Defense Health Care: Comprehensive Oversight Framework Needed to
Help Ensure Effective Implementation of a Deployment Health
Quality Assurance Program (22-JUN-07, GAO-07-831).
Overseas deployments expose servicemembers to a number of
potential risks to their health and well-being. However, since
the mid-1990s, GAO has highlighted shortcomings with respect to
the Department of Defense's (DOD) ability to assess the medical
condition of servicemembers both before and after their
deployments. Following GAO's May 1997 report, Congress enacted
legislation (10 U.S.C. 1074f) that required the Secretary of
Defense to establish a medical tracking system for assessing the
medical condition of servicemembers before and after deployments.
GAO was asked to determine (1) whether DOD has established a
medical tracking system to comply with requirements of 10 U.S.C.
1074f pertaining to pre- and postdeployment medical examinations,
and (2) the extent to which DOD has effectively implemented a
deployment health quality assurance program as part of its
medical tracking system. In conducting this review, GAO analyzed
pertinent documents and interviewed DOD officials.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-07-831
ACCNO: A71226
TITLE: Defense Health Care: Comprehensive Oversight Framework
Needed to Help Ensure Effective Implementation of a Deployment
Health Quality Assurance Program
DATE: 06/22/2007
SUBJECT: Data collection
Health care programs
Health care services
Internal controls
Medical information systems
Medical records
Military personnel
Program evaluation
Quality assurance
Reporting requirements
Program implementation
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GAO-07-831
* [1]Results in Brief
* [2]Background
* [3]DOD Has a System in Place to Comply with Requirements for De
* [4]DOD Has Established a Deployment Health Quality Assurance Pr
* [5]DOD Has Established a Deployment Health Quality Assurance Pr
* [6]DOD Does Not Have a Comprehensive Oversight Framework to Det
* [7]DOD Has Not Identified All Results-Oriented Performance
Meas
* [8]DOD Has Not Enforced Its Policy Requiring the Services to
Re
* [9]DOD Site Visits to Assess the Services' Deployment Health
Qu
* [10]Conclusions
* [11]Recommendations for Executive Action
* [12]Agency Comments and Our Evaluation
* [13]Appendix I: Scope and Methodology
* [14]Appendix II: Pre- and Postdeployment Health Assessment Quest
* [15]Appendix III: Individual Medical Readiness
* [16]Appendix IV: Comments from the Department of Defense
* [17]Appendix V: GAO Contact and Staff Acknowledgments
* [18]GAO Contact
* [19]Acknowledgments
* [20]Related GAO Products
* [21]Order by Mail or Phone
Report to the Ranking Member, Subcommittee on National Security and
Foreign Affairs, Committee on Oversight and Government Reform, House of
Representatives
United States Government Accountability Office
GAO
June 2007
DEFENSE HEALTH CARE
Comprehensive Oversight Framework Needed to Help Ensure Effective
Implementation of a Deployment Health Quality Assurance Program
GAO-07-831
Contents
Letter 1
Results in Brief 3
Background 6
DOD Has a System in Place to Comply with Requirements for Deployment
Medical Examinations 10
DOD Has Established a Deployment Health Quality Assurance Program, but the
Lack of a Comprehensive Oversight Framework Hampers Effective
Implementation 13
Conclusions 19
Recommendations for Executive Action 19
Agency Comments and Our Evaluation 20
Appendix I Scope and Methodology 22
Appendix II Pre- and Postdeployment Health Assessment Questionnaires 24
Appendix III Individual Medical Readiness 30
Appendix IV Comments from the Department of Defense 32
Appendix V GAO Contact and Staff Acknowledgments 35
Related GAO Products 36
Abbreviations
AMSA Army Medical Surveillance Activity
DHSD Deployment Health Support Directorate
DMSS Defense Medical Surveillance System
DNA Deoxyribonucleic Acid
DOD Department of Defense
GPRA Government Performance and Results Act of 1993
HIV Human Immunodeficiency Virus
IPV Inactivated Poliovirus
MMR Measles, Mumps, and Rubella
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separately.
United States Government Accountability Office
Washington, DC 20548
June 22, 2007
The Honorable Christopher Shays
Ranking Member
Subcommittee on National Security and Foreign Affairs
Committee on Oversight and Government Reform
House of Representatives
Dear Mr. Shays:
Overseas deployments expose servicemembers to a number of potential risks
to their health and well-being. However, since the mid-1990s we have been
reporting on DOD's shortcomings with respect to assessing the medical
condition of servicemembers both before and after their deployments.
Following our May 1997 report,1 Congress enacted legislation2 that
required the Secretary of Defense to establish a medical tracking system
to assess the medical condition of servicemembers before and after
deployments to locations outside the United States. The elements of the
system, as required by the law, included, among other things, the use of
pre- and postdeployment medical examinations. As part of the system, the
law also required DOD to establish a quality assurance program to evaluate
the success of the system in ensuring that servicemembers receive pre- and
postdeployment medical examinations and that record-keeping requirements
with respect to the system are met. However, our September 2003 report
highlighted many instances of noncompliance with DOD's deployment health
requirements and reiterated the need for DOD to establish a quality
assurance program to ensure that these requirements are met.3 In September
2004, we reported similar findings for reserve forces.4 Further, our
November 2004 report raised concerns that overall compliance with DOD's
force health protection and surveillance policies for servicemembers who
deployed in support of Operation Iraqi Freedom varied by service, by
installation, and by policy requirement.5 More recently, in October 2005
we reported that evidence suggested that some reserve component members
have deployed into theater with preexisting medical conditions that could
not be adequately addressed in-theater.6
1GAO, Defense Health Care: Medical Surveillance Improved Since Gulf War,
but Mixed Results in Bosnia, [22]GAO/NSIAD-97-136 (Washington, D.C.: May
13, 1997).
2National Defense Authorization Act for Fiscal Year 1998, Pub. L. No.
105-85, S 765 (1997) (codified at 10 U.S.C. S 1074f).
3GAO, Defense Health Care: Quality Assurance Process Needed to Improve
Force Health Protection and Surveillance, [23]GAO-03-1041 (Washington,
D.C.: Sept. 19, 2003).
4GAO, Military Personnel: DOD Needs to Address Long-term Reserve Force
Availability and Related Mobilization and Demobilization Issues,
[24]GAO-04-1031 (Washington, D.C.: Sept. 15, 2004).
