to Danyelle while she
    served our country.
        First, let me say I am not a lawyer or a politician. I have
    never done anything like this before. However, I am here today
    to share with you the tragedy of Danyelle's death. She did not
    die in combat or any military operation. She died from gross
    negligence of the medical providers on the ship she served, the
    USS Ronald Reagan. Her death was very preventable. Instead, she
    died in excruciating pain instead of being properly treated.
        When Danyelle came to me and said, ``Dad, I want to join
    the military and serve my country,'' she wanted to join the
    Navy to start a career as a sailor on a ship. When she
    approached me, I said, ``I am concerned for you.'' She said,
    ``Dad, I will be okay,'' with that big smile I remember so
    much, a smile I will never see again. Little did I know, on
    October 10, 2016, I would get that knock at the door at 9:03
    a.m. telling me my daughter was dead, not from bullets, but
    from sepsis.
        Like many who have children who have served in the
    military, we live in fear of two officers knocking at our door.
    Danyelle was not in combat. We were crushed when they told us
    she had died of cardiac arrest. We thought it was impossible.
    How could my daughter die of cardiac arrest? Our lives changed
    forever.
        Danyelle died on the USS Ronald Reagan, not at war. This,
    tragically, was completely avoidable. Her death was the result
    of gross negligence/malpractice. If the medical providers on
    the USS Ronald Reagan had given her a simple treatment of
    antibiotics, instead of turning her away, she would be here
    today.
        When we reached out to attorneys around the country to
    represent us, they said, no, that we couldn't do anything.
    Someone told us to reach out to Attorney Natalie Khawam. They
    said she was a strong fighter for our military. We did, and she
    was willing to help us seek justice for Danyelle.
        Ms. Khawam told us that you, Chairman Speier, are an
    incredible advocate for our military, and that you are the
    champion of the Richard Stayskal Military Accountability Act.
    So, today, I did come here to share with you the tragedy of our
    daughter's death and to share with you what is wrong with the
    system you created to seek justice for sailors like my Danyelle
    die when they are victims of medical malpractice.
        We all believed, when Congress passed the SFC [Sergeant
    First Class] Richard Stayskal Military Accountability Act under
    your leadership, we would finally have justice and
    accountability for victims like Danyelle. Unfortunately, we
    could not seek justice for Danyelle, as you, this Congress, has
    intended and we hoped.
        Sadly, we learned from our attorneys at ForTheMilitary.com,
    that despite your hard work, Chairman Speier, and Congress'
    intent, the Department of Defense has decided not to allow
    claims from sailors on vessels or ships like Danyelle's. That
    is not what Congress intended; it is the opposite.
        I have also learned that they will not allow claims by
    sailors or soldiers when they are treated at military
    facilities outside the United States in places like Italy,
    Germany, and England, where we have big U.S. military
    hospitals. So, just because a military hospital is not in the
    U.S., the care doesn't have the same medical standard. This is
    wrong.
        The DOD issued guidelines that do not align with what
    Congress intended: justice for victims of medical malpractice.
    Worse, I am told, if a sailor like Danyelle were to file a
    claim and be denied, the appeal of the denial goes back to the
    panel made up by either Army, Navy, or Air Force. So, the
    military decides the cases and the appeals. That is like the
    home team getting to be their own referee in a football game.
    It is just not fair or what I think you intended. These denials
    should be heard by an independent Federal judge, like other
    Federal claims. That would be fair.
        Chairwoman Speier, the law, as written today, can't bring
    justice to Danyelle or me or my wife, but you can make changes
    that will allow for these other problems, like the appeal and
    where the hospital is located be corrected. Without these
    changes, the military will continue policing their selves; the
    military will decide if they are right or wrong. And worse,
    they will also determine the appeals if someone like me were to
    lose the case. I urge you to stop this now and correct these
    problems.
        I know you and other Congressmembers care about our
    military and want them to have the best medical care possible.
    And when that care causes their death or harm, they should be
    compensated for that harmful maltreatment. Please make these
    changes and bring our military and our families justice today.
        Danyelle was robbed of her life and her career. Let her
    mistreatment and death remind us that our military and families
    deserve justice now. Please fix the Stayskal Act to work the
    way you intended to bring justice to victims and their
    families.
        Thank you.
        [The prepared statement of Mr. Luckey can be found in the
    Appendix on page 82.]
        Ms. Speier. Thank you, Mr. Luckey.
        Again, this committee mourns with you the loss of your
    daughter.
        Ms. Silas, from the [General] Accountability Office, you
    are recognized.

    STATEMENT OF SHARON SILAS, DIRECTOR, GOVERNMENT ACCOUNTABILITY
                         OFFICE HEALTHCARE TEAM

        Ms. Silas. Thank you.
        Chairwoman Speier, Ranking Member Gallagher, and members of
    the subcommittee, I am pleased to be here today to discuss
    GAO's ongoing work reviewing DOD's monitoring of providers'
    qualifications and competence in military medical facilities.
    My testimony today summarizes preliminary observations we have
    developed during the course of our review.
        DOD provides health care to over 9 million beneficiaries
    through its Military Health System and employs a variety of
    physicians, dentists, and other providers that provide a range
    of healthcare services from routine examinations to complex
    surgical procedures. As such, it is imperative that DOD ensure
    that these providers are delivering timely quality care to
    military service members and their families; and that any
    concerns that may arise about the quality and safety of care
    being delivered by these providers is immediately addressed.
        Like other healthcare systems, DOD is responsible for
    ensuring that their providers deliver safe care to patients.
    Since the Military Health System's review of DOD provider
    quality-of-care issues in 2014, Congress has required DOD to
    transfer management of domestic medical facilities from the
    military departments to DHA [Defense Health Agency]. In 2019,
    DHA issued standardized clinical quality management procedures
    intended to ensure that individual providers, qualified and
    competent, deliver safe, high quality care to patients across
    all military departments.
        GAO is currently reviewing procedures that occur under
    DHA's clinical quality management: credentialing and
    privileging, focused preventional practice evaluations, and the
    review of potential compensable events--that is, patient safety
    events--that could result in payments to the patient or their
    families. And GAO found a number of instances where facilities
    and DHA were not adhering to procedures.
        First, as part of credentialing and assigning clinical
    privileges to providers, DHA policy requires military medical
    facilities to verify a provider's qualifications, such as
    education and licensure, when providers are first onboarded at
    the medical facility, and then, to periodically assess the
    provider's credentials and privileges thereafter.
        However, as part of our ongoing review, we have found that
    the selected facilities were not always following the DHA
    credentialing and privileging procedures. For example, we have
    learned that facilities were not consistently verifying that
    all of their providers' medical licenses were valid. In
    addition, it appears that, for about three-quarters of the
    applicable providers, these facilities do not have
    documentation that ongoing evaluations were conducted every 6
    months, as required.
        Second, military medical facilities are also required to
    conduct focused professional practice evaluations for cause,
    which are conducted when concerns are raised about a provider's
    care. Our ongoing review indicates that, for the 20 focused
    evaluations we reviewed, documentation that 2 key
    requirements--criteria and metrics--were not consistently
    documented in the focused evaluation plans. Both are important
    to determining whether the provider has successfully completed
    the evaluation.
        Lastly, based on our work to date, DHA has not always
    completed reviews of patient safety events that could
    potentially result in compensation or did eventually result in
    payments to the patient or their families. For example, for the
    12 cases we identified that did result in payments to patients
    or their families, for about half of the cases, DHA reviews
    were not completed within the 270-day requirement. And further,
    none of these cases were reported, as required, to HHS's
    [Department of Health and Human Services'] national repository
    that contains information on adverse actions taken against the
    provider and provider medical practice malpractice payments.
        Finally, our preliminary observations indicate that DHA
    does not sufficiently monitor facilities' adherence to its
    clinical quality management procedures. For example, DHA
    officials told us they run some reports related to
    credentialing and privileging from a database, but those
    reports are pretty limited. Furthermore, the database does not
    include all required documentation, such as the documents
    related to the provider ongoing evaluations.
        We also learned that DHA has not been monitoring a
    facility's implementation of its reviews of potential
    compensable events. Instead, DHA is focusing on only monitoring
    compensable event cases that have resulted in payments.
        As DHA continues to implement its clinical quality
    management procedures, ensuring DHA policies and procedures are
    properly adhered to by the military medical facilities can help
    to ensure that service members, military retirees, and their
    families receive safe, high quality care. And when the care
    does not meet those standards, DHA can hold those providers
    accountable.
        We will continue to assess these issues as part of our
    ongoing work, and we plan to make recommendations, as
    appropriate.
        Thank you. That concludes my prepared statement, and I
    would be happy to answer any questions that you might have.
        [The prepared statement of Ms. Silas can be found in the
    Appendix on page 89.]
        Ms. Speier. Thank you, Ms. Silas.
        We are in the middle of a roll call, but there are still
    300 Members who haven't voted. So, what I would like to do is
    give members the opportunity to ask some questions.
        Mr. Gallagher.
        Mr. Gallagher. I will start with Ms. Silas. Thank you,
    Madam Chairwoman.
        Can you tell us more about the shortcomings GAO found in
    DHA's efforts to monitor medical facilities' adherence to
    procedures? Why is this important? And what more could DHA be
    doing to make sure its facilities are adhering to those
    procedures?
        Ms. Silas. Certainly. So, as I mentioned, we looked at
    three different types of procedures. We looked at credentialing
    and privileging, in which we looked at a sample of 100
    providers from 4 military treatment facilities. We found
    instances of where, during the credentialing process, the
    facilities were not always verifying providers' licenses, as I
    mentioned in my testimony. So, for example, a provider could
    have licenses in multiple states, and we would find that some
    of the licenses haven't been verified.
        We also looked at ongoing professional practice
    evaluations. And these are routine evaluations that occur every
    6 months. We found that about three-quarters of the providers
    did not have documentation that these were even conducted.
        The other procedures that we looked at were under focused
    professional evaluations for cause. We looked at 20 evaluations
    from the 4 military treatment facilities. And we found, for
    example, that facilities were rarely documenting all of the
    required elements that are needed to determine whether or not a
    provider had successfully met all of the requirements for the
    evaluation.
        And then, lastly, we looked at patient safety events. We
    looked at two groups of events. We looked at potential
    compensable events. We identified 19 from the 4 facilities
    included in our review. And we found two issues of non-
    adherence.
        One, at the beginning of the review, facilities are
    supposed to consider taking an adverse privileging action
    against a provider, if the safety events were particularly
    egregious. And we found that there was no documentation that
    any consideration was ever taken.
        We also found that there were issues with kind of meeting
    the timeframes, the required timeframes, for these reviews. The
    facilities were supposed to conduct these potential compensable
    event reviews with 180 days of notification that the event had
    happened. And we found about 80 percent of those cases were not
    completed with that required time. We saw that, in these cases,
    the days ranged from 91 to 546 days in some instances.
        For the second group of patient safety events that we
    looked at, we identified 12 patient safety events that resulted
    in payments to either the service member or their families. We
    found that DHA did not complete these reviews for reporting out
    on these reviews within the required timeframe, which was 270
    days. We found that about half of the 12 cases were incomplete
    and exceeded that timeframe.
        But, in particular, what we found, too, is that, for those
    reviews that were not completed within the 270-day timeframe,
    none of those cases or those providers were reported to the
    National Practitioner Data Bank, which is HHS's repository for
    information on provider quality-of-care issues. So, if a
    provider has an adverse privileging action that's taken against
    them, it would be reported to HHS.
        And in this instance, there is a requirement within DHA
    procedures that, if these patient safety events that have
    resulted in payment exceed the 270-day requirement, then they
    need to be reported to the National Practitioner Data Bank.
        Mr. Gallagher. Well, thank you.
        I was going to cede my time to Mr. Jackson, but I am almost
    out of it. But we have, I think, 300 people left to vote. So,
    you should have a full 5 minutes if we go.
        So, in the 50 seconds I have remaining, I just would ask
    both Mr. Luckey and Mr. Del Barba, what is the single biggest
    lesson you have learned from this terrible and tragic
    experience that you have had with the Military Health System?
    In either order.
        Mr. Del Barba. Sir, the military healthcare system does not
    listen to the needs of the service members. It is that simple.
    We go and we ask for help, and we are denied treatment.
        Mr. Gallagher. Mr. Luckey.
        Mr. Luckey. My daughter shouldn't have to be denied
    medical. She signed up to serve her country. That is all she
    wanted, was to serve her country. And to be denied medical,
    that is not right.
        Mr. Gallagher. Thank you.
        Ms. Speier. And in both of your cases, a simple antibiotic
    given over a period of 5 to 7 days would have solved the
    problem, correct?
        Mr. Del Barba. Yes, correct. And I actually went to sick
    call and a physical therapist a total of 6 times before my body
    went septic.
        Mr. Luckey. And Danyelle, she went to medical several times
    and was turned away, and each time it got worse.
        Ms. Speier. Thank you.
        Ms. Houlahan, you are recognized for 5 minutes.
        Ms. Houlahan. I have been struggling with whether or not to
    even ask my prepared questions, mostly because I just want to
    say I am sorry and to express my deep appreciation and
    gratitude to you all for sharing your stories, and also, to
    your families for being there for your loved ones. And I know
    how hard this process is and how scary it is to tell your
    truth. So, thank you.
        I served in the military myself and grew up in a military
    family. And so, I know a couple few things about military
    health care.
        And I would like to understand better, maybe with my one
    question, from a parenting perspective, from a loved one's
    perspective, what can we be doing better to better integrate
    other people from a family into the decisionmaking process in
    health care and into, frankly, your experience when your
    daughter, unfortunately, did pass away and your experience of
    learning of her healthcare journey?
        I know that you are an adult. I know that your daughter is
    an adult. But I am struck by this need that we have to make
    sure that we are also including people who may not be
    physically present in your family, but who might want to be
    engaged and involved in the health care choices and processes
    that you are going through.
        So, I would love to know from you all if there is any
    lessons learned that we can be taking advantage of.
        Before I let you answer, it is reflective, Madam Chair, of
    our experience with Vanessa Guillen and her family as well.
    Different circumstances, but just the same kind of feeling of
    these are young people who are experiencing medical trauma or
    trauma in general, and how can we better involve the family
    members?
        Mr. Luckey. Tell us the truth. Don't try to hide. We want
    to know what happened. It is just not right how they treated my
    daughter. And me, personally, I don't want any other family to
    have to experience what we are experiencing now. Like I said,
    this has changed our whole life. Daily functions is difficult.
    Every day is a difficult day. My daughter should have never
    been denied medical treatment on the ship she served, the USS
    Ronald Reagan. That ship is named after the 40th President of
    the United States, and she wanted to serve on that ship.
        Ms. Houlahan. Thank you, sir.
        And, Mr. Del Barba.
        Mr. Del Barba. Yes. I think it is just accountability for
    myself and for other service members. The military isn't
    accountable for their actions. It is not fair to not only
    myself, but to my family, putting them through what they went
    through. It is sad and it is something that shouldn't happen to
    anybody.
        When you are sick and you need medicine, you should not be
    denied the medicine. You should be taken seriously. I
    understand there is people in training that try to get out of
    training and try to fake it, but it should be taken seriously.
    Every single person should be taken seriously. Because most of
    these people that aren't taken seriously aren't as lucky as I
    am; they don't have their lives anymore.
        Ms. Houlahan. No, and this is the thing that I am also
    struck by, is how young you are; how young your daughter was. I
    want to make sure that we are treating--when somebody goes to
    the doctor, they are going because they are genuinely sick. It
    should be the going-in assumption, and I know that that's not
    always the case with young people, and particularly, people of
    color, specifically. And so, I think that it is something that
    we should be very attentive and tuned to.
        Thank you. I yield back.
        Ms. Speier. The gentlewoman yields back.
        The gentleman from Texas, Dr. Jackson, is recognized for 5
    minutes.
        And my apologies to Ms. Escobar. You were in line at the
    head of the line.
        Dr. Jackson. Thank you, Madam Chair. I appreciate it.
        First off, thank you to the witnesses for being here. We
    really appreciate your testimony.
        To you, Mr. Del Barba, I can't tell you how sorry we are
    for the disability and the way this has changed your life.
        To Mr. Luckey, our condolences to you and your family. I
    can't imagine what it is like to have your child taken from you
    at such a young age like that.
        Coming from military medicine and having been a military
    provider, it's just horrifying to hear your stories, and I
    really appreciate your being here and telling us how this goes.
        I will say that, having come from military medicine, I can
    say that I think, overall, the military does a fairly good job
    in most aspects with health care, but the stories that you tell
    are unacceptable. They can never happen again, if we can
    prevent this. So, we have to do everything we can to figure out
    how we stop this.
        I think that practicing military medicine is very unique.
    It is a unique environment to practice in. Having come from
    that particular environment, I will tell you, there is a
    balance between operational requirements and the medical
    training and competencies that are required that is different
    than if you were just practicing medicine out in the civilian
    sector. There are other time constraints and other requirements
    that you have to factor into your schedule that, ultimately and
    unfortunately, take away from some of your ability to provide
    maybe the best care that you could for patients at times.
        I think, also, it is complicated by the fact that, in the
    military, we all have to watch for this, and I know the flag
    and general officers here from our medical community will agree
    with me on this, that it is difficult in military medicine
    sometimes to always be thinking about worst-case scenario, when
    you are really used to taking care of a very young and healthy
    population.
        And we don't see the population of patients that you see in
    the civilian sector with the very young and the very old, and
    some of the really sick folks, and some of the horrible, tragic
    things that happened to you, Mr. Del Barba, and to your
    daughter, Mr. Luckey. Those are things that are more rare in
    the military practice environment than they are in the civilian
    practice.
        But that is on us to figure out how to fix that. That is on
    us to go out and make sure that we are getting that training
    out in the civilian sector and that we are exposing ourselves
    to that type of stuff, so that we don't put your family
    members, your loved ones, in a situation where they are the
    victims of our inability to recognize those kinds of things.
        And I will say that there is a little bit of a component on
    us coming together with the three branches of the military
    recently, trying to combine in practice as one, and learn how
    to approach things as one organization, not three separate
    organizations--the Army, the Navy, and the Air Force.
        So, Ms. Silas, I was going to ask you a question. In your
    experience, what part of the issues you were discussing
    earlier--with the credentialing issues, the training
    shortfalls, the lack of quality assurance, things of that
    nature--how much of that is related to our efforts right now? I
    mean, we started this effort back in 2012, I think, to bring
    military medicine under one umbrella with DHA. How much of it
    is related to the fact that we still have not got there where
    we have got everybody together under one umbrella, and how much
    is because we are dropping the ball because we don't have clear
    responsibilities in certain areas?
        Ms. Silas. Thank you for the question.
        I think it is very much related. I think that--and again,
    these are all preliminary observations from our ongoing work--
    the sense that we get from this review is that:
        One, the facilities are not, generally are not adhering to
    a lot of the procedures for the credentialing, privileging, and
    the safety events, and the focused evaluations, the things that
    we looked at.
        The policies and procedures that were published, I think
    there is a lack of clarity around those procedures. There is
    definitely the sense of moving and trying to bring the
    different military services under DHA. I think there needs to
    be some clarification around the procedures and the language
    that is used in there. Some of the facilities were interpreting
    some of the language in the procedures differently.
        There is a lack of awareness of some of the different new
    procedures. I mean, this is 2019 when they were implemented. I
    think that a lot of the facilities are adjusting to that.
        I also think, at least at the DHA level, they are really
    still amping up their monitoring of facilities' adherence to
    these procedures. They are trying to still ramp up capacity.
    They are trying to determine what information they need; where
    that information is located, and then, the tools they need to
    actually conduct the monitoring.
        Dr. Jackson. Thank you. I appreciate that.
        And I will just close by saying, you know, I do think it is
    a problem, especially when you are looking at our other
    providers--our medics, our corpsmen, our physical therapists,
    our PAs [physician assistants], things of that nature--with
    them taking care of the mostly healthy, young population that
    we have right now.
        I know, when I was a physician in charge of those types of
    folks, it was one of my biggest fears that we were going to
    miss something like that, because the mindset wasn't out there
    looking for it.
        So, we cannot excuse what happened to you and your
    families. We will try our best to fix this, to make this right.
        And once again, I really appreciate your time for being
    here and telling us your story. It makes a really big
    difference.
        With that, I yield back, ma'am.
        Ms. Speier. There are still 146 Members that haven't voted.
        Would you like to go forward, Ms. Escobar?
        Ms. Escobar. I would like to, yes.
        Ms. Speier. Ms. Escobar is recognized for 5 minutes.
        Ms. Escobar. Thank you, Madam Chair.
        I, first, want to say to Mr. and Mrs. Luckey how incredibly
    sorry I am for your loss. I cannot imagine what you all have
    had to endure.
        To Mr. Del Barba and his family, also, so incredibly sorry
    for what you have endured. And it has taken, I know, tremendous
    courage to be here in front of us and to tell your story, and
    to hold us accountable. And I really appreciate that you are
    doing that, and that you are here to tell Congress that we need
    to do something. So, we hear you loudly and clearly.
        I also want to recognize in the audience Mayra Guillen, who
    is the sister of the late Vanessa Guillen. Thank you for being
    here. She is here with counsel.
        I have a question for Ms. Silas. Just listening to the
    litany of issues and the lack of following procedure, and the
    amount of time that it has taken to understand and digest and
    follow policies and processes, I cannot wrap my head around why
    that is so.
        During this whole process, as you were taking a look at all
    of this, what do you think is behind that? Is it lack of
    resources? Is it a culture that refuses to change? Is it still
    too much bureaucracy? What are your thoughts?
        Ms. Silas. I think that there is a couple of things going
    on.
        One is this is a massive transition that is happening. And
    it is going to require not only kind of putting the right
    procedures in place and the tools that I mentioned, but also it
    is going to mean a change in culture.
        And it has been a couple of years now, and we have the
    policies and we have the procedures in place. There definitely
    needs to be a look at those procedures to ensure that there is
    some clarity around some of the language that is in there. I
    think the staff at the facility level is definitely trying to
    adhere to these procedures as well as they can, but the
    procedures are not necessarily written as clearly as they could
    be. And so, that is leading to a lot of interpretation.
        And again, as I mentioned, DHA is still continuing to ramp
    up their monitoring. One of the things that I think we found in
    our review is there is a centralized database, CCQAS
    [Centralized Credentials Quality Assurance System], where a lot
    of the information around credentialing and privileging is
    supposed to be entered. But it also doesn't contain a lot of
    information or documentation that is needed for some of the
    other processes or procedures that need to be monitored.
        So, I think there is just still a lot of work needed to
    kind of lay the groundwork in terms of a centralized data
    system where information is going to be put, and that DHA, in
    their monitoring, understands where that information is and,
    then, how to use it.
        Ms. Escobar. I appreciate that. It is just mind-boggling
    that it has taken the Federal Government this long really to do
    right by the people who are in our care or should be in our
    care.
        A second question about the current malpractice claims
    process. How can we improve it to better allow for
    accountability and protections of victims of negligence?
        Ms. Silas. Well, the scope of our current review does not
    include a review of malpractice claims. The new law that is
    governing malpractice claims is relatively new. And so, there
    weren't any cases at the time within the scope of the timeframe
    for our review to include that. So, I can't really speak
    directly to that.
        Ms. Escobar. It would be interesting to follow, I think, to
    make sure that we understand, going forward, whether that is as
    efficient a process as needs to be. Because that is, in my
    view, a core function of accountability and a way for families
    to try to achieve some justice.
        With that, I am out of time.
        Thank you all again, especially to the Del Barba family, to
    the Luckey family. Really appreciate your presence here today.
    Your testimony was really powerful.
        Madam Chair, I yield back.
        Ms. Speier. The gentlewoman yields back.
        There are 99 persons who have yet to vote. 69? Oh, I can't
    read. All right.
        So, we are going to stand in recess. It will probably be a
    little more than like an hour and 15 minutes because we have a
    series of votes. And then, we will return and continue the
    questioning.
        Thank you.
        [Recess.]
        Ms. Speier. The Military Personnel Subcommittee will
    reconvene. And Ms. Silas is back. All right.
        Mrs. Bice is here. Let's see. We left off with Ms. Escobar.
    We will now go to Mrs. Bice from Oklahoma for 5 minutes.
        Would you like to pass for a moment?
        Mrs. Bice. Madam Chair, if that would be okay.
        Ms. Speier. Sure. Of course.
        We will go to Dr. Wenstrup.
        Dr. Wenstrup. Two seconds.
        Ms. Speier. Okay.
        All right. Mrs. Bice, you are recognized for 5 minutes.
        Mrs. Bice. Thank you, Madam Chairwoman.
        And I want to say, first of all, to the Luckey family, my
    condolences to all of you. I can't imagine getting that knock
    at the door. So, please know that my heart and prayers go out
    to both of you.
        And, Mr. Del Barba, you and I had the chance to speak
    briefly. As the mother of a 21-year-old myself, I cannot
    imagine the suffering that you go through and how traumatic
    that has been for your parents. And certainly, your story is
    incredibly important for us to all hear, so that no other
    service member has to endure the type of pain that you have
    endured over these last months and years.
        Before I ask a couple of questions, I think, to Ms. Silas,
    I do want to ask, can you talk a little bit about your recovery
    from the infections that you had?
        Mr. Del Barba. Yes. Of course.
        So, I was in the ICU [intensive care unit] at Fort Sam
    Houston, Brooke Army Medical Center, for 100 days. I did have
    43 surgeries. I was discharged from the hospital in May, around
    Memorial Day weekend.
        I learned how to walk on a prosthetic; did a lot of
    strength training, and stuff, for my leg. It took me until
    about March--so, almost a year--to finally walk and be able to
    come home to my family and friends.
        Yeah, the wounds have taken over 2 years to heal, and the
    scars will never look anything like normal ever again in my
    life. But they are still healing. Honestly, to this day, they
    are still so very fragile; my leg is. And I still go to PT
    [physical therapy] every week for my right leg, as I have nerve
    damage on my right leg where I can't really walk correctly
    because of my ankle.
        And, yeah, that is pretty much it.
        Mrs. Bice. Thank you for that.
        This question is, actually, to Ms. Silas. The GAO report
    has stated that some facilities have had cases that resulted in
    payments that have exceeded the time required for those
    reviews. Can you elaborate on the process which should be
    implemented to improve the delays? And was Fort Benning
    included in the review on this GAO report?
        Ms. Silas. Well, first, I can't identify the military
    treatment facilities that we included in our review. It was
    something that we negotiated with our clients as part of this
    review, because it is important to have some confidentiality,
    so that folks, the staff that we are talking to, will be
    forthcoming in the information.
        So, I can say that we did include, of the four facilities,
    two of the facilities are on the West Coast and one was on the
    East Coast and one was in the South.
        In terms of the patient safety events that resulted in
    payment, those reviews are conducted by DHA. Once the military
    treatment facilities have determined that there hasn't been a
    standard of care met, DHA has kind of what I call two bites of
    the apple to do some additional reviews. And they have 270 days
    to conduct these reviews.
        And what we found, as I mentioned in my testimony, about
    half of the 12 cases that we included in our review exceeded
    that 270-day timeframe. And the range of days that we found for
    those cases was from 420 days to up to 746 days. And the clocks
    for those start as soon as the payments have been made, either
    to the patient or the families.
        Mrs. Bice. And quick followups. You mentioned that you
    reviewed four facilities. Are the rest of these facilities
    across the country being evaluated in some way, shape, or form?
    And are they being graded on their performance by these
    metrics?
        Ms. Silas. Not as part of our review. We limited our review
    to the four selected military treatment facilities.
        Mrs. Bice. Why only four?
        Ms. Silas. We made the selection based on, one, limiting
    it, so we were able to conduct the review in a reasonable
    amount of time. We had to look through a number of records to
    look at all three types of procedures.
        But we did try to ensure that, at least with the providers,
    we looked at a sample of 100 providers with a non-generalizable
    sample. We took a sample of 25 providers from each of the 4
    military facilities. And then, for the focused professional
    evaluations and the patient safety events, we selected the
    total number of patient safety events that occurred at those
    four facilities.
        Mrs. Bice. Okay. Thank you.
        And, Madam Chair, my time has expired. I yield back.
        Ms. Speier. The gentlewoman yields back.
        The gentleman from California, Mr. DeSaulnier, is
    recognized for 5 minutes.
        Mr. DeSaulnier. Thank you, Madam Chair, and thank you to
    the ranking member, for having this hearing and being so
    tenacious, as you always are.
        Mr. Del Barba and family, thank you for being here and your
    courage. Dad, thank you for just telling me your story as well.
        Mr. Luckey, Derrick, thank you and your wife and your
    family for having my staff be part of your life. I've talked
    about this often.
        So, tell me, how long was it before Danyelle got sick and
    when she saw a doctor?
        Mr. Luckey. Danyelle had been going back and forth to
    medical, I believe, from 10/3 to 10/9. She had been going back
    and forth to medical. And she kept being turned away. And I
    believe, on the day she died--wait a few minutes.
        Mr. DeSaulnier. Well, as I remember the story, she was in
    for 5 months. She was on the ship for 2 weeks. Ten days? Two
    weeks.
        Mr. Luckey. Yes, she was on the ship for 2 weeks, and she
    became sick. And she kept going back and forth to medical for
    several days until the day she died. And that is when they
    figured out that she had died, I guess.
        Mr. DeSaulnier. Right. Tell my colleagues the story about
    when she was lying on the ground and one of the medical
    shipmates said----
        Mr. Luckey. Danyelle was trying to get to medical, but the
    corpsman would not help her. So, her sailor brothers and
    sisters took her to medical because she could no longer walk.
    And she, basically, laid on the floor. If that wasn't for her
    sailor brothers and sisters, that is where she would have died,
    right there on the floor.
        Mr. DeSaulnier. So, you have heard from some of her friends
    who were on that ship, but at your house I was lucky enough to
    meet one of her best friends. Tell us--their side of the story
    is not consistent with the Navy's side of the story of what
    happened factually.
        Mr. Luckey. Well, I believe Danyelle was being evacuated to
    another destination, but the person who we spoke to is saying
    that they didn't see her get off the aircraft. So, basically,
    she died on the Reagan. That is what they saw.
        Mr. DeSaulnier. So, you mentioned in your opening
    testimony, in one of the things I think we need to change on
    this, is she was not in a medical facility onshore in the
    United States of America. So, your claim was denied because she
    was on a U.S. Navy ship, is that correct?
        Mr. Luckey. That is correct.
        Mr. DeSaulnier. And that is one of the things that needs to
    be changed in this?
        Mr. Luckey. That is correct. The Congress intended to bring
    justice and accountability to military malpractice. However,
    DOD went and narrowly interpreted your intent by denying all
    victims that were harmed on ships outside of the U.S. This is
    not fair.
        Mr. DeSaulnier. How did you feel when you found that out? I
    mean, you sent your daughter out to serve in the military, and
    then, on this, seems like a technicality that makes no sense,
    you couldn't seek justice.
        Mr. Luckey. No. This could have been prevented. This could
    have been prevented if they would have gave her medical
    treatment.
        Mr. DeSaulnier. Right. But, even after that, your ability
    to seek justice with your attorney----
        Mr. Luckey. It has been difficult. It has been very, very
    difficult.
        Mr. DeSaulnier. Do you know of any repercussions to the
    people who were in the chain of command who denied--were they
    promoted?
        Mr. Luckey. I am pretty sure someone has been--how should I
    say this? You know----
        Mr. DeSaulnier. Promoted?
        Mr. Luckey. That is correct. I believe a lot of them has
    been promoted, including the captain of the Reagan, Captain
    Donnelly. I believe they have been promoted, and the other
    service members, I believe they may still be in the military to
    continue their career, while my daughter lost her life and her
    career.
        Mr. DeSaulnier. Thank you, Mr. Luckey.
        My time is up. I yield back. Thank you, Madam Chair.
        Ms. Speier. The gentleman's time has expired.
        The gentleman from Ohio, Dr. Wenstrup, is recognized for 5
    minutes.
        Dr. Wenstrup. Thank you.
        I just want to express my condolences to Mr. Del Barba and
    your family and the entire Luckey family. I just want to say
    that I thank you for being here today.
        And know that the effort will be made from this end, as
    best we can, to make sure that all of our troops always have
    the right providers in the right places with the right
    credentials, and the appropriate complement of all the tools
    that they need to treat people at all times.
        God bless you all. You are in my thoughts and prayers.
        I yield back.
        Ms. Speier. The gentleman yields back.
        The gentlelady from California, Ms. Jacobs, is recognized
    for 5 minutes.
        Ms. Jacobs. Well, thank you so much, Madam Chair.
        And I want to thank all the witnesses for being here and
    telling what are not easy stories to have to relive. And I am
    so sorry that you have to keep doing it to get us to take
    action.
        Ms. Silas, in a recent GAO report that was published on
    September 17, 2018, reported that MHS largely uses separate
    measures for direct and purchased care on its dashboards and
    tracks the quality of care delivered by civilian providers and
    purchased care in the aggregate, rather than individually; that
    MHS lacks the information it needs to make comparable
    assessments of the quality of care delivered across the MHS as
    a whole. To your knowledge, is this report still accurate? And
    what, if anything, has the Military Health System done to
    overcome this information gap?
        Ms. Silas. So, to my knowledge, I believe that some of the
    recommendations are still open from that review. I can't speak
    directly to the particular recommendations, but I am familiar
    with some of the findings from that report. But I am glad to
    take this for the record and get back to you about the status
    of the recommendations on that and what progress has been made.
        [The information referred to was not available at the time
    of printing.]
        Ms. Jacobs. Thank you. I appreciate that.
        And one other question for you is: In reviewing these
    medical treatment facilities' clinical quality management
    efforts, has GAO discovered any reasons why facilities are not
    consistently adhering to DHA procedures?
        Ms. Silas. Yes. I mean, based on our preliminary
    observations--again, this work is ongoing--it seems to appear,
    again, that there is a lack of clarity in the procedures. For
    example, we found that some of the language that is used in
    there, in the procedures, is not consistent. There is also a
    lack of definition. Some of the facility staff had different
    interpretations of what was initiation of a potential
    compensable event and what was the end of a potential
    compensable event review. And then, there was just a general
    kind of lack of awareness or a lack of understanding of the
    procedures.
        Ms. Jacobs. Okay. Thank you.
        Well, I will look forward to your answer for the record in
    my first question.
        And, Madam Chair, I yield back.
        Ms. Speier. The gentlewoman yields back.
        I will now ask questions for 5 minutes.
        Mr. Del Barba, is it true that at one point you were so
    depressed that you attempted to take your life?
        Mr. Del Barba. Yes, November 12, 2019, which was the same
    year as the accident happened.
        Ms. Speier. And when you were seeking care, your drill
    sergeant was reluctant to take you, is that correct?
        Mr. Del Barba. Yes, correct. So, one of my drill sergeants
    was notified by my peers in the barracks that I was not feeling
    good and that I needed to go to the hospital. He proceeded to
    tell this battle buddy that, ``Has he already gone to sick
    call?'' And the battle buddy said, ``Yes, a couple of times.''
    And he said, ``Well, there's nothing we can really do.'' This
    was 24 to 48 hours before my body went into septic shock.
        Ms. Speier. So, if I remember correctly, on Friday, you
    went to sick call and complained about a sore throat and pain
    in your leg.
        Mr. Del Barba. So, Thursday, I went to sick call and
    complained about sore throat and pain in my legs. I was swabbed
    for strep A. There are two types of swabs they do. One comes
    back rapid test, about 5 to 10 minutes. The other one takes 24
    to 48 hours. Rapid test came back negative. The next day, that
    24 to 48 hour test came back positive. However, in the system,
    whoever wrote that note said, ``Notify Monday in the morning.''
    And this was on Friday. They waited, they wanted----
        Ms. Speier. But it was in your record at that point?
        Mr. Del Barba. It was in my record, yes.
        Ms. Speier. And then, on Sunday, you went to the ER
    [emergency room], and the doctor showed you enough time, 3
    minutes, to say that you were fine, and evidently, didn't even
    look at your record because it would have been in your record,
    correct?
        Mr. Del Barba. Yes, correct. I did--I went to the ER doctor
    on Sunday, February--I want to say it was February 9th. Tenth.
    February 10th. Excuse me. And I saw the doctor for--he clocked
    in and clocked out for 3 minutes, and that was the time, and he
    told me I was fine and that my legs were sore due to the
    running. And he just prescribed me throat lozenges for my sore
    throat.
        Ms. Speier. That is such gross incompetence.
        Mr. Del Barba. Yes.
        Ms. Speier. And it doesn't take a QAI for 3 years to
    determine that that is gross incompetence.
        Now, if I am not mistaken, you also were mistreated by the
    drill sergeant who forced you to go up the stairs at the
    hospital, is that right?
        Mr. Del Barba. Correct. So, I mean, I experienced a lot of
    bullying and harassment from the drill sergeants.
        That Sunday, when I went to the doctor at sick call, it
    wasn't the emergency room, but it was up a flight of stairs. My
    legs did feel like sandbags and they were hurting. They were in
    so much pain that I wanted to take the elevator up, but, you
    know, as privates, we are advised to take the stairs. So, I
    literally had to have my battle buddy carry, not carry me on my
    shoulder, but I had to put a lot of weight on his shoulder just
    to get up those flights of stairs, to be seen for 3 minutes by
    this doctor.
        Ms. Speier. And after you were diagnosed with strep, was
    there an outbreak?
        Mr. Del Barba. Yes, correct. So, on Tuesday, February 19th,
    Martin Army Hospital Surgeon General, Lieutenant Colonel Ethan
    Miles, contacted my parents. I was in a coma at this time.
    Fifty-six positive cases in my company, Bravo Company; 405
    positive cases in 2 brigades at Fort Benning.
        Fort Benning requested an order of 10,000 units from Pfizer
    at the estimated cost of $1.7 million. Pfizer told Fort Benning
    they only had 60,000 units available for the entire world.
        Private Christopher Huss, who was also in my company, he
    died January 22nd due to sepsis. He had a heart attack.
        Ms. Speier. Again, Dez, you are a remarkable young man. And
    this is such a gross disservice to you and your family. And I
    hope that our colleagues who are here listening to you
    recognize that there are changes that have to be made.
        Mr. Luckey, did the Navy ever take responsibility for their
    failures?
        Mr. Luckey. No, not at all.
        Ms. Speier. Did the Navy tell you if they made any changes
    in response to Danyelle's death?
        Mr. Luckey. We haven't heard anything from the Navy.
        Ms. Speier. All right. Just for the record, Mr. Luckey,
    there is something called legislative intent. And since I was
    the author of the legislation, the intention was to recognize
    that, when you are not in a war zone, when you are at a
    military medical facility, whether it is in the CONUS
    [continental United States] or if it is in Europe or if you are
    on a ship, you should be receiving quality care. If there is
    malpractice associated with that care and you are not in a war
    zone, then you should be eligible for compensation under the
    Stayskal Act. That was my intention. That is what passed the
    House and the Senate and became law. So, if we have to clarify
    that in the NDAA this year, we will attempt to do that.
        Mr. Luckey. Thank you.
        Ms. Speier. Ms. Silas? Am I pronouncing it right or wrong?
        Ms. Silas. Silas, yes, it is Silas.
        Ms. Speier. Ms. Silas, thank you for your outstanding work.
        I want to ask you a question. If it has been over 270 days
    and there is a QAI--there might even be 2 QAIs that are not in
    synch--but it is over 270 days, is there a requirement that it
    be reported to the national database?
        You are muted, I think.
        Ms. Silas. Oh, can you hear me now?
        Ms. Speier. Yes.
        Ms. Silas. Okay. Yes, that is correct. They need to be
    reported to the National Practitioner Data Bank.
        Ms. Speier. And what is the penalty if it is not?
        Ms. Silas. I am not sure. I don't think there is a penalty
    for it.
        Ms. Speier. Right.
        Ms. Silas. Yes.
        Ms. Speier. Okay. You also reference that, in your review,
    you found selected facilities did not adhere to the DHA
    requirements for these 19 potentially compensable events, event
    reviews, in 2 key areas.
        First, at the initiation of the reviews, the selected
    facilities did not document their consideration of whether to
    remove the providers from care and take adverse privileging
    action against any of the providers in your review. So, it
    wasn't documented, and you have no reason to believe that there
    was action taken, is that correct?
        Ms. Silas. That is correct. I mean, based on our reviews,
    the only way, because we are reviewing documents, the only way
    that we know that any consideration was taken is that it needs
    to be documented, and it should be documented in the file. And
    for all of those reviews, we did not have any documentation of
    that consideration of taking an adverse privileging action or
    pulling that provider offline.
        Ms. Speier. And whether it was actually a compensated event
    or a potentially compensable event, it should be documented?
        Ms. Silas. Yes.
        Ms. Speier. And there should be an effort made to assess
    whether or not the provider should be removed from providing
    care?
        Ms. Silas. Exactly. Because even in the patient safety
    events that result in payment, they start out as a potential
    compensable event. So that that consideration should always be
    taken.
        Ms. Speier. All right. I thank you.
        I have exceeded my time.
        We will now thank all of our witnesses who have done a
    remarkable job under, I think, very painful circumstances. I
    think you have heard from every member on this committee that
    we are deeply troubled by the events.
        We are saddened by the loss of Danyelle's life. It was an
    unnecessary loss of life. It was not a complicated set of
    circumstances.
        And to Mr. Del Barba, what you have endured is just
    unforgivable, and I just hope the rest of your life is
    everything you want it to be.
        And I hope, by virtue of both of your experiences here
    today, that the military is going to recognize it has an
    obligation; it has an obligation to communicate with the
    families and the service member who have been injured or there
    has been a loss of life. There has to be more transparency, and
    we have got to make sure that we have quality care provided to
    our service members. It is just fundamental to everything that
    we believe in.
        So, again, I thank you.
        We are now going to recess for just a few minutes to allow
    our next panel----
        Mr. Luckey. Excuse me. Can I read this, please?
        Ms. Speier. Mr. Luckey, yes?
        Mr. Luckey. I have this here. This is the Corpsmen's
    Hospital Pledge.
        ``I solemnly swear myself before God and these
    witnesses''--these corpsmen raised their right hand--``I
    solemnly pledge myself before God and these witnesses to
    practice faithfully all of my duties as a member of the
    Hospital Corpsmen. I hold the care of the sick and injured to
    be a privilege and a sacred trust and will assist the Medical
    Officer with loyalty and honesty. I will not knowingly permit
    harm to come to any patient.''
        And this is what they did to my daughter.
        ``I will not partake nor administer any unauthorized
    medication. I will hold all personal matters pertaining to the
    private lives of the patients in strict confidence. I dedicate
    my heart, my mind, and strength to work before me. I shall do
    all within my power to show myself an example of all that is
    honorable and good throughout my naval career.''
        My daughter's career was taken from her, while these people
    here continue with their lives and their career.
        Thank you.
        Ms. Speier. Thank you, Mr. Luckey. Thank you both.
        [Recess.]
        Ms. Speier. We are now going to welcome our second panel:
    Lieutenant General Ronald Place, Director of the Defense Health
    Agency; Lieutenant General R. Scott Dingle, Surgeon General of
    the Army; Rear Admiral Bruce Gillingham, Surgeon General of the
    Navy; Lieutenant General Robert I. Miller, Surgeon General of
    the Air Force.
        Welcome.
        Lieutenant General Place, do you want to begin?

    STATEMENT OF LTG RONALD J. PLACE, USA, DIRECTOR, DEFENSE HEALTH
                                 AGENCY

        General Place. Chairwoman Speier, Ranking Member Gallagher,
    distinguished members of this subcommittee, I am honored to
    represent the Defense Health Agency, and its dedicated military
    and civilian medical professionals in the Military Health
    System, in describing our comprehensive enterprise approach to
    ensuring high quality of care in the Military Health System,
    the MHS.
        However, before doing so, I have added some handwritten
    comments, if I could, because I think it is important for me to
    address Mr. Del Barba and the Luckey family.
        Your testimony today was compelling and heartbreaking. It
    is clear that you have suffered tremendous losses, and I
    apologize for those losses. I take it very seriously when there
    are bad outcomes from a medical care provider within our
    system. I am deeply committed to ensuring we learn from your
    losses, so we can better our healthcare system, so we can have
    fewer losses. My goal is to make this health system stand as
    one of the finest, if not the finest, in the Nation. And those
    who serve their country should expect that.
        I say this not only as the leader of the Defense Health
    Agency, but as a husband, father of two currently serving
    service members, and a grandfather whose family also receives
    their care in our system. You have my word.
        Madam Chairwoman, the DHA now exercises authority,
    direction, and control over all MTFs [military treatment
    facilities] worldwide. Quality starts with the individual
    medical personnel we recruit and onboard every day. The
    credentialing and privileging process serves as the foundation
    for high quality and safe care by ensuring qualified and
    competent staff deliver care in a manner consistent with their
    education and training.
        The DHA oversees accreditation and certifications for
    hospitals and clinics, as well as specialty-specific
    certifications and quality assurance programs. In fact, the DOD
    participates in multiple civilian accreditation programs and is
    held to the same standards as our private sector healthcare
    colleagues. I will mention just a few of those programs here,
    while my written testimony provides a more comprehensive list.
        The DHA manages an enterprise-level contract for the Joint
    Commission for all MTFs, and all DOD MTFs are fully accredited.
    At the specialty level, the MHS participates in numerous
    voluntary healthcare collaboratives that help drive improvement
    and allow us to compare our performance with others. These
    include the National Surgical Quality Improvement Program,
    NSQIP, a collaborative led by the American College of Surgeons;
    the National Perinatal Information Center, NPIC, a consortium
    of more than 80 health systems with high volume obstetric care.
    The list goes on and on--from laboratories to blood banks and
    pharmacy programs, and so much more.
        For patient safety, our DHA programs, similarly,
    incorporate strategies and practices from the private sector
    and use widely accepted measures for performance. Over the last
    4 years, the DOD has seen improved patient safety performance.
    Again, specific performance improvements were noted in the
    testimony submitted by the Department.
        While I am confident in our processes for ensuring high
    quality care and proud of our performance as measured against
    peers in American medicine, the Department also has clear
    policies and procedures in place when patient safety incidents
    occur.
        The Department has taken steps to methodically implement
    section 731 of the FY [fiscal year] 2020 NDAA, which amended
    the Military Claims Act by allowing members of the uniformed
    services, or their representatives, to file claims for
    compensation for personal injury or death caused by the medical
    malpractice of a DOD healthcare provider in an MTF. In those
    claims where a claimant disagrees with the determination, we
    have an appeals process with appeals Board members who have no
    prior connection with the cases they are reviewing.
        In cases where a military medical malpractice claim Active
    Duty, disability, or death payment is made, additional reviews
    are required by the DHA headquarters, including an external
    peer review and specialty consultant review. Following these
    additional reviews, I am responsible for rendering a final
    provider determination and reporting decisions.
        The Department is grateful for the support and oversight
    from this subcommittee on patient safety and quality-of-care
    programs in the Military Health System. We are confident that
    recent changes put in place within the MHS properly respond to
    both the spirit and letter of legislatively directed changes.
    And we will continue to closely manage these vital programs on
    behalf of the service members and families we are privileged to
    serve.
        I appreciate the opportunity to appear before you today,
    and I look forward to your questions.
        [The prepared statement of General Place can be found in
    the Appendix on page 105.]
        Ms. Speier. All right. Lieutenant General Dingle.

     STATEMENT OF LTG R. SCOTT DINGLE, USA, SURGEON GENERAL OF THE
       ARMY, AND COMMANDING GENERAL, UNITED STATES ARMY MEDICAL
                                COMMAND

        General Dingle. Chairwoman Speier, Ranking Member
    Gallagher, and distinguished members of the subcommittee, thank
    you for the opportunity to speak to you on behalf of our Army's
    health professionals.
        The committee's investment, combined with the Army's
    deliberate emphasis on patient safety, enhances medical
    readiness, and I thank you.
        I appreciate the first panel expressing their personal
    stories and testimonies. It resonated because people are our
    number one priority.
        My unwavering commitment as the 45th Army Surgeon General
    is to ensure the health and safety of our soldiers and families
    first and foremost. Maintaining the confidence at military
    treatment facilities or at our operational sites requires a
    dedicated total Army Medicine force. This is about taking care
    of our people.
        Together with the Defense Health Agency, we will accomplish
    these goals by focusing on advancing toward zero preventable
    harm in the delivery of medical care. As a key enabler, Army
    Medicine is committed to our high reliability organizational
    mission and the operational environment, and the core
    competencies of patient safety. In conjunction with the Defense
    Health Agency, we are advancing toward zero preventable harm
    through training and oversight across the continuum of health
    care to maximize reduction of medical risk.
        Army Medicine is also synchronized with the Defense Health
    Agency to meet the needs of the operational force. From the
    foxhole to the fixed facility, Army Medicine follows one
    clinical quality management standard.
        The military department's operational units and the medical
    treatment facilities are inextricably linked. The medical
    treatment facility is the premier readiness platform for our
    medical personnel to hone and sustain the mission-essential
    clinical skills needed to perform their duties downrange.
        My enduring responsibility is unchanged: to exercise my
    duties as the Army Secretary's senior medical advisor and
    medical integrator by certifying Army health care capabilities
    are trained and ready.
        Army Medicine's focus has pivoted to the operational
    medicine, but we will ensure operational standards are in
    accordance with the policies, guidelines, and procedures.
    Patient safety is essential for a strong, healthy, and
    resilient Army, and is the most critical indicator of our
    readiness to deploy, fight, and win our Nation's wars.
        In closing, Army Medicine is committed to people first. We
    remain vigilant, as we strive towards reduced preventable
    medical errors.
        I appreciate the subcommittee's work and the continued
    support to our soldiers, families, and your longstanding
    support to Army and Army Medicine. Army Medicine is Army
    strong.
        I look forward to your questions.
        [The prepared statement of General Dingle can be found in
    the Appendix on page 114.]

    STATEMENT OF RADM BRUCE L. GILLINGHAM, USN, SURGEON GENERAL OF
          THE NAVY, AND CHIEF, BUREAU OF MEDICINE AND SURGERY

        Admiral Gillingham. Thank you, Chairwoman Speier.
        First and most importantly, Mr. Luckey and Mr. Del Barba,
    thank you for your powerful testimony. I know this wasn't easy,
    and we are grateful for the courage you demonstrated. I learned
    a lot listening to your statements, and as the leadership of
    the Military Health System, we needed to hear from you.
        To Mr. Luckey and the Luckey family, you suffered a
    profound loss with Danyelle's tragic death. I know you continue
    to grieve. I want you to know that we, Danyelle's Navy family,
    mourn her passing as well. The loss of a shipmate and family
    member is heartbreaking. It impacts all of us who serve in
    America's Navy.
        Madam Chairwoman, Ranking Member Gallagher, members of the
    subcommittee, thank you for conducting this hearing on patient
    safety and quality of care. You, rightfully, hold us
    accountable to provide service members and families health care
    that is high quality, safe, and accessible.
        Please know we never waver from our commitment to protect
    the health of those who go in harm's way. As part of our solemn
    obligation to these sailors, Marines, and their families, we
    are continuing our strong commitment to high reliability within
    Navy Medicine, appropriately, in conjunction and collaboration
    with the Defense Health Agency, Army, and Air Force.
        High reliability practices are critical for success in
    high-risk Navy environments, such as submarines, aircraft
    carriers, and diving operations, in order to enable teams to
    avoid the detrimental impacts of mistakes. We have emulated
    their example within the Military Health System because we
    recognize that the three HRO [high reliability organization]
    pillars--leadership engagement, continuous process improvement,
    and a culture of safety--directly translate to better outcomes
    and the sustained delivery of high quality patient care.
        For me, this commitment to HRO was deeply rooted in my
    early professional development. As a pediatric orthopedic
    surgeon, I was mentored by a highly regarded Navy orthopedist,
    Captain John Webster, who demonstrated high reliability in all
    aspects of patient care. In my view, he was ahead of his time
    in applying key principles of safety and quality in the
    operating room.
        But he also recognized that he couldn't do it alone. He
    knew that patient care, and the relentless pursuit of better
    outcomes and fewer errors, is interconnected and complex and
    involves teams of people--people working together in a culture
    of trust, cooperation, and mutual respect for a common purpose.
    And I should add, all empowered to speak up about issues
    impacting the safety of the care we deliver.
        I have seen the powerful impact of high reliability
    throughout my career--as a surgeon operating in commands such
    as Naval Medical Center San Diego; in combat, where I led a
    surgical shock trauma platoon into Khatun, Iraq, during the
    Second Battle of Fallujah; in command of military medical
    treatment facilities with large medical staffs; and as the
    fleet surgeon guiding the provision of care in the naval
    operational forces; now, in my current role as the Navy Surgeon
    General. These experiences inspire me to broaden and deepen our
    efforts to eliminate preventable patient harm.
        For Navy Medicine, high reliability represents a commitment
    to safety, quality, resiliency, and operational success
    wherever naval forces operate. To this end, we established the
    Navy Medicine Quality and Safety Leadership Academy;
    specifically equipped our leaders with HRO tools to
    communicate, anticipate, identify, resolve, and then,
    ultimately, rapidly share and apply the lessons through the
    enterprise.
        Our providers are expertly trained, and we hold them
    accountable for the care they provide. We do rigorous work,
    including provider credentialing, privileging, patient safety
    reporting, and other critical components, following the
    requirements specified in the DHA's Clinical Quality Management
    Program, as well as in compliance with other applicable Navy
    directives.
        We recognize that we cannot completely eliminate all
    errors, either human or systemic, but we must be persistent in
    our rigorous self-assessment, rapid-cycle feedback, and high-
    velocity learning to continuously improve. As a high
    reliability organization privileged to care for our Nation's
    warfighters and their families, we can never be content.
        Chairwoman Speier, thank you for your leadership in this
    area, and I look forward to your questions.
        [The prepared statement of Admiral Gillingham can be found
    in the Appendix on page 120.]

    STATEMENT OF LT GEN ROBERT I. MILLER, USAF, SURGEON GENERAL OF
                             THE AIR FORCE

        General Miller. Good afternoon, Chairwoman Speier, Ranking
    Member Gallagher, and distinguished members of the
    subcommittee.
        It is an honor and a privilege to appear before you today,
    as the Surgeon General of the Air Force and Space Force, to
    discuss Air Force Medicine clinical quality management
    processes and functions, to include patient safety and
    healthcare risk management.
        Before I continue, I also want to thank Mr. Del Barba and
    Mr. Luckey for their testimony.
        I want to reiterate my commitment to patient safety for all
    Military Health System beneficiaries. We started our journey
    towards becoming a high reliability organization in 2015, when
    my predecessor, Lieutenant General Mark Ediger, launched the
    Trusted Care Program.
        Even now, high reliability remains the foundation for the
    care we provide. Additionally, we remain partnered with the
    Defense Health Agency's high reliability efforts. Together, our
    processes ensure a culture and practice of safeguarding patient
    safety in the operational and non-operational environments.
        Today, I would like to highlight two aspects of that
    collaborative partnership towards quality and safe patient
    care. First, the AFMS's [Air Force Medical Services'] clinical
    quality management transition to the DHA, and second, the
    AFMS's operational quality program.
        Due to the DHA transition, the Air Force Medical Operations
    Agency's legacy Clinical Quality Management Office transitioned
    from a large organization that supported 76 military treatment
    facilities, all downrange facilities, and patient transport
    missions to a streamlined office supporting the operational
    environment. Currently, our Clinical Quality Management
    Division falls within the Air Force Medical Readiness Agency,
    or AFMRA, and has been renamed AFMRA Operational Quality. This
    support now focuses on our deployed facilities and air medical
    transport capabilities.
        I am happy to report the Air Force operational facilities
    comply with DHA Clinical Quality Management procedural manuals.
    Additionally, the Air Force quality policies have been updated
    to align with the DHA procedural manuals.
        The AFMRA Operational Quality Division is focused on
    development, implementation, and sustainment of Clinical
    Quality Management procedures and guidance for safe and quality
    health care in operational environments. Our patient safety and
    healthcare risk management teams use proactive assessments to
    reduce risk and harm across the enterprise, as well as afford
    an analysis of events to identify gaps in healthcare delivery
    and mitigation strategies to prevent future harm.
        Mitigation and reduction of risk in the delivery of
    operational health care is paramount. Proactive management of
    safe and quality care includes review of Joint Patient Safety
    Reports from our downrange and patient transport environments
    to develop and improve processes to reduce the potential for
    harm in the deployed environment.
        Regardless of location, if a patient safety event occurs,
    the event is entered into the Joint Patient Safety Reporting
    System. These can be events that could have caused harm and did
    not reach the patient or one that caused harm by reaching the
    patient. In either case, an event review occurs through an
    analysis of the healthcare delivery process, with the aim of
    identifying the gaps that contributed to or directly caused the
    event.
        Additional healthcare risk management activities involve a
    review of the care that was delivered. If the standard-of-care
    review identifies potential misconduct, a significant deviation
    from the standard of care, or other significant concerns, then
    an adverse action to hold the involved provider accountable is
    pursued.
        In summary, AFMS remains committed to being a high
    reliability organization and is committed to maintaining the
    quality and safety of care delivered in the operational
    environment. Our program focuses on risk mitigation,
    transparency, and delivery of trusted care anywhere. We work
    hand in hand with the Defense Health Agency. A culture of
    learning and safety is paramount to the success of our
    operational quality program.
        Our AFMS team is working to ensure our airmen and guardians
    get the safe, high quality health care they deserve, and I
    remain dedicated to safeguarding that diligence, as their
    Surgeon General.
        I look forward to your questions. Thank you.
        [The prepared statement of General Miller can be found in
    the Appendix on page 128.]
        Ms. Speier. Thank you all.
        I will resist asking my questions until the end.
        Ranking Member Gallagher, you are recognized for 5 minutes.
        Mr. Gallagher. And I would like to yield my time to the
    gentleman from Ohio, Dr. Wenstrup.
        Ms. Speier. Dr. Wenstrup, you are recognized for 5 minutes.
        Dr. Wenstrup. Thank you, Madam Chair, and thank you,
    Ranking Member, for the opportunity to participate in this
    today.
        And I want to thank our witnesses here today for being
    here.
        A point of personal privilege, if I can. General Dingle, I
    want to thank you for your opening up the opportunity for the
    service members to be able to converse with you by expansion of
    your consultant program. And I want to thank you for that. I
    think it has been a great opportunity for us and for Army
    Medicine.
        The MHS is a vital component of our National Security
    Strategy. There is no doubt about it; it needs to be. And the
    Defense Health Agency is a critical element of the MHS. It was
    established as part of a larger effort to reorganize military
    healthcare programs and services.
        We have learned a lot in the last couple of years as well,
    I think, through COVID [coronavirus disease]. Population
    medicine is extremely important in the military. We need to
    preserve that.
        And there are concerns that Congress has tasked DHA with
    increasing responsibility, despite it being limited by its
    construct as an integrated combat support agency. And I have
    been working on this issue for several years now, you know,
    even after leaving this committee. But, as a surgeon who served
    reserve and active, personal experiences as a surgeon,
    conversations I have had with active and retired officials,
    some that sat in your seats, experiences in private practice, I
    have grown some concerns with MHS transition, and I think a lot
    of people have.
        Looking at further changes in the MHS, I think we need to
    ensure that we are able to provide what we often hear is the
    medically ready force and a ready medical force operationally,
    and all the while preserving population health for service
    members, their families, at home and abroad; retirees, for that
    matter. So, I want to make sure that we are not sacrificing
    readiness for population health, and make sure that we can do
    the best of both.
        So, through the experiences and listening to many
    stakeholders, I think that we could greatly benefit the MHS,
    and all the patients in their care, with a functional specified
    command, is what I call it. And if I could, I would like to
    submit for the record some of what we have worked on involving
    the Military Health System and possible reforms to it.
        Certainly, this isn't cut and dried, but it offers a
    specified command, a three-star command, that I think would,
    potentially, make us all more functional across everything we
    are trying to achieve. And I certainly would want input on that
    from each and every one of you, as I have sought some of that
    already, as you know.
        I know that some of the concerns that we have came from
    Congress. And I remember at a hearing with the previous Surgeon
    General, your predecessor, General Dingle, where we were
    discussing--one of the members was reading a letter from
    combatant commanders saying: this is going to be difficult for
    us, really challenged; that we are worried about this. And
    General West said, ``Well, we're just doing what Congress asked
    us to do.''
        And that is why I want to engage from this end, because if
    we are asking some things to do, maybe good intentions that
    aren't necessarily the best for us, where do we go from there?
    And how do we make a difference to make your life easier and
    more productive in many ways?
        We want flexibility. We want the services to be able to
    weigh in across all compositions. We have joint situations. We
    have service-specific situations. Reserve flexibility. Are you
    backfill or are you operational? Are you both? And certainly,
    respecting the value of our MTFs, and I think that that is an
    important thing.
        So, we want to enhance, also, opportunities between
    military and civilian operations, where we can learn to train
    each other. And we see a lot more of that happening today,
    which I think has been very, very helpful.
        I guess in the time that I have, I will just go with one
    question. With the understanding that each service has unique
    needs, how would you describe or assess the level of ownership
    you have over the personnel and medical training readiness
    within each of your services?
        General Dingle. Representative Wenstrup, I will start.
        From the Army, I own the soldiers. I am responsible for
    their readiness, a trained and ready force. And I do that
    through what we call individual critical task lists. So, for
    every specialty, I am responsible to make sure that that
    soldier can perform his or her duty, not just in the fixed
    facility where we sharpen the acumen, but also downrange in the
    operational environment. So, I do have control over those
    soldiers to ensure their readiness, and in conjunction with the
    Defense Health Agency, I leverage internal training, as well as
    military-civilian partnerships.
        Admiral Gillingham. Thank you, Congressman.
        Similarly, in the Navy, my responsibility is command and
    control of all naval medical forces within our medical force,
    and the manning, training, and equipping of them to make sure
    they are ready to perform downrange. We have found that, by
    establishing Naval Medical Readiness Training Commands within
    the MTFs to oversee those responsibilities, in conjunction with
    the DHA as a training range, that model is working well, albeit
    some growing pains. But we continue to collaborate with the DHA
    to make that successful.
        General Miller. Thank you, Congressman.
        And similar for the Air Force. I would say that, as we
    focus on organized training and equipping our force, and
    especially our medics, our MTFs are our readiness training
    platforms. It is the focus. Sometimes we do need to go to
    civilian facilities, as needed, to supplement that training,
    but the preference is always to work within the military
    training facilities. That training starts at METC [Medical
    Education and Training Campus] for enlisted medics; different
    for the officers.
        And I would also like to comment that it is more than just
    the Active Duty; it is the total force. It is the Guard. It is
    the Reserves. And you put that whole team together, which is
    critical to make sure that we are delivering that trusted care
    across the globe.
        Dr. Wenstrup. You mentioned working with DHA. I think that
    is an important component of that conversation.
        General Place. Yes, sir. As already indicated by three
    Surgeons, the services control the forces. We are in dialog
    about how they might help within the MTFs, but the services
    control the forces.
        Ms. Speier. The gentleman yields back.
        The gentleman from Texas, Dr. Jackson, is recognized for 5
    minutes.
        Dr. Jackson. Thank you, Madam Chair.
        I just want to briefly say, as a relatively new Member of
    Congress, and new to this subcommittee as such, I am looking
    for opportunities to make a difference. And I will tell you, as
    the only physician on this subcommittee, and as a career Navy
    emergency medicine physician, I think that this is an area--all
    of these issues involving military medicine is going to be one
    of the main areas that I intend to focus on for my foreseeable
    future here in Congress, on having a big impact. I just think
    that everybody needs to pick their niche. I think that this
    will become my niche in this subcommittee.
        And so, I say that because I was just looking, and per last
    year's budget, almost 8 percent of the DOD funding was
    dedicated to the Military Health Systems. That is quite a lot.
    And I have been trying to figure out where can I make an impact
    in military medicine.
        And I start by saying that I am not doing it to shake
    anything up or to identify any problems. I am doing it, as
    somebody who comes from your community, to find ways that I can
    help you make military medicine better for all of us. Because,
    just like General Place was saying, I, too, have family
    members, including a son and a daughter-in-law, that are on
    Active Duty as well, and I want their career to be fulfilling,
    and I want them to get the medical care that they need in the
    process and be ready to fight and do what they have to do as
    well. So, I approach it in that regard.
        And I have had the honor to spend a little time with
    General Miller, and I really enjoyed that, sir. And I think you
    have got a great attitude and I think we are going to work
    together well. I am going to enjoy working with you.
        I personally know Admiral Gillingham pretty well, and he is
    an aggressive and well-respected leader in Navy Medicine. I
    hope to get to know the two of you a little bit better as time
    goes on.
        But my question would be, I guess, in general, I am trying
    to figure out exactly where we are at in the general process.
    Because I was on Active Duty back in 2012-2013, whenever DHA
    came about, and the branches were trying to figure out where
    everybody fit in and how it was all going to work. And I know
    it was a mess to start with, right, and you would assume that
    it would be with an organization the size of military health
    care, you know, trying to come together and just completely
    restructure. I know that there was some growing pains early on.
    I am assuming that a lot of that stuff has been overcome.
        I have been going out and trying to be active and figure
    out exactly where I can have an impact, and what is broken and
    what I can help fix from here. And I have been to San Diego. I
    have been to Walter Reed. I have been out to Brooke Army
    Medical Center. So, I am making my rounds and I am going to
    continue to do that. I am going to continue to visit as many
    MTFs, clinics, and things as I can.
        I am going to continue to ask people what is working; what
    is not working. As a Member of Congress, what would you like to
    see me work on? What would you like to see me help you fix, so
    on and so forth?
        But I ask you guys that as well, and I am sure that the
    stuff that comes to your level might be different than the
    stuff that is happening with the folks that are on the ground,
    some of the doctors and nurses that are directly taking care of
    patients.
        But I will say that I still think that there is a little
    bit, when I talk to folks--and I am hoping that, you know, you
    try to disarm people as much as you possibly can when you go
    into these situations, especially I don't think of myself as a
    Congressman, quite honestly, at this particular point. When I
    get back in the military MTF, I feel like, you know, this is
    where I have been for the last 25 years. I don't feel like I am
    out of place.
        But I think a lot of people are hesitant to talk to me
    about certain things. And I get a lot of people that are just
    like, ``Well, everything is fine. We don't need any help.'' But
    I get the sense that everything might not be completely fine.
    There may be issues, but I don't know what they are.
        So, my question to you all, to start with, would be, what
    is working and what is not working with the transition? And
    what, as a Member of Congress on this subcommittee that deals
    with military health, can I do to help you guys facilitate your
    efforts to make military medicine, to make it the absolute best
    that it can possibly be?
        General Place. Well, Representative Jackson, thanks for the
    discussion and the question.
        Knowing how all the process works, the legislative
    proposals, you know, they are working their way through OMB
    [Office of Management and Budget], and you will see them.
        I think all of us will say that we are working way better
    today than we did a year ago, and I think we will say that we
    are working way better a year ago than we were 3 years ago, and
    way better 3 years ago than we were 5 years ago. So, I think
    you will see a united organization here between all of us and
    the organizations that we lead.
        I think that the best discussions are often held informally
    as a methodology of organizational ideas exchanging. So, I
    think I speak for myself when saying I look forward to getting
    to know you a little bit better as well, and how we can have
    those discussions. But I don't have specific things that I
    would recommend that you address today along those lines.
        General Dingle. Representative Jackson, I would add that we
    are not where we were and we are moving the ball down the
    field. However, there are challenges that we are learning. And
    so, we are in the assessment phase because this is new.
        We, as a team, from the Director and all the Surgeon
    Generals, working together to implement the law, as well as DOD
    policy. We are learning, discovering and learning, as we go
    through, to include the initial question from Representative
    Wenstrup about readiness, and as I assess the readiness of
    soldiers.
        And so, I, too, welcome the discussion. At the same time,
    imperative that we give the opportunity to do a detailed
    assessment internal as well as external; and then as General
    Place mentioned, we are using the legislative proposal process,
    through the Department of Defense, for the initial ones.
        Admiral Gillingham. Thank you, Congressman Jackson, for
    that question.
        I would say--you asked specifically what is working--I
    think COVID taught us the power of our unified approach. DHA
    did a terrific job interacting in the interagency, particularly
    as we got ready for vaccine distribution. And then, working
    closely with them, we were able to translate that into our
    unique operational environments. I think that rapid-cycle
    feedback that General Place has spoken about in terms of the
    practice management guidelines for the treatment of COVID,
    which is now in its eighth edition, demonstrates the power of
    having a central organization that can collate that experience,
    and then, allow us to execute through our respective services.
        So, I, too, welcome the opportunity. I think we will be
    speaking next week. I look forward to that, sir, and appreciate
    your support and advocacy.
        Ms. Speier. The gentleman's time has expired.
        All right. Let me start off with Admiral Gillingham.
        You heard Mr. Luckey talk about the loss of his daughter.
    What have we learned from the loss of her life? What has the
    Navy done differently because she received such incompetent
    care?
        Admiral Gillingham. Thank you for that question, Madam
    Chairwoman.
        I can assure you that Navy Medicine investigated the facts
    and circumstances surrounding Seaman Luckey's medical care. We
    examined lapses in systems and protocols. That we made
    standard-of-care determinations. But that we developed improved
    processes, not just aboard USS Reagan, but we shared those
    throughout the fleet and across our medical treatment
    facilities, and with the DHA. And that we have addressed the
    accountability of the involved care providers. We have grown as
    an organization due to that unfortunate, tragic loss.
        Ms. Speier. Can you be specific about what changes have
    been made in terms of providing medical care on ships?
        Admiral Gillingham. Certainly. We developed a fleetwide
    sepsis screening. So, when an individual comes to sick call
    aboard ship, the corpsman can use that screening tool to detect
    whether there are risk factors for that individual to develop
    sepsis. In addition, then, the treatment protocol that follows,
    should sepsis be identified. And that has also been shared with
    our MTFs.
        We implemented a process we call SURGE, which is Supporting
    Urgent Responses across the Global Enterprise. These are
    reviews that go to a site, if there has been an event, even
    potentially near-misses, so that we can learn the maximum from
    those cases and apply that.
        And we also have deployed the Joint Patient Safety
    Reporting System across the fleet and in all of our operational
    environments.
        Ms. Speier. Thank you.
        Lieutenant General Dingle, since Mr. Del Barba's incident,
    what changes has the Army made in how they care for service
    members in training units?
        General Dingle. Representative Speier, again, not to repeat
    what Rear Admiral Gillingham said, we have conducted all of
    those investigations, in conjunction with the Defense Health
    Agency, the lessons learned, the clinical practical guidelines,
    not just at that location, but across the Military Health
    System. We work through and with the Defense Health Agency
    because it is----
        Ms. Speier. Well, I understand all of that. I want to know
    what you have done differently.
        What is pretty clear to me is that the likelihood for,
    whether it is strep or sepsis, is much more likely in a setting
    where you have people living very close together. It appeared
    that, in the case of Fort Benning, there wasn't enough
    antibiotics to provide to the other service members. So, how
    are you anticipating that?
        General Dingle. Representative Speier, if I can take that
    for the record, I could give you much more detail than the
    numbers and what we have done, as I synchronize that with the
    Defense Health Agency.
        [The information referred to was not available at the time
    of printing.]
        Ms. Speier. All right.
        In all of your settings, spinal meningitis is much more
    prevalent and spreads much more quickly in living situations
    where people are close together. It happens on college
    campuses, and it could happen in a setting where you are on a
    ship or in close quarters in a barracks.
        Have all of the service members, upon participating in
    basic training, receiving the actual shot? I guess it is a
    vaccine; I am not sure.
        General Dingle. Yes, ma'am, penicillin. We have started
    administering that at [inaudible].
        Ms. Speier. I am sorry, you have started doing that?
        General Dingle. Ma'am, we had stopped for a period at that
    location, and then, reimplemented, through the lesson learned
    from this incident.
        Ms. Speier. So, are all basic training recruits actually
    receiving that kind of a vaccine?
        General Dingle. Yes, ma'am, penicillin.
        Ms. Speier. And how about in the Navy?
        Admiral Gillingham. Yes, ma'am, to my knowledge, we are
    doing that.
        Ms. Speier. General Miller, Air Force?
        General Miller. Yes, ma'am, also.
        Ms. Speier. All right.
        General Place, in your opening comments, you referenced the
    goal of the DHA as ready, reliable care. And that struck me
    kind of oddly. Reliable is not quality. Reliable is not
    comprehensive. Reliable, arguably, could be 3 minutes in the
    ER. So, why is that word used versus one that kind of
    emphasizes quality?
        General Place. The use of the word ``reliability'' is taken
    from high reliability concepts, to become a high reliability
    organization. And the tenets of high reliability is where that
    word is coming from.
        Ms. Speier. Well, I would recommend that you reevaluate
    that.
        You have all heard about the GAO study. It is preliminary
    in nature.
        The one question I didn't ask Ms. Silas is, what grade
    would you give these services, based on the fact that 16
    percent of the credentials of the healthcare professionals are
    never verified, never confirmed?
        Now, that falls under you, Lieutenant General Place. That
    is your responsibility. You can delegate it, but the fact that
    16 percent haven't been looked at should send alarms. Does it
    not send alarms to you?
        General Place. Congressman, the alarm is always on. I mean,
    the depth and breadth of the requirements that the GAO study is
    looking at is significant. And quite honestly, I will agree
    with the preliminary results that she described to you. I think
    those are accurate.
        But I am not sure that the characterization that you are
    making is as accurate as it could be. And here is why I am
    saying that: one of the examples--and I happen to know some of
    the preliminary results that she was describing--when it came
    to licensing, the specific case that she is talking about, that
    particular provider had 10 licenses--10. And eight of them were
    primary-source-verified.
        Now is the requirement to do all of them? And the answer is
    yes. Should we have done better? The answer is yes. But I
    wouldn't infer from that that there is no checking for the
    licensure of the providers.
        Ms. Speier. Well, I mean, the fact of the matter is--and I
    wish she was still here--there were 100 cases pulled at 4
    installations. And of those 100 records, 16 of them had not
    been verified.
        Now, in this one you are referencing that 8 of the 16
    licensures had been of this one person. But I think the
    expectation is that we are not credentialing--we are not
    allowing anyone to provide health care to our service members
    unless we have verified their credentials.
        So, if you need more staff, then you should tell us. Do you
    need more staff to complete that function?
        General Place. At this point, I think it would be premature
    to say that. And that gets back to the other comment that she
    mentioned. The quality requirements that we have now, that I
    signed out, as one of my first acts as the Director of the
    Defense Health Agency in October of 2019, was a marked
    expansion of the clinical quality requirements, massive. And we
    are still in the process of implementing all of them perfectly.
        And quite frankly, I think the help of the GAO to help us
    see ourselves better, where we are not meeting those
    expectations--my expectation is to be perfect.
        Ms. Speier. Okay. So, she has also said very clearly that,
    if a QAI takes more than 270 days, you are supposed to report
    it to the National Practitioner Data Bank. Have you done that
    in all of these cases?
        General Place. No, ma'am, not in all these cases.
        Ms. Speier. And why not?
        General Place. Part of the reason, the clock starts when
    the payment is made, not when we find out----
        Ms. Speier. No, that is not right. That is, actually, not
    right. It starts on day 270, whether you have completed the QAI
    or not.
        General Place. I understand that----
        Ms. Speier. And there are cases where you do not
    compensate, but they are compensatable, but have not been
    reviewed for whether or not that practitioner should no longer
    be providing services.
        I think we are all interested in the same thing. We don't
    want practitioners out there providing services to our service
    members who either need more training or have forgotten their
    training, or just are not good physicians or healthcare
    professionals. Correct?
        General Place. Yes, ma'am. Agreed.
        Ms. Speier. So, it seems like we should be checking their
    credentials. We should be reporting it to this data bank, and
    we should be evaluating whether or not they should be put on
    administrative leave, pending the results of the cases.
        I mean, when a police officer shoots his gun and someone
    dies or is injured, they are immediately put on administrative
    leave while there is an investigation that is undertaken.
        In many of these cases, these practitioners continued to
    practice, and some were even promoted, correct?
        General Place. I don't know the details of all the cases
    that we are describing, but I can see how that would happen,
    yes, ma'am.
        Ms. Speier. All right. So, my understanding is that,
    whatever the GAO report finalizes, you are going to embrace it
    and you are going to make the changes necessary to comply with
    it?
        General Place. Absolutely, yes, ma'am.
        Ms. Speier. The personnel performing these QAIs, how are
    they selected? How do you ensure their independence from
    command influence or personal loyalties within their unit?
        General Place. Is that question for me?
        Ms. Speier. Yes.
        General Place. They are not a part of units. The
    headquarters people that I have are not associated with units.
        Ms. Speier. Okay. So, the question is, how do you guarantee
    that this kind of review that is being done is by persons that
    are independent? From different facilities? Don't know the
    provider that is being reviewed? How do you make sure there is
    not a conflict of interest?
        General Place. Well, exactly as you described it at first.
    They are not part of the same unit. And the panel that we use
    within our headquarters is not associated with the health care
    being delivered.
        Similarly, we use a commercial program, a commercial
    company, as an independent second opinion for these cases, as
    another independent way of evaluating them.
        Ms. Speier. So, when do you send cases for external
    reviews? What is the status? What is the determination that is
    made?
        General Place. If the local level says status or standard
    of care met, then those go to an external peer review.
        Ms. Speier. If standards are met?
        General Place. If we say internally in our evaluation of
    the standard of care is met, those are the ones that are sent
    to an external peer review. So, it is not just, ``Well, we all
    got together, and, yes, we are all together here. So, no,
    nothing to see here.'' If we determine internally that standard
    of care is met, then we send it to an external peer review.
        Ms. Speier. Okay. How many QAIs has the Department
    completed over the past 3 years?
        General Place. Ma'am, because of title 10, I can't tell you
    that in this forum. I am happy to provide that to you offline,
    as your status as chairwoman.
        Ms. Speier. Okay. Would you do that, please?
        General Place. Yes, ma'am.
        Ms. Speier. And then, also provide to us how many found
    that the standard of care was not met? And how many providers
    were reported to the National Practitioner Data Bank for
    failing to meet the standard of care.
        General Place. Yes, I will get with your staff for the
    specific questions, and we will provide that.
        Ms. Speier. All right.
        Those are my questions.
        Anything else anyone wants to add?
        All right. We thank you very much for your service and for
    being here today.
        We have got to get this right. Those two results are
    untenable. I think you appreciate that. I hope that you will
    redouble your efforts.
        With that, we stand adjourned.
        [Whereupon, at 5:34 p.m., the subcommittee was adjourned.]
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                                A P P E N D I X

                                 March 30, 2022

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                  PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                                 March 30, 2022

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                  QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                                 March 30, 2022

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                       QUESTIONS SUBMITTED BY MS. SPEIER

        Ms. Speier. Over the past three years, how many QAIs did the
    Department complete, how many found that the standard of care was not
    met, and how many providers were reported to the National Practitioner
    Data Bank for failing to meet the standard of care?
        General Place. [No answer was available at the time of printing.]
        Ms. Speier. How will Mr. Del Barba learn whether the healthcare
    providers who failed him are held accountable?
        General Place. [No answer was available at the time of printing.]
        Ms. Speier. What will DHA do to ensure that it has reviewed and
    documented 100% of direct-care system provider credentials and
    licensing?
        General Place. [No answer was available at the time of printing.]
        Ms. Speier. Why is the Department unable to complete timely quality
    assurance investigations (according to the 180-day and 270-day
    timeframes established by policy), and in some cases does not initiate
    a review at all? What are you doing to ensure these reviews are
    initiated and completed on time? What additional resources or
    authorities do you need to complete QAIs on time?
        General Place. [No answer was available at the time of printing.]
        Ms. Speier. What is the status of the Sec. 721 FY2017 NDAA required
    workforce plan?
        General Place. [No answer was available at the time of printing.]
        Ms. Speier. DHA has still not addressed the Inspector General's
    August 10, 2020, recommendations (``Evaluation of Access to Mental
    Health Care in the Department of Defense'') to establish a behavioral
    health workforce plan and revise access-to-care standards for
    behavioral health. What is the status of the behavioral health work
    force plan that was recommended by the DOD IG [inspector general] in
    2020, and when will DHA implement these recommendations?
        General Place. [No answer was available at the time of printing.]
        Ms. Speier. To each service, please confirm whether or not your
    service administers Meningococcal vaccines to boot camp entrants.
        General Dingle. [No answer was available at the time of printing.]
        Ms. Speier. To each service, please confirm whether or not your
    service administers Meningococcal vaccines to boot camp entrants.
        Admiral Gillingham. Navy and Marine Corps recruits receive Menactra
    to prevent invasive meningococcal disease caused by Neisseria
    meningitidis serogroups A, C, Y, and W-135.
        Ms. Speier. To each service, please confirm whether or not your
    service administers Meningococcal vaccines to boot camp entrants.
        General Miller. Per Air Force Instruction 48-110, Immunizations and
    Chemoprophylaxis for the Prevention of Infectious Diseases, all basic
    trainees and other accessions are required to receive meningococcal
    vaccine within the first 2 weeks of training, if they do not have
    evidence of a previous vaccination within the previous 5 years.
                                     ______

                       QUESTIONS SUBMITTED BY MS. ESCOBAR
        Ms. Escobar. One of the issues my office has heard about from staff
    and leadership at William Beaumont Army Medical Center is how hard it
    has been to find civilian nurses. The nurse shortage is certainly a
    nationwide issue not limited to the military, but it is especially
    detrimental to an underserved community like El Paso. For example,
    William Beaumont has actively reached out to local colleges with
    nursing programs to provide experience to the nursing students and many
    times the hospital will want to hire them immediately after they
    graduate.
        Unfortunately, if the hospital did want to hire them at the GS-7
    pay scale, which is typical of most RN positions, the prospective nurse
    would need a year of work experience prior to being hired on unless
    they met a Superior academic achievement standard. While the Superior
    Academic Achievement avenue is available, staff at William Beaumont
    have made it clear they are still facing hurdles trying to hire
    civilian nurses directly out of college even when they have experience
    working at William Beaumont. Additionally, if William Beaumont finds an
    exceptional nursing student locally and want to hire them above the GS-
    7 pay scale to compete with other hospitals, they are not able because
    of a blanket one year work experience requirement. This leaves them to
    go to other hospitals in the area or worse, leave the region entirely.
        Have DHA and the services heard from other military hospitals
    regarding the lack of civilian nurses they are facing? How are DHA and
    the services addressing the long-term civilian nurse staffing shortage?
    Have you considered ``pipeline'' programs from local colleges to the
    military hospitals that could include a waiver process negotiated with
    the Office of Personnel Management?
        General Place. [No answer was available at the time of printing.]
        Ms. Escobar. Another item my office has heard about is that because
    William Beaumont is solely an Army hospital, they do not have the
    benefit of having other service branch members coming through Beaumont
    to train at or support the hospital like at Joint Bases. Allowing for
    cross pollination across the services could be beneficial to not only
    the Army and William Beaumont, but the entire military health system
    and the medical population it serves.
        Director Place, what are your thoughts on the possibility of
    allowing medical staff from other branches to do ``tours'' at single
    service hospitals like William Beaumont? Does such a program already
    exist?
        General Place. [No answer was available at the time of printing.]
        Ms. Escobar. One of the issues my office has heard about from staff
    and leadership at William Beaumont Army Medical Center is how hard it
    has been to find civilian nurses. The nurse shortage is certainly a
    nationwide issue not limited to the military, but it is especially
    detrimental to an underserved community like El Paso. For example,
    William Beaumont has actively reached out to local colleges with
    nursing programs to provide experience to the nursing students and many
    times the hospital will want to hire them immediately after they
    graduate.
        Unfortunately, if the hospital did want to hire them at the GS-7
    pay scale, which is typical of most RN positions, the prospective nurse
    would need a year of work experience prior to being hired on unless
    they met a Superior academic achievement standard. While the Superior
    Academic Achievement avenue is available, staff at William Beaumont
    have made it clear they are still facing hurdles trying to hire
    civilian nurses directly out of college even when they have experience
    working at William Beaumont. Additionally, if William Beaumont finds an
    exceptional nursing student locally and want to hire them above the GS-
    7 pay scale to compete with other hospitals, they are not able because
    of a blanket one year work experience requirement. This leaves them to
    go to other hospitals in the area or worse, leave the region entirely.
        Have DHA and the services heard from other military hospitals
    regarding the lack of civilian nurses they are facing? How are DHA and
    the services addressing the long-term civilian nurse staffing shortage?
    Have you considered ``pipeline'' programs from local colleges to the
    military hospitals that could include a waiver process negotiated with
    the Office of Personnel Management?
        General Dingle. [No answer was available at the time of printing.]
        Ms. Escobar. One of the issues my office has heard about from staff
    and leadership at William Beaumont Army Medical Center is how hard it
    has been to find civilian nurses. The nurse shortage is certainly a
    nationwide issue not limited to the military, but it is especially
    detrimental to an underserved community like El Paso. For example,
    William Beaumont has actively reached out to local colleges with
    nursing programs to provide experience to the nursing students and many
    times the hospital will want to hire them immediately after they
    graduate.
        Unfortunately, if the hospital did want to hire them at the GS-7
    pay scale, which is typical of most RN positions, the prospective nurse
    would need a year of work experience prior to being hired on unless
    they met a Superior academic achievement standard. While the Superior
    Academic Achievement avenue is available, staff at William Beaumont
    have made it clear they are still facing hurdles trying to hire
    civilian nurses directly out of college even when they have experience
    working at William Beaumont. Additionally, if William Beaumont finds an
    exceptional nursing student locally and want to hire them above the GS-
    7 pay scale to compete with other hospitals, they are not able because
    of a blanket one year work experience requirement. This leaves them to
    go to other hospitals in the area or worse, leave the region entirely.
        Have DHA and the services heard from other military hospitals
    regarding the lack of civilian nurses they are facing? How are DHA and
    the services addressing the long-term civilian nurse staffing shortage?
    Have you considered ``pipeline'' programs from local colleges to the
    military hospitals that could include a waiver process negotiated with
    the Office of Personnel Management?
        Admiral Gillingham. Congresswoman Escobar, Navy Medicine's civilian
    nurse vacancy rate has been approximately 15 percent during the last
    year. We have similar staffing challenges faced by the other Services,
    Veterans Administration, and the private sector. All healthcare
    organizations are competing for limited nursing talent, while
    concurrently experiencing an increasing demand for their services in
    all health care settings. This is particularly evident during the
    response to the COVID-19 pandemic. We continue to use special salary
    rates, retention, recruitment, and relocation incentives in an effort
    to recruit and retain nurses. In addition, we have also used the
    Accelerated Nurse Promotion Program to hire certified nurses who
    graduate from BSN [Bachelor of Science in Nursing] programs into
    positions that allow them to reach the full performance level within a
    few years, as training opportunities allow.
        Ms. Escobar. One of the issues my office has heard about from staff
    and leadership at William Beaumont Army Medical Center is how hard it
    has been to find civilian nurses. The nurse shortage is certainly a
    nationwide issue not limited to the military, but it is especially
    detrimental to an underserved community like El Paso. For example,
    William Beaumont has actively reached out to local colleges with
    nursing programs to provide experience to the nursing students and many
    times the hospital will want to hire them immediately after they
    graduate.
        Unfortunately, if the hospital did want to hire them at the GS-7
    pay scale, which is typical of most Registered Nurse (RN) positions,
    the prospective nurse would need a year of work experience prior to
    being hired on unless they met a Superior academic achievement
    standard. While the Superior Academic Achievement avenue is available,
    staff at William Beaumont have made it clear they are still facing
    hurdles trying to hire civilian nurses directly out of college even
    when they have experience working at William Beaumont. Additionally, if
    William Beaumont finds an exceptional nursing student locally and want
    to hire them above the GS-7 pay scale to compete with other hospitals,
    they are not able because of a blanket one year work experience
    requirement. This leaves them to go to other hospitals in the area or
    worse, leave the region entirely.
        Have the Defense Health Agency (DHA) and the services heard from
    other military hospitals regarding the lack of civilian nurses they are
    facing? How are DHA and the Services addressing the long-term civilian
    nurse staffing shortage? Have you considered ``pipeline'' programs from
    local colleges to the military hospitals that could include a waiver
    process negotiated with the Office of Personnel Management?
        General Miller. Yes, the Air Force (AF) has similar staffing issues
    as other Service Components, VA, private sector. All healthcare
    organizations are competing for limited resources. The AF employs
    special salary rates and retention/recruitment/relocation incentives to
    compete with other healthcare organizations for compensation.
        The Air Force has historically experienced a shortfall of civilian
    Registered Nurses (RN) partially due to the inability to promote
    Licensed Practical and Vocational Nurses (LPN/LVN) due to the one year
    of experience at the RN level required by the Office of Personnel
    Management (OPM) qualification standards. However, with the transition
    of RNs, LPNs, and LVNs from the Services to the Defense Health Agency
    (DHA), the responsibility to develop an action plan addressing the
    shortfall and/or request considerations to the OPM qualifications
    standards will fall under the DHA purview. The Air Force Medical
    Service (AFMS) has and will continue to provide subject matter
    expertise to assist DHA with addressing this issue.
                                     ______

                       QUESTIONS SUBMITTED BY MS. JACOBS
        Ms. Jacobs. What policies are in place to ensure service members
    and families will receive continuity of care during Permanent Change of
    Station (PCS) transitions?
        General Place. [No answer was available at the time of printing.]
        Ms. Jacobs. What are your thoughts on allowing out-of-state
    professional licensed therapists to continue assisting with the long
    wait times for service members for behavioral health therapy
    appointments? TRICARE currently allows out-of-state appointments under
    the temporary coverage regulations for COVID-19. Should the DHA
    continue allowing this service?
        General Place. [No answer was available at the time of printing.]
        Ms. Jacobs. What is the current turnover rate for military
    healthcare providers? Is there a disparity between private healthcare
    and military providers' experience and education?
        General Place. [No answer was available at the time of printing.]
        Ms. Jacobs. What is the protocol for suspected malpractice from a
    military provider?
        General Place. [No answer was available at the time of printing.]
        Ms. Jacobs. Over the past several years the Services have put
    forward plans that would substantially reduce the number of military
    medical billets. Both the FY 21 and FY 22 NDAAs included provisions
    directing the Services to pause all medical billet cuts and review the
    impact of cuts on patient care. Can you provide an update on the review
    process and detail what steps will be taken to ensure patient safety
    and access to care if military medical billets are reduced?
        General Place. [No answer was available at the time of printing.]
        Ms. Jacobs. As military medical billets are cut and some MTFs are
    ``right-sized,'' we can anticipate that increasing numbers of TRICARE
    beneficiaries will be shifted to the purchased care network. The
    purchased care system is not under your direct administration but is
    still part of the military health system. How can DHA ensure that
    patient safety and access to high quality of care is maintained as more
    beneficiaries are shifted out of the direct care system?
        General Place. [No answer was available at the time of printing.]
        Ms. Jacobs. A 2018 GAO report indicated that a fragmented and
    inconsistent tracking process across the military services and DHA has
    impeded efforts to ensure DHA has complete information about sentinel
    events and subsequent root cause analysis reports. Now that DHA has
    authority, direction and control over most military treatment
    facilities, what steps have been taken to achieve a single system to
    track and monitor sentinel events, root cause analyses, and corrective
    action implementation plan reports? Are there any additional steps DHA
    plans to take to improve the completeness and reliability of DHA's
    patient safety data as well as its ability to identify and implement
    system-wide improvements related to patient safety?
        General Place. [No answer was available at the time of printing.]
        Ms. Jacobs. What policies are in place to ensure service members
    and families will receive continuity of care during Permanent Change of
    Station (PCS) transitions?
        General Dingle. [No answer was available at the time of printing.]
        Ms. Jacobs. What are your thoughts on allowing out-of-state
    professional licensed therapists to continue assisting with the long
    wait times for service members for behavioral health therapy
    appointments? TRICARE currently allows out-of-state appointments under
    the temporary coverage regulations for COVID-19. Should the DHA
    continue allowing this service?
        General Dingle. [No answer was available at the time of printing.]
        Ms. Jacobs. What is the current turnover rate for military
    healthcare providers? Is there a disparity between private healthcare
    and military providers' experience and education?
        General Dingle. [No answer was available at the time of printing.]
        Ms. Jacobs. What policies are in place to ensure service members
    and families will receive continuity of care during Permanent Change of
    Station (PCS) transitions?
        Admiral Gillingham. I appreciate the question Congresswoman Jacobs.
    Navy Medicine wants to ensure there are there are programs and policies
    in place to support continuity of care for our transferring personnel
    and their families. With each set of Permanent Change of Station
    orders, our Navy Personnel Command includes instructions on how to
    obtain medical care if needed while enroute to the new duty station, as
    well as a reminder to enroll in the new TRICARE Region upon arrival. In
    addition, our worldwide access to service members' electronic medical
    records helps ensure that providers at the gaining military treatment
    facility can see previous care plans and treatments. Specific efforts
    for continuity of care by the TRICARE Managed Care Support Contractors
    would be under the purview of the Defense Health Agency (DHA). Navy
    Medicine works closely with the DHA to support these efforts.
        Ms. Jacobs. What are your thoughts on allowing out-of-state
    professional licensed therapists to continue assisting with the long
    wait times for service members for behavioral health therapy
    appointments? TRICARE currently allows out-of-state appointments under
    the temporary coverage regulations for COVID-19. Should the DHA
    continue allowing this service?
        Admiral Gillingham. I am grateful for the authorities that were
    provided during the COVID-19 pandemic to ensure our patients received
    the care they needed. The increase in the use of virtual mental health
    proved to be particularly impactful as both patents and providers
    utilized this technology. In general, I support license portability as
    a means to improve access to care; however, I defer the system-wide
    assessment to the Defense Health Agency to include consideration as to
    whether these TRICARE temporary authorities should become permanent.
        Ms. Jacobs. What is the current turnover rate for military
    healthcare providers? Is there a disparity between private healthcare
    and military providers' experience and education?
        Admiral Gillingham. The 5 year loss rates for Navy healthcare
    providers is as follows: Medical Corps (11 percent); Dental Corps (10
    percent); Medical Service Corps (8 percent); and Nurse Corps (8
    percent). Our providers' experience and education is equal to or
    greater than those practicing in the private sector. In addition, our
    clinicians have access to graduate health education programs that rank
    among the best in the Nation.
        Board certification is a mark of distinction and is an indication
    that the healthcare provider's education and training go beyond the
    minimum standards and competency requirements in a given specialty.
    Achieving this standard is a rigorous process, requiring a clinician to
    meet or exceed predetermined stringent levels of knowledge, skills and
    abilities for recognition amongst their peers. In addition, our
    physicians, dentists and nurses possess board certification at higher
    rates than their private sector civilian counterparts. We are proud of
    our dedicated and high performing Navy Medicine healthcare
    professionals
        Ms. Jacobs. What is the protocol for suspected malpractice from a
    military provider?
        Admiral Gillingham. Navy Medicine appropriately holds our providers
    accountable for the care they provide. Our processes are fair,
    thorough, rigorous and in compliance with both applicable Department of
    Defense, Department of Navy, and Bureau of Medicine and Surgery
    instructions. Whether they occur in the Fleet, Fleet Marine Force, or
    MTF, patient safety events are reported in the Joint Patient Safety
    Reporting system. If the event meets DOD reportable event criteria,
    then a comprehensive systematic analysis, such as a root cause
    analysis, is required. This analysis is used to thoroughly evaluate
    patient safety concerns and improve quality of care. A patient safety
    event determined to have reached a patient and which is likely to
    result in a possible financial loss to the Federal Government, is
    considered a potentially compensable event (PCE). The PCE review
    process includes a standard of care determination for each provider who
    actively provided care. PCEs where the standard of care was not met by
    one or more providers are reviewed by the credentials committee and a
    written review of the case is submitted to the privileging authority.
    The written review includes an analysis of whether or not the deviation
    from standard of care caused or contributed to the patient safety event
    and a recommendation as to whether to place the provider on a
    monitoring and evaluation plan assessing the provider's performance
    regarding care related to the PCE or initiate an adverse privileging
    action.
        An adverse privileging action may be appropriate when professional
    competency is questioned. This process begins with an individual
    provider being temporarily removed from clinical practice through a
    summary suspension of clinical privileges while a quality assurance
    investigation (QAI) is initiated to examine alleged deficits in medical
    knowledge, expertise or judgment. Summary suspension of clinical
    privileges lasting longer than 30 calendar days is a reportable action
    to the National Practitioner Data Bank (NPDB). The credentials
    committee or medical executive committee will review the completed QAI
    and make recommendations on clinical privileges.
        Our process in taking an action that adversely affects a provider's
    clinical practice is similar to the civilian sector in that we meet the
    rigorous due process standards for professional review actions as
    required by the Healthcare Quality Improvement Action of 1986. Adverse
    clinical actions that result in restriction, reduction, revocation or
    denial of clinical privileges are reported to the NPDB and one's state
    of licensure. Such actions are also recorded in the clinician's DOD
    credentials file in the Joint Centralized Credentials Quality Assurance
    System.
        Ms. Jacobs. Over the past several years the Services have put
    forward plans that would substantially reduce the number of military
    medical billets. Both the FY 21 and FY 22 NDAAs included provisions
    directing the Services to pause all medical billet cuts and review the
    impact of cuts on patient care. Can you provide an update on the review
    process and detail what steps will be taken to ensure patient safety
    and access to care if military medical billets are reduced?
        Admiral Gillingham. The FY20 through FY22 National Defense
    Authorization Acts have prohibited any realignments or reductions to
    military medical end strength. There have been no reductions in active
    duty Navy medical providers at this time and there are no reductions
    planned in FY23. Navy is continuing the analysis of the medical
    divestiture plan, engaging directly with Defense Health Agency to
    develop a mitigation plan for divestitures, to include examining the
    impact of divestitures on military medical treatment facilities on Navy
    and Marine Corps installations. The Navy is finalizing comprehensive
    analysis of Joint Medical Estimate and the operational plans for
    medical requirements, enduring homeland defense mission and pandemic
    response.
        Ms. Jacobs. What policies are in place to ensure service members
    and families will receive continuity of care during Permanent Change of
    Station (PCS) transitions?
        General Miller. Medical continuity of care during PCS transitions
    is covered in AFMAN 41-210, Tricare Operations and Patient
    Administration, Air Force Instruction (AFI) 40-701, Medical Support to
    Family Member Relocation and Exceptional Family Member Program (EFMP)
    and AFI 44-172, Mental Health.
        1. AFMAN 41-210 discusses Medical In/Out-processing, and highlights
    the requirement in out-processing for individuals enrolled in
    Exceptional Family Member Program, or navigating the Family Member
    Relocation Program/Process, that medical documents are scanned into
    their electronic health record prior to the screening as required in
    accordance with AFI 40-701.
        2. AFI 40-701 notes that upon sponsor in-processing, the EFMP-M
    staff members within the MTFs collaborate with Medical In/Out-
    Processing POCs to establish procedures to ensure prompt identification
    of families with special needs during base in-processing.
        3. AFI 44-172 notes that the Mental Health (MH) Flight will be
    included on the installation out-processing checklist to screen Service
    member's records. MH technicians will review the out-processing list
    and will screen the electronic health record (EHR) for any MH Flight/
    Behavioral Health Outpatient (BHOP) treatment during the last 180 days,
    including care received during deployment or temporary duty assignment.
        a. If this screen is positive, a MH provider (MHP) will review the
    record to assure care received has been appropriately terminated and
    there is no need for ongoing follow up.
        b. Transfer of MH information will be accomplished IAW DODI 6490.10
    and this instruction. When transferring to a new command, transfer of
    clinical care of a Service member receiving MH care within the MTF
    system shall be arranged through direct MHP-to-MHP communication via
    secure methods (e.g., telephone call or encrypted e-mail), as
    clinically indicated by the losing MHP. The MHP at the receiving
    location shall have a level of expertise consistent with the patient's
    mental health needs and treatment plan.
        4. Additionally, as the Defense Health Agency (DHA) has authority,
    direction and control of the processes related to healthcare delivery
    and patient safety, DHA policy and instructions, once published, will
    establish the MHS-wide standards for care coordination and care
    continuity.
        Ms. Jacobs. What are your thoughts on allowing out-of-state
    professional licensed therapists to continue assisting with the long
    wait times for service members for behavioral health therapy
    appointments? TRICARE currently allows out-of-state appointments under
    the temporary coverage regulations for COVID-19. Should the DHA
    continue allowing this service?
        General Miller. Allowing licensed out-of-state mental health
    therapists to practice across state lines via tele-behavioral health
    appointments is vital to reducing long wait times for appointments and
    should be continued.
        1. Mental Health clinics continue to be undermanned even as demand
    for services grows.
        2. Although mental health manpower authorizations remained largely
    the same from 2017 to 2020, available Full Time Equivalents decreased
    from 555 to 468, while demand steadily increased by approximately 24%
    from 2012 through 2019.
        3. The shortage of mental health providers within the DAF reflects
    the shortage of providers nationwide, however, the ratio of the supply
    of providers to population varies significantly from state to state and
    region to region further complicating the problem.
        4. The Southeastern United States has the highest resident to
    provider ratio in the country. Among the 10 states with the most
    significant mental health provider shortages, 5 states are in the
    Southeast, which means TRICARE beneficiaries in that region have
    diminished access to care unless the supply of providers is bolstered
    through initiatives such as authorization for TRICARE providers to
    render service across state lines.
        5. As the number of referrals of Active Duty members to mental
    health clinics outside the MTF grows, those members become increasingly
    more impacted by state and regional provider shortages.
        6. Additionally, as the DHA has authority, direction and control of
    the processes, personnel, and facilities related to healthcare delivery
    and patient safety, DHA policy and instructions, developed with
    consideration of Service inputs for operational requirements, once
    published, will be the controlling military medical treatment facility
    policy
        Ms. Jacobs. What is the current turnover rate for military
    healthcare providers? Is there a disparity between private healthcare
    and military providers' experience and education?
        General Miller. Regarding physicians in the military, we assess on
    average 280 new physicians per year and an average of 310 physicians
    separate or retire each year.
        The education and training our military providers receive is
    consistent with our civilian counterparts. The graduate medical
    education requirements for military programs are the same as those
    found in civilian training institutions since we are all governed by
    the same Accreditation Council for Graduate Medical Education (ACGME).
    Also, within the Military Treatment Facility (MTF), providers are held
    to equivalent privileging and credentialing requirements as civilian
    healthcare providers.
        Ms. Jacobs. What is the protocol for suspected malpractice from a
    military provider?
        General Miller. When a concern for clinical performance or conduct
    is identified, it triggers the initiation of a well-codified process,
    established to investigate clinical quality concerns, protect patients
    and afford due process to the involved provider.
        1. The Clinical Adverse Action Process Flow is a detailed multi-
    step process with multiple branch points and actions taken according to
    findings discovered and/or actions taken during the course of the
    process.
        2. The most important aspect of the process occurs when a clinical
    quality concern is identified. The involved provider(s) is immediately
    removed from practice while a quality assurance investigation takes
    place.
        3. The outcome of the investigation and resulting due process
    procedures can have results that range from returning the provider to
    practice with no limitations, being placed under supervision for a
    specified period of time, or having their clinical privileges
    permanently revoked.
        4. For full details on this protocol, please refer to the
    attachment entitled, ``Clinical Adverse Action Process Flow.''
        5. Because the DHA has authority, direction and control of the
    processes, personnel, and facilities related to healthcare delivery and
    patient safety, DHA policy and instructions, developed with
    consideration of Service inputs for operational requirements, control
    military medical treatment facility policy.
                                     ______

                       QUESTIONS SUBMITTED BY DR. JACKSON
        Dr. Jackson. According to the TRICARE website, when you retire from
    the military, you must enroll in a TRICARE plan within 90 days after
    your retirement. As somebody who is just coming off active duty, those
    90 days go by extremely quickly. General Place, what are the potential
    benefits and adverse consequences of extending this period of time?
        General Place. [No answer was available at the time of printing.]
        Dr. Jackson. Brooke Army Medical Center, or BAMC, is the only Level
    1 Trauma Center within the Military Health System. It serves San
    Antonio and the surrounding region, caring for military and civilian
    trauma patients to provide the premier medical readiness training
    platform for military medicine. The knowledge, skills, and abilities
    gained by military healthcare personnel at BAMC are vital for ensuring
    our medical readiness is at a level necessary to ensure we can respond
    to a future conflict in the Indo-Pacific.
        General Place, with the transfer of the MTFs to DHA, have there
    been unique challenges associated with civilian care at the Level 1
    trauma center at BAMC?
        General Place. [No answer was available at the time of printing.]
        Dr. Jackson. The Navy provided information to my office that 6.5%
    of officer end strength in the Navy is made up of the Medical Corps,
    yet only 4.5% of the Navy's authorized flag billets are medical
    personnel.
        Only 1.9% of those are from the Navy Medical Corps.
        This discrepancy concerns me because there is not an accurate
    representation of senior leaders in the Navy advocating for the needs
    of medical personnel.
        I asked the Army and the Air Force for this information on February
    8th, yet I don't believe we have received that.
        General Dingle, does this discrepancy exist in the Army as well? If
    so, do you have concerns that your Medical Corps is not being
    accurately represented by the current number of medical general
    officers?
        General Dingle. [No answer was available at the time of printing.]
        Dr. Jackson. The Medical Officer of the Marine Corps, or the TMO,
    advises on all matters regarding Marine Corps healthcare and serves as
    the functional expert for the health and safety of the Marines.
        Admiral Gillingham, are you aware of any plans to get rid of the
    TMO? If so, could you justify that plan for the committee?
        Admiral Gillingham. Navy is required to reduce the number of flag
    Officer billets in 2022 by 14 in accordance with the reductions
    mandated in the FY17 NDAA, Navy's support to establish the Space Force,
    and the additional billet required for the special prosecutor mandated
    in the FY22 NDAA. By the end of 2022, Navy will have reduced more than
    nine percent of flag officer billets. These disproportionate cuts come
    at a high cost to maintaining operational readiness, impede Navy's
    efforts in an already challenging operational environment, and run
    counter to the demands of the long-term strategic competition the
    nation faces, which require more, rather than less, senior uniformed
    leadership and expertise in the dominant physical domain of concern,
    the maritime domain. The reduction of one and two star Navy staff
    positions reduces development opportunities for junior warfighter flag
    officers to the detriment of the Navy enterprise and the Joint Force
    and limits the enterprise expertise these flag officers can only gain
    outside of warfighting billets, in areas such as financial management,
    strategic plans and policy, strategic warfare, and operations analysis.
    This expertise is gained primarily in junior flag officer staff
    positions. Removing these positions eliminates necessary development
    opportunities used to groom one and two star admirals for future
    positions as three and four star admirals. Within this context and
    following a comprehensive review, the Secretary of the Navy approved
    the decision to reduce the Medical Officer of the Marine Corps as one
    of the 14 required billet offsets. The alternative was to reduce
    another key operational billet.
        Dr. Jackson. The Navy provided information to my office that 6.5%
    of officer end strength in the Navy is made up of the Medical Corps,
    yet only 4.5% of the Navy's authorized flag billets are medical
    personnel.
        Only 1.9% of those are from the Navy Medical Corps.
        This discrepancy concerns me because there is not an accurate
    representation of senior leaders in the Navy advocating for the needs
    of medical personnel.
        I asked the Army and the Air Force for this information on February
    8th, yet I don't believe we have received that.
        General Miller, does this discrepancy exist in the Air Force as
    well? If so, do you have concerns that your Medical Corps is not being
    accurately represented by the current number of medical general
    officers?
        General Miller. The Air Force Medical Service (AFMS) data presented
    below for Congressman Jackson's query shows the AFMS comprises 18% of
    total Air Force officers while AFMS general officers (10 total)
    comprise 5.4% of Air Force general officers. There is no known
    operational or care delivery impact as a result of this current rank
    composition. The AFMS is structured through the Line of the Air Force
    (LAF). This unique force structure empowers LAF senior leaders and
    general officers to advocate on behalf of the medical components, which
    amplifies advocacy achieved by medical general officers.
                                     ______

                        QUESTIONS SUBMITTED BY MR. CARL
        Mr. Carl. There have been advances in point-of-need care solutions
    for rapid multi-threat pathogen detection to support Warfighter health
    and readiness. Such rapid multi-pathogen detection can enable near
    realtime identification of deadly pathogens or viruses which can result
    in quickly quarantining and providing the necessary medical
    countermeasure to treat the disease. As a result, the operating forces
    would see improved readiness. I am interested to know if the agency is
    giving priority to programs that are seeking advances in these rapid
    multi-pathogen detection systems designed for point of care/need
    application?
        General Place. [No answer was available at the time of printing.]
        Mr. Carl. We know that wound infection remains the greatest risk to
    life and restoration of function after combat. We also know that when
    infection is not deadly, it can lead to other traumas like amputation.
    So early infection diagnosis is key to troop survival and health. Can
    you talk about the programs and goals that DHA has to develop rapid,
    point-of-need care?
        General Place. [No answer was available at the time of printing.]

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