[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                    
          
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                   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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