In light of these long-standing problems, you asked us to examine DOD's
compliance with the legislative requirement to perform pre- and
postdeployment medical examinations on servicemembers and DOD's deployment
health quality assurance program. This report addresses (1) whether DOD
has established a medical tracking system to comply with requirements of
10 U.S.C. S 1074f pertaining to pre- and postdeployment medical
examinations, and (2) the extent to which DOD has effectively implemented
a deployment health quality assurance program as part of its medical
tracking system.
To address our objectives, we obtained and reviewed pertinent documents,
reports, and information related to DOD's deployment health requirements
and deployment health quality assurance program from officials at the
Assistant Secretary of Defense for Health Affairs, Deployment Health
Support Directorate (DHSD); the Offices of the Surgeons General for the
Army, Air Force, and Navy; the Army Medical Surveillance Activity (AMSA);
and the Combined Fleet Forces Command and Naval Environmental Health
Center. To determine whether DOD has established a medical tracking system
to comply with requirements of 10 U.S.C. S 1074f pertaining to pre- and
postdeployment medical examinations, we reviewed 10 U.S.C. S 1074f to
identify system requirements and DOD policies and other guidance to
identify the measures DOD uses to establish the medical condition of
servicemembers as part of this system. In addition, we obtained a legal
opinion from DOD's Office of General Counsel regarding DOD's compliance
with the requirement of 10 U.S.C. S 1074f to perform pre- and
postdeployment medical examinations. To determine the extent to which DOD
has effectively implemented a deployment health quality assurance program
as part of its medical tracking system, we obtained and analyzed relevant
DOD policies to identify requirements of the program. We also interviewed
key officials with DHSD and the services' Offices of the Surgeon General
to obtain a comprehensive understanding of the processes, procedures, and
controls used for monitoring and overseeing the deployment health quality
assurance program. We obtained and analyzed the results of site visits
conducted by DHSD in calendar years 2005 and 2006. To determine the
reliability of DOD's quality assurance program reports, we obtained and
analyzed data collection instruments and other documentation used to
record, summarize, and report the services' compliance with deployment
health requirements. We also discussed with responsible DOD officials,
including representatives from the military services, their methodology
for ensuring that information collected and reported is as accurate and
reliable as possible. Where possible, we tested data by comparing
information from the data collection instruments or summary documents with
available source documents. We identified issues of inconsistency and
incompleteness in DOD's data and, therefore, determined the data to be
insufficiently reliable for the purpose of assessing compliance with
deployment health requirements and we are making a recommendation to
address this issue accordingly. In conducting our review, we limited our
focus to the procedures that DOD has in place to medically assess
servicemembers before and after their deployments. Other issues, such as
recent controversies associated with alleged deployments of medically
unfit servicemembers to Iraq, did not fall within the scope of this
review. These issues will be addressed as part of a separate review. We
performed our work from September 2006 through May 2007 in accordance with
generally accepted government auditing standards. For more detailed
information on our scope and methodology, see appendix I.
5GAO, Defense Health Care: Force Health Protection and Surveillance Policy
Compliance Was Mixed, but Appears Better for Recent Deployments,
[25]GAO-05-120 (Washington, D.C.: Nov. 12, 2004).
6GAO, Military Personnel: Top Management Attention Is Needed to Address
Long-standing Problems with Determining Medical and Physical Fitness of
the Reserve Force, [26]GAO-06-105 (Washington, D.C.: Oct. 27, 2005).
Results in Brief
DOD has established a medical tracking system to comply with the
requirements of 10 U.S.C. S 1074f to perform predeployment and
postdeployment medical examinations through a variety of deployment health
activities. This section of the law requires the Secretary of Defense to
establish a system to assess the medical condition of servicemembers
deployed outside the United States. According to the law, the system is to
include the use of medical examinations, including an assessment of mental
health and the drawing of blood samples, both before and after deployment.
DOD has established a medical tracking system to assess the medical
condition of servicemembers intended to ensure that only medically and
mentally fit servicemembers deploy outside of the United States. For
example, DOD's system includes the use of pre- and postdeployment health
assessment questionnaires and reviews of servicemembers' medical records
(e.g., physical examinations, immunizations, dental history). The
predeployment health assessment questionnaires, which are to be completed
no earlier than 60 days prior to deployment, are a series of questions
about servicemembers' current medical (including dental) and mental health
conditions, including prescriptions, vision issues, and any medical
concerns servicemembers might have. These questionnaires and
servicemembers' medical records are to be reviewed by a health care
provider to confirm whether servicemembers have received standard and
theater-specific immunizations and recent medical (physical) examinations
that identify diseases and medical conditions that may prevent them from
deploying. Based on the responses to the predeployment questionnaires and
the review of the medical records, servicemembers may be referred for
further testing and evaluation prior to deployment. Also, within 30 days
prior to or after redeploying,7 servicemembers are to complete the
postdeployment health assessment questionnaire. The postdeployment
questionnaires are to be reviewed by a health care provider, along with
servicemembers' medical records, to evaluate current health status,
deployment experiences, environmental exposures, and health concerns
related to their deployments. Based on these reviews, the health care
provider may recommend additional clinical evaluation or treatment as
needed. In response to an inquiry from our office, DOD's Office of General
Counsel explained that the health assessments the department performs meet
the requirement of 10 U.S.C. S 1074f for pre- and postdeployment medical
examinations. We conclude that DOD's interpretation is reasonable.
DOD has also established a deployment health quality assurance program as
part of its medical tracking system, but lacks a comprehensive oversight
framework to help ensure effective implementation of the program. Thus,
DOD does not have the information it needs to evaluate the effectiveness
and efficiency of its quality assurance program. The Government
Performance and Results Act of 19938 (GPRA) provides federal agencies with
a framework for developing oversight, which includes establishing
reporting requirements and performance measures. DOD's deployment health
quality assurance program policy specifies four elements of DOD's program:
(1) monthly reports on active and reserve component servicemembers'
deployment health assessment data from centralized databases maintained by
AMSA, (2) quarterly reports on service-specific deployment health quality
assurance programs, (3) periodic visits to military installations to
complement and validate the services' deployment health programs, and (4)
an annual report to the Assistant Secretary of Defense for Health Affairs
on the department's quality assurance program. DOD guidance requires each
of the services to create their own quality assurance programs based on
these elements. While DOD has established a program that includes these
four elements, DOD cannot determine whether the program has been
effectively implemented because DOD does not have a comprehensive
oversight framework with all the specific reporting requirements and
necessary performance measures to evaluate the services' compliance with
deployment health requirements or to help ensure that the services are
implementing the program consistently.
7For the purposes of this report, we use the terms "redeploying" and
"redeployed" to mean returning from deployment.
8Pub. L. No. 103-62 (1993).
o Monthly AMSA reports: Although DOD requires monthly reports from
AMSA on servicemembers' deployment health data, it does not
provide AMSA with results-oriented performance measures and
specific reporting requirements that would enable DOD to determine
the departmentwide compliance with deployment health requirements.
For example, DOD's policy does not require that AMSA provide
critical information needed to assess compliance with deployment
health requirements, such as the total number of servicemembers
that deployed/redeployed during the reporting period. Without
knowing the total number of servicemembers deployed/redeployed,
DOD cannot determine the extent to which servicemembers completed
the required pre- and postdeployment health assessment
questionnaires.
o Quarterly reports on the services' programs: While DOD's policy
requires that the services report on service-specific compliance
with deployment health requirements in their quarterly reports,
DOD has not enforced this requirement. Consequently, each service
is choosing to selectively report on requirements, which prevents
the department from having a complete picture/assessment of
compliance with deployment health requirements across the
services. For example, while the Army reports on only a sample of
servicemembers who deploy or redeploy during the reporting period,
the Air Force reports on the total number of servicemembers who
deploy or redeploy during the reporting period. However, the
Army's report includes all overseas locations of deployment
whereas the Air Force only reports on deployments in support of
Operations Iraqi Freedom or Enduring Freedom.
o Site visits: While DHSD conducts four visits per year to
military installations to assess the services' deployment health
quality assurance programs, it does not have quality controls in
place to ensure the accuracy or completeness of the information it
collects. DHSD representatives use data collection instruments to
facilitate their program reviews, but DHSD officials told us that
none of these instruments are reviewed by an independent or second
reviewer. Independent reviews are a key aspect of quality controls
that reduce the risk of errors in a quality assurance program. In
our review of calendar years 2005 and 2006 DHSD site visit reports
and supporting documentation, we found instances of incomplete
data including missing dates for when pre- and postdeployment
health assessment questionnaires were administered. Moreover, we
found that DHSD did not always adhere to DOD's deployment health
requirements when assessing the programs. For example, while not
all servicemembers received blood draws upon redeployment within
the required time frame, DHSD made determinations in their site
visit reports that the services had adhered to the requirements.
Because of these weaknesses, DOD's annual report does not provide
DOD and congressional decision makers with complete,
comprehensive, and accurate information to determine if the
department is complying with its own deployment health
requirements. Moreover, DOD and congressional decision makers are
unable to determine whether DOD has effectively implemented a
quality assurance program to determine or assure Congress that
servicemembers are medically and mentally fit to deploy and to
determine their medical and mental condition upon return. Having
an effective deployment health quality assurance program is
critically important given DOD's long-standing problems with
assessing the medical condition of active and reserve component
servicemembers both before and after their deployments, and has
become even more important in the current environment, where these
servicemembers continue to deploy overseas in significant numbers
in support of ongoing military operations.
We are recommending that DOD develop a comprehensive oversight
framework with reporting requirements and results-oriented
performance measures to improve the implementation of its
deployment health quality assurance program. In written comments
on a draft of this report, DOD concurred with our recommendations.
DOD's comments are reprinted in appendix IV.
Background
In November 1997, Congress included a provision in the National
Defense Authorization Act for Fiscal Year 19989 that required the
Secretary of Defense to establish a medical tracking system for
servicemembers deployed overseas. Specifically, the legislation
required the following:
9Pub. L. No. 105-85, S 765 (1997).
"(a) SYSTEM REQUIRED--The Secretary of Defense shall establish a
system to assess the medical condition of members of the armed
forces (including members of the reserve components) who are
deployed outside the United States or its territories or
possessions as part of a contingency operation (including a
humanitarian operation, peacekeeping operation, or similar
operation) or combat operation.
"(b) ELEMENTS OF SYSTEM--The system described in subsection (a)
shall include the use of predeployment medical examinations and
postdeployment medical examinations (including an assessment of
mental health and the drawing of blood samples) to accurately
record the medical condition of members before their deployment
and any changes in their medical condition during the course of
their deployment. The postdeployment examination shall be
conducted when the member is redeployed or otherwise leaves an
area in which the system is in operation (or as soon as possible
thereafter).
"(c) RECORDKEEPING--The results of all medical examinations
conducted under the system, records of all health care services
(including immunizations) received by members described in
subsection (a) in anticipation of their deployment or during the
course of their deployment, and records of events occurring in the
deployment area that may affect the health of such members shall
be retained and maintained in a centralized location to improve
future access to the records.
"(d) QUALITY ASSURANCE--The Secretary of Defense shall establish a
quality assurance program to evaluate the success of the system in
ensuring that members described in subsection (a) receive
predeployment medical examinations and postdeployment medical
examinations and that the recordkeeping requirements with respect
to the system are met."
The Assistant Secretary of Defense for Health Affairs has the
responsibility for establishing the overall policy and guidance
necessary for DOD to implement the required medical tracking
system, including the associated quality assurance program. Within
the Office of the Assistant Secretary of Defense for Health
Affairs, the Deputy Assistant Secretary of Defense for Force
Health Protection and Readiness has responsibility for the
day-to-day operations and management of both the medical tracking
system and the quality assurance program. It is then the
responsibility of the Offices of the Surgeons General of the Army,
Navy, and Air Force to implement and manage the day-to-day
operations of the medical tracking system and the quality
assurance program within the respective services.
Our prior work has highlighted weaknesses in DOD's assessment of
servicemembers' health before and after deployment. In September
2003, we reported that the Army and Air Force did not comply with
DOD's force health protection and surveillance requirements for
many servicemembers deploying in support of Operation Enduring
Freedom in Central Asia and Operation Joint Guardian in Kosovo.10
Specifically, our review disclosed problems with the Army's and
Air Force's implementation of DOD's force health protection and
surveillance requirements in the following areas: (1) deployment
health assessments, (2) immunizations and other predeployment
requirements, and (3) the completeness of medical records and
centralized data collection. Our September 2003 report also raised
concerns over a lack of DOD oversight of departmentwide efforts to
comply with health surveillance requirements. Specifically, we
reported that an effective quality assurance program had not been
established at the Office of the Assistant Secretary of Defense
for Health Affairs or at the Offices of the Surgeons General of
the Army or Air Force to help ensure compliance with force health
protection and surveillance policies. We believed that the lack of
such a system was a major cause of the high rate of noncompliance
and thus recommended that the department establish an effective
quality assurance program to ensure that the military services
comply with the force health protection and surveillance
requirements for all servicemembers. The department concurred with
our recommendation, and in January 2004 began implementation of
its deployment health quality assurance program.
In September 2004, we reported similar issues related to DOD's
ability to effectively manage the health status of its reserve
forces.11 Specifically we noted that DOD's centralized database
had missing and incomplete predeployment health assessment
questionnaires because not all of the required health information
collected from reserve component members had reached DOD's central
data collection point. We recommended that the Secretary of
Defense take steps to ensure that predeployment health assessment
questionnaires are submitted to the centralized data collection
point as required. DOD concurred with our recommendation and noted
that revised guidance was currently in coordination to clarify the
requirement for submitting predeployment health assessments to the
centralized database.
In November 2004, we reported that overall compliance with DOD's
force health protection and surveillance policies for
servicemembers who deployed in support of Operation Iraqi Freedom
varied by service, by installation, and by policy requirement.12
At that time, we did not evaluate the effectiveness of DOD's
deployment health quality assurance program because of the
relatively short time of its implementation.
10See [53]GAO-03-1041 .
11See [54]GAO-04-1031 .
Finally, in October 2005 we reported that evidence suggested that
reserve component members have deployed into theater with
preexisting medical conditions that could not be adequately
addressed in-theater.13 We also reported that DOD had limited
visibility over the health status of reserve component members
after they are called to duty and is unable to determine the
extent of care provided to those members deployed with preexisting
medical conditions despite the existence of various sources of
medical information. We recommended that the Secretary of Defense
determine what preexisting medical conditions should not be
allowed into specific theaters of operations and to take steps to
ensure that each service component consistently utilizes these as
criteria for determining the medical deployability of its reserve
component members. We also recommended that the Secretary of
Defense explore using existing tracking systems to track those who
have treatable preexisting medical conditions in theater. DOD
partially concurred with our recommendation concerning the
identification of preexisting medical conditions that would
preclude deployment and noted that the services had made advances
in identifying some preexisting conditions that would preclude
deployment, but also stated that due to the ever-changing nature
of theater of operations this list could never be fully
comprehensive or fully enforceable. DOD also concurred with our
recommendation pertaining to the use of existing tracking systems
to track treatable preexisting medical conditions. Specifically,
DOD indicated that ongoing refinements to these systems based on
lessons learned would improve the documentation of medical
conditions throughout the military services including information
concerning reserve members with preexisting conditions.
12See [55]GAO-05-120 .
13See [56]GAO-06-105 .
DOD Has a System in Place to Comply with Requirements for Deployment
Medical Examinations
DOD has established a medical tracking system to comply with the
requirement of 10 U.S.C. S 1074f to perform predeployment and
postdeployment medical examinations through a variety of
deployment health activities, including the use of pre- and
postdeployment health assessment questionnaires along with reviews
of servicemembers' medical records. This section of the law
requires the Secretary of Defense to establish a medical tracking
system to assess the medical condition of servicemembers deployed
outside the United States. According to section 1074f(b)(1), the
system is to include the use of medical examinations, including an
assessment of mental health and the drawing of blood samples, both
before and after deployment.
In DOD's May 1998 report to Congress, the department outlined its
approach to establish a medical tracking system for servicemembers
deployed overseas.14 As part of this approach, DOD performed
medical examinations using predeployment and postdeployment health
assessment questionnaires, including an assessment of mental
health and drawing of blood samples, both before and after
deployment. The predeployment assessment consisted of a series of
questions about the servicemembers' current medical (including
dental) and mental health conditions, including prescriptions,
vision issues, and any medical concerns servicemembers might have.
In 2002, DOD established the requirement that the predeployment
assessment was to be completed within 30 days prior to deployment.
The postdeployment assessment consisted of a series of questions
about the servicemembers medical and mental health condition
resulting from having been deployed. It was to be completed prior
to leaving the theater of operation or within 30 days of final
departure from theater. Examples of the pre- and postdeployment
questionnaires can be found in appendix II.
In August 2006, DOD replaced and expanded its approach with a
comprehensive deployment health program.15 Within the programs,
DOD required the military services to perform a number of
activities designed to monitor servicemembers' health before and
after deployments, including the following:
14Department of Defense Report to Congress: Medical Tracking System for
Members Deployed Overseas (May 1998).
15Department of Defense Instruction 6490.03, Deployment Health (Aug. 11,
2006).
o Predeployment Activities. First, servicemembers are required to
complete a predeployment health assessment questionnaire no
earlier than 60 days prior to deployment. Second, the
questionnaires are required to be reviewed by a health care
provider16 to determine whether the servicemember is fit to
deploy. To make this determination, the health care provider
should review both the servicemembers' medical records and
responses to the questions. The medical records are reviewed and
evaluated against the following six individual medical readiness
elements: whether the servicemember has (1) received an annual
assessment for changes in health status; (2) any
deployment-limiting conditions such as pregnancy, asthma, severe
traumatic injuries with incomplete rehabilitation, etc.; (3) oral
conditions that if not treated could result in dental emergencies;
(4) received all required immunizations; (5) received medical
readiness laboratory tests such as HIV testing and has current DNA
samples on file, (6) all required individual medical equipment.
For more detailed information about individual medical readiness
requirements see appendix III. Prior to deployment, DOD requires
that any condition that causes a servicemember to receive a
failing mark in any of these six elements be corrected. Corrective
actions could include providing the servicemember with required
immunizations, screening for tuberculosis, or drawing serum
specimens. Based on the health care provider review and the
responses to specific questions on the assessment, servicemembers
may be referred, prior to deploying, to the appropriate health
care provider(s) for further testing and evaluation, if needed,
for medical conditions or concerns (e.g., cardiac, mental health).
DOD requires that the completed questionnaire be placed in the
servicemember's medical record and a copy be sent to AMSA for
record keeping.
o Postdeployment Activities. DOD requires that a postdeployment
health assessment questionnaire be completed during the period
from 30 days prior to and 30 days after redeployment. The
completed form is to be placed in the servicemember's medical
record and a copy sent to AMSA. In addition, a review of the
servicemembers' medical records and a face-to-face meeting with a
trained health care provider17 are to be completed within 30 days
of redeployment to discuss the individual's responses on the
postdeployment health assessment, mental health or psychosocial
issues commonly associated with deployments, prescription
medications taken during deployment, and concerns about possible
environmental or occupational exposures. Additional requirements
include documentation of medical referrals or concerns resulting
from deployment, documentation of the results of any follow-up
examinations, tuberculosis screening for high-risk servicemembers,
and blood serum sample collection within 30 days of redeployment.
In 2005, DOD issued a new policy requiring a postdeployment health
reassessment questionnaire as well.18 The purpose of the
reassessment is to identify health concerns that emerge over time
after deployment and is to be conducted between 90 and 180 days
after servicemembers return to their home station.
16DOD defines "health care provider" as a nurse, medical technician,
medic, or corpsman.
17DOD defines a "trained health care provider" as a physician, physician
assistant, nurse practitioner, advanced practice nurse, independent duty
corpsman, independent duty medical technician, or Special Forces medical
sergeant.
We requested the views of DOD's Office of General Counsel on DOD's
compliance with the medical examination requirement of section
1074f.19 DOD's Office of General Counsel noted that DOD's May 1998
report to Congress provided the department's understanding that
the medical examination requirement was satisfied by the plan to
carry out health assessments. DOD's Office of General Counsel
pointed out that subsequent to this report to Congress, Congress
did not, until October of 2006,20 amend section 1074f or otherwise
establish a requirement different than that described in the
department's 1998 report. DOD's Office of General Counsel further
pointed out that subsequent to DOD's 1998 report, Congress did
enact other laws that refer to health assessments required by
section 1074f.21 DOD's Office of General Counsel concluded that
"although the term `medical examination' was not defined in the
original 1997 statute, from 1998 until the present, both DOD and
the Congress have used the terms `medical examination' and `health
assessment' synonymously to describe the Military Health System
pre- and postdeployment action required by section 1074f."
18Assistant Secretary of Defense for Health Affairs Memorandum,
"Postdeployment Health Reassessment" (Mar. 10, 2005).
19Letter from Mr. John Casciotti, Associate Deputy General Counsel (Health
Affairs), DOD Office of General Counsel to Mr. John Van Schaik, Assistant
General Counsel, GAO Office of General Counsel, November 6, 2006.
20Section 1074f was amended by section 738 of the John Warner National
Defense Authorization Act for Fiscal Year 2007, Pub. L. No. 109-364, to
provide that the pre- and post-deployment medical examination should
include an "assessment" of mental health and traumatic brain injury as
well as further details on the elements of the quality assurance program
required under section 1074f(d)(1), including information on the types of
health care providers conducting "postdeployment health assessments."
21Ronald W. Reagan National Defense Authorization Act for Fiscal Year
2005, Pub. L. No. 108-375, SS 732(b) and 739 (2004).
The term "medical examinations" in the statute could be
interpreted to mean medical activities beyond those included in
DOD's current deployment health program as described above.
However, DOD's use of a variety of deployment health activities,
including the use of pre- and postdeployment health assessment
questionnaires along with reviews of servicemembers' medical
records is a reasonable interpretation of section 1074f.
DOD Has Established a Deployment Health Quality Assurance Program,
but the Lack of a Comprehensive Oversight Framework Hampers
Effective Implementation
DOD has established a deployment health quality assurance program
as part of its medical tracking system, but lacks a comprehensive
oversight framework to help ensure effective implementation of the
program. DOD's deployment health quality assurance program policy
outlines four specific elements--such as monthly reports on
servicemembers' deployment health data from a centralized database
maintained by AMSA--and it requires each of the services to create
their own quality assurance programs based on these elements.
While DOD has established a program that includes these four
elements, it cannot determine whether the program has been
effectively implemented because DOD does not have a comprehensive
oversight framework with all the specific reporting requirements
and necessary performance measures to evaluate the services'
compliance with deployment health requirements or to ensure that
the services are implementing the program consistently.
DOD Has Established a Deployment Health Quality Assurance Program
In response to congressional mandates and a GAO recommendation, in
January 2004 DOD established a deployment health quality assurance
program, as part of its medical tracking system, designed to
assess compliance with deployment health requirements. DOD's
policy and implementing guidance for the program is contained in a
memorandum from the Assistant Secretary of Defense for Health
Affairs.22 DOD's policy delegates the responsibility for executing
the program to the Deputy Assistant Secretary of Defense for Force
Health Protection and Readiness, DHSD, and to the military
services. According to the policy, DOD's program consists of the
following four elements:
o Periodic reporting on pre- and postdeployment health
assessments. AMSA is required to provide (at a minimum) monthly
reports to DHSD on active and reserve component servicemembers'
deployment health assessment data.
22Assistant Secretary of Defense for Health Affairs Memorandum, "Policy
for Department of Defense Deployment Health Quality Assurance Program"
(Jan. 9, 2004).
o Periodic reporting on service-specific deployment health quality
assurance programs. The services are required to provide (at a
minimum) quarterly reports to DHSD on the status and findings,
including compliance with deployment health requirements, of their
respective required quality assurance programs.
o Periodic visits to military installations to assess deployment
health programs. The program requires joint visits by
representatives from DHSD and from service medical departments to
military installations for the purpose of complementing and
validating the services' deployment health quality assurance
reporting.
o An annual report on the DOD deployment health quality assurance
program. The program requires that DHSD prepare and coordinate
with the services an annual report on the status of the
requirements of the program to the Assistant Secretary of Defense
for Health Affairs.23
DOD Does Not Have a Comprehensive Oversight Framework to Determine
Whether Its Deployment Health Quality Assurance Program Has Been
Effectively Implemented
DOD has not established a comprehensive oversight framework for
its deployment health quality assurance program, which is
necessary to ensure the program's effective implementation. GPRA
provides federal agencies with a model framework for developing
program oversight.24 Specifically, GPRA establishes a
results-oriented framework that identifies, among other things,
performance measures and reporting requirements. However, DOD does
not have a comprehensive oversight framework with all the specific
reporting requirements and necessary performance measures to
evaluate the services' compliance with deployment health
requirements or to help ensure that the services are implementing
the program consistently. Because DOD's deployment health quality
assurance program lacks a comprehensive oversight framework, the
program, as currently implemented, does not provide decision
makers with the information they need to evaluate the
effectiveness and efficiency of either DOD's or the services'
respective quality assurance programs. In reviewing DOD's program,
we found problems with its implementation of the monthly AMSA
reports, the quarterly service-specific reports, and the DHSD site
visits. Because DOD's annual report is based on information from
these three elements, the department's annual report does not
provide DOD or congressional decision makers with the complete,
comprehensive, and accurate information necessary to determine
whether the department is complying with its own deployment health
requirements. Moreover, DOD and congressional decision makers are
unable to determine whether DOD has effectively implemented a
quality assurance program that reasonably assures that
servicemembers are medically fit to deploy.
23Subsequent legislation required that information on DOD's deployment
health quality assurance program be provided to Congress. Specifically,
section 739 of Pub. L. No. 108-375 (Oct. 28. 2004) amended title 10 of the
United States Code by adding section 1073b. Section 1073b requires that
DOD submit annually to the Armed Services Committees of the Senate and the
House of Representatives reports on health protection quality, including
the recording of health assessment data in military health records.
24GAO, Results-Oriented Government: GPRA Has Established a Solid
Foundation for Achieving Greater Results, [57]GAO-04-38 (Washington, D.C.:
Mar. 10, 2004).
DOD Has Not Identified All Results-Oriented Performance Measures
and Has Not Provided AMSA with Specific Reporting Requirements
DOD's deployment health quality assurance program requires that
AMSA submit to DHSD monthly reports on active and reserve
component servicemembers' deployment health assessment data. The
deployment health assessment data that AMSA reports are collected
individually by the services and maintained centrally in the
Defense Medical Surveillance System (DMSS) at AMSA.25 However, in
reviewing AMSA's reports we found that while the reports provide
some data on servicemembers' deployment health, they do not
provide all the essential information necessary to assess the
services' compliance or determine departmentwide compliance with
all deployment health requirements. This problem results largely
because DOD has not identified all the necessary results-oriented
performance measures and provided AMSA with specific reporting
requirements for all deployment health requirements. DOD's policy
identifies some performance measures that could be used to assess
whether the services are complying with selected deployment health
requirements, such as measures for the identification of
deployed/redeployed personnel and whether pre- and postdeployment
health assessment questionnaires are on file at AMSA. However,
DOD's policy does not identify performance measures for additional
deployment health requirements such as whether servicemembers
received all required immunizations. In addition, DOD's policy
does not identify reporting requirements related to all deployment
health data needed to effectively assess compliance with its own
deployment health requirements. For example, DOD's policy does not
require that AMSA provide critical information needed to assess
compliance with deployment health requirements, such as the total
number of servicemembers that deployed/redeployed during the
reporting period. Without knowing the total number of
servicemembers deployed/redeployed, DOD cannot determine the
extent to which servicemembers completed the required pre- and
postdeployment health assessment questionnaires. Similarly, DOD's
policy does not require that the AMSA reports specify whether
servicemembers completed pre- and postdeployment questionnaires
within required time frames (no earlier than 60 days prior to
deployment, and during the period from 30 days prior to and 30
days after redeployment), which is necessary to determine whether
servicemembers are completing the required questionnaires in a
timely manner. In addition, DOD's policy only specifies that
AMSA's reports include information related to selected
postdeployment health requirements, such as the accomplishment of
blood samples, the number of referrals, and the number of
referrals accomplished. As a result, DOD does not have all of the
essential information necessary to assess the services' compliance
or determine departmentwide compliance with all deployment health
requirements.
25According to AMSA, the DMSS database contains up-to-date and historical
data on diseases and medical events (e.g., hospitalizations, ambulatory
visits, reportable diseases, and health risk appraisals) for military
personnel and deployments.
DOD Has Not Enforced Its Policy Requiring the Services to Report
on Compliance with Deployment Health Requirements
DOD's deployment health quality assurance program requires that
the services submit to DHSD quarterly reports regarding their
compliance with deployment health requirements; however, DOD has
not enforced its reporting requirements. DOD's policy specifies
that the services' quarterly reports address three key elements:
(1) the identification of deployed/redeployed personnel, (2)
completion of applicable pre- and postdeployment health assessment
questionnaires and related requirements (e.g., immunizations,
blood samples, referrals), and (3) inclusion of deployment-related
health documentation in permanent medical records. However, DOD's
policy does not specify uniform standards that should be used in
collecting and reporting the required information. Instead, DOD's
policy directs the services to determine the scope and methodology
of their respective programs, including associated performance
measures. The services' differing interpretations of DOD's policy
have resulted in the services utilizing different approaches for
the collection and reporting of the required information in their
quarterly reports.
Our review of the services' quarterly reports for calendar years
2004, 2005, and 2006 found that DHSD has not enforced the
reporting requirements outlined in its policy. Specifically, we
identified differences in the extent to which the services report
compliance with applicable pre- and postdeployment health
assessment questionnaires and related requirements such as drawing
blood serum samples. For example, the Navy's reports only include
its compliance with postdeployment requirements and do not include
information regarding predeployment requirements. As another
example, the Marine Corps' reports do not always include
information regarding its compliance with pre- and postdeployment
requirements for drawing blood serum samples. Furthermore, with
regard to the inclusion of deployment-related health documentation
in permanent medical records, only the Army and the Air Force
provide DHSD with information in their quarterly reports regarding
whether deployment-related health documentation is included in
servicemembers' permanent medical records.
In addition, we found that the services report information to DHSD
using different criteria. For example, while the Army reports on
only a sample of servicemembers who deploy or redeploy during the
reporting period, the Air Force reports on the total number of
servicemembers who deploy or redeploy during the reporting period.
Moreover, the Army's report includes all locations of deployment
whereas, according to Air Force officials, the Air Force only
reports on deployments in support of Operations Iraqi Freedom or
Enduring Freedom. Further, the Marine Corps' reports include the
total number of Marines that deployed and redeployed during the
reporting period in addition to those Marines who deployed in
earlier reporting periods but who are still deployed.
The lack of guidance or standards for providing the required
information in the services' quarterly reports has created a
number of problems for DOD. For example, the lack of standards
hampers DOD's ability to compare compliance across the military
services and therefore report overall departmentwide compliance
because the services do not always provide DHSD with complete and
consistent information regarding the status and findings of their
respective programs.
DOD Site Visits to Assess the Services' Deployment Health Quality
Assurance Programs Do Not Have Quality Controls in Place
DOD's deployment health quality assurance program requires that
DHSD conduct at least four visits per year to military
installations for the purpose of assessing the services'
deployment health quality assurance programs. While DHSD has
conducted the minimum number of site visits required each year
since 2004, it does not have the quality controls in place to
ensure that the deployment health data collected and reported are
complete and accurate. Federal internal control standards require
that data control activities, such as edit checks, verification,
and reconciliation, be conducted and documented to help provide
reasonable assurance that program objectives are being met.26
While not a formal audit, DOD's deployment health quality
assurance program is designed to identify strengths and weaknesses
with the program and, when appropriate, make changes to ensure
that deployment health requirements are being met.
DHSD relies on the use of data collection instruments to
facilitate the collection of information, but does not provide for
an independent verification of the completeness and accuracy of
data obtained from the medical records. DHSD officials told us
that none of the data collection instruments from their site
visits are reviewed by an independent or second reviewer to ensure
that the information recorded is accurate or complete. Independent
verification is an important internal control activity under
segregation of duties designed to reduce the risk of errors. We
identified numerous instances where the information captured by
DHSD's hard-copy and electronic data collection instruments was
incomplete. Specifically, for our review of hard-copy data
collection instruments from DHSD site visits in 2005, we found
that 99 of 140 data collection instruments (71 percent) from a
site visit to a Marine Corps' installation contained one or more
incomplete data fields, while for a site visit to an Air Force
installation, 53 of 126 data collection instruments (42 percent)
had one or more incomplete data fields. In addition, we found some
instances where either the deployment date or the redeployment
date data fields were not complete. In addition, our review of
electronic data collection instruments for 2006 found at least one
incomplete data field in 53 of 299 data collection instruments (18
percent) that we reviewed. Without independent verification of the
data recorded by the reviewer, DHSD does not have any assurance
that the compliance information recorded accurately reflects the
compliance status for the records reviewed.
In addition, our review of available DHSD site visit data for
calendar year 2005 found that DHSD did not always adhere to DOD's
deployment health requirements when assessing the services'
programs. Specifically, we identified numerous instances where the
reviewing DHSD officials did not consistently apply DOD's
standards for completing pre- and postdeployment health assessment
questionnaires, drawing pre- and postdeployment blood samples, and
receiving required immunizations within specified time frames. For
example, our review of data from DHSD's site visits identified a
total of 99 out of 567 medical records (17 percent) where one or
more deployment health requirement had not been completed within
established time requirements, yet the site visit summary
indicated the requirement for those immunizations had been met. In
addition, our review of DHSD's site visit data verifying the
existence of data within DMSS and at the serum repository at AMSA
found that for 100 out of 295 records (34 percent), timeliness
standards had not been properly applied for at least one
deployment health requirement such as the completion of pre- and
postdeployment health assessment questionnaires or drawing pre-
and postdeployment blood samples. Because DHSD officials were not
properly applying DOD's timeliness standards, reported compliance
for DHSD's site visit reports for 2005 may be overstated.
26See GAO, Standards for Internal Control in the Federal Government,
[58]GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and Internal
Control Management and Evaluation Tool, [59]GAO-01-1008G (Washington,
D.C.: August 2001).
Conclusions
As servicemembers continue to deploy overseas in significant
numbers in support of ongoing military operations, it is
increasingly important that DOD be able to accurately assess the
medical condition of those servicemembers both before and after
their deployments. Although DOD has established a deployment
health quality assurance program, it has not developed a
comprehensive oversight framework with all the specific reporting
requirements and performance measures needed to provide oversight
of, and ensure effective implementation of the program. Having an
effective deployment health quality assurance program is
critically important given DOD's long-standing problems with
assessing the medical condition of active and reserve forces both
before and after their deployments. Without such a framework, the
ability of decision makers--both within DOD and Congress--to make
informed, fact-based decisions regarding whether the department is
complying with its own deployment health requirements is limited.
Moreover, until DOD implements a more effective deployment health
quality assurance program, it will not be well positioned to
determine or assure Congress that servicemembers are medically and
mentally fit to deploy and to determine their medical and mental
condition upon return.
Recommendations for Executive Action
To improve DOD's ability to effectively implement its deployment
health quality assurance program, we recommend that the Secretary
of Defense direct the Assistant Secretary of Defense for Health
Affairs to develop a comprehensive oversight framework to evaluate
the services' compliance with deployment health requirements and
to ensure that the services are implementing the program
consistently. Such a framework should do the following:
o Provide AMSA with specific reporting requirements and
results-oriented performance measures to evaluate the services'
adherence to deployment health requirements, including identifying
the total number of servicemembers deployed/redeployed and
administering pre- and postdeployment health assessment
questionnaires within required time frames, which would enable
AMSA to develop information regarding departmentwide compliance.
o Enforce the requirement for the services to report on all
deployment health requirements on a quarterly basis.
o Establish quality controls, including independent reviews of
data, to ensure the accuracy or completeness of the information
DHSD collects in its site visits to military installations.
Agency Comments and Our Evaluation
DOD provided written comments on a draft of this report and agreed
with our recommendations.
In commenting on our recommendations, the Assistant Secretary of
Defense for Health Affairs commented that the department
recognizes the need for a more comprehensive oversight framework
to better ensure effective implementation of the deployment health
quality assurance program. To that end, the Office of the Deputy
Assistant Secretary of Defense for Force Health Protection and
Readiness recently published a new instruction27 on force health
protection quality assurance. The Assistant Secretary further
commented that the department is now developing reporting
requirements along with results-oriented performance measures--as
our report recommends--that will serve to better evaluate
compliance and facilitate consistent implementation across the
military services. Specifically, the Assistant Secretary commented
that the department will (1) work with AMSA and the military
services to specify reporting requirements, jointly refine
performance measures for critical deployment health activities,
and strive to achieve better alignment of deployment-related
information among AMSA, the services, and the Defense Manpower
Data Center to get a more accurate picture of compliance; and (2)
continue to perform joint site visits to military installations as
a critical complement to centralized monitoring through AMSA and
DMSS, while including independent verification as an internal
quality control mechanism during on-site medical records review.
Our review of the department's new instruction and its planned
actions indicate that DOD is taking steps in the right direction.
If the department follows through with its efforts, we believe
that it will be responsive to our recommendations. DOD's comments
are reprinted in appendix IV.
27Department of Defense Instruction 6200.05, Force Health
Protection (FHP) Quality Assurance (QA) Program (Feb. 16, 2007).
As we agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution
of it until 30 days from the date of this letter. We will then
send copies of the report to the Secretary of Defense, the
Assistant Secretary of Defense for Health Affairs, the Deputy
Assistant Secretary of Defense for Force Health Protection and
Readiness, the Secretaries of the Army, Navy, and Air Force. We
will also send copies to others who are interested and make copies
available to others who request them. This report will also be
available at no charge on GAO's Web site at [27]http://www.gao.gov
.
If you have any questions regarding this report, please contact me
at (202) 512-3604 or [28][email protected] . Contact points for our
Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major
contributions to the report are listed in appendix V.
Sincerely yours,
Brenda S. Farrell
Director, Defense Capabilities and Management
Appendix I: Scope and Methodology
To address our objectives, we obtained and reviewed pertinent
documents, reports, and information related to the Department of
Defense's (DOD) deployment health requirements and deployment
health quality assurance program. We also interviewed responsible
officials at the Assistant Secretary of Defense for Health
Affairs, Deployment Health Support Directorate (DHSD); the Offices
of the Surgeons General for the Army, Air Force, and Navy; the
Army Medical Surveillance Activity (AMSA); and the Combined Fleet
Forces Command and Naval Environmental Health Center in the
Washington, D.C., and Norfolk, Virginia, areas.
To determine whether DOD has established a medical tracking system
to comply with requirements of 10 U.S.C. S 1074f pertaining to
pre- and postdeployment medical examinations, we compared
statutory requirements to DOD policies and requirements.
Specifically, we reviewed relevant sections of 10 U.S.C. S 1074f
to identify system requirements and system elements. We also
reviewed DOD policies, directives, and instructions to identify
the measures that DOD uses to establish the medical condition of
servicemembers and compared these measures to the system
requirements and system elements. In addition, we obtained a legal
opinion from DOD's Office of General Counsel regarding DOD's
compliance with the requirement of 10 U.S.C. S 1074f to perform
pre- and postdeployment medical examinations.
1Pub. L. No. 103-62 (1993).
2See GAO, Standards for Internal Control in the Federal Government,
[60]GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and Internal
Control Management and Evaluation Tool, [61]GAO-01-1008G (Washington,
D.C.: August 2001).
To determine the extent to which DOD has effectively implemented a
deployment health quality assurance program as part of its medical
tracking system, we obtained and analyzed various documents,
including DOD's and the services' deployment health quality
assurance program policies establishing requirements for the
program; the Government Performance and Results Act of 1993;1 and
federal internal control standards.2 We also interviewed key
officials with DHSD and the services' Offices of the Surgeons
General to obtain a comprehensive understanding of the processes,
procedures, and controls used for monitoring and overseeing the
deployment health quality assurance program. We obtained and
analyzed the results of the program's periodic reporting for
calendar years 2004, 2005, and 2006, including monthly AMSA
reports, the quarterly service-specific reports, and DOD's annual
report, to determine the content of the reports, compliance rates
with deployment health requirements, and any trends in compliance
rates, both within and among the services. We also obtained and
analyzed the results of site visits conducted by DHSD in calendar
years 2005 and 2006. To determine the reliability of DOD's quality
assurance program reports, we obtained and analyzed data
collection instruments and other documentation used to record,
summarize, and report the services' compliance with deployment
health requirements. We also discussed with responsible DOD
officials, including representatives from the military services,
their methodology for ensuring that information collected and
reported is as accurate and reliable as possible. Where possible,
we tested data by comparing information from the data collection
instruments or summary documents with available source documents.
We identified issues of inconsistency and incompleteness in DOD's
data and, therefore, determined the data to be insufficiently
reliable for the purpose of assessing compliance with deployment
health requirements and we are making a recommendation to address
this issue accordingly.
In conducting our review, we limited our focus to the procedures
that DOD has in place to medically assess servicemembers before
and after their deployments. Other issues, such as recent
controversies associated with alleged deployments of medically
unfit servicemembers to Iraq, did not fall within the scope of
this review. These issues will be addressed as part of a separate
review.
We performed our work from September 2006 through May 2007 in
accordance with generally accepted government auditing standards.
Appendix II: Pre- and Postdeployment Health Assessment Questionnaires
Appendix III: Individual Medical Readiness
In January 2006, DOD published an instruction,1 requiring that the
services report individual medical readiness. Individual medical
readiness is intended to provide operational commanders, military
department leaders, and primary care managers the ability to
monitor the medical readiness status of their personnel, ensuring
a healthy and fit fighting force that is medically ready to
deploy. DOD Instruction 6025.19 requires quarterly individual
medical readiness reports submitted by the Surgeons General of the
services to the Force Health Protection Council summarizing the
individual medical readiness status of active and selected reserve
members (both officers and enlisted) who are available to deploy.
Assessing individual medical readiness status is a continuous
process and contains six key elements for which servicemembers are
rated as either pass or fail. These elements include the
following:
o Periodic Health Assessment: An annual assessment for changes in
health status, especially changes that could affect a member's
ability to perform military duties.2 Each service is responsible
for determining how it will meet DOD's requirement for the
completion of the Periodic Health Assessment.
o Pass: current Periodic Health Assessment
o Fail: overdue Periodic Health Assessment (not
accomplished within 3 months after the month in which
it is due)
o Deployment-limiting Conditions: Defined by military
department-specific policies. Examples include pregnancy, asthma,
and severe traumatic injury with incomplete rehabilitation.
o Pass: no deployment limiting conditions
o Fail: deployment limiting conditions exist
o Dental Readiness: All services use the same classification
system to assess and monitor dental readiness.
o Pass: class 1 (no dental treatment or reevaluation
required within the next 12 months) or 2 (patients
have the potential for dental emergencies with the
next 12 months but it is not likely if certain
treatments are obtained)
o Fail: class 3 (patients with oral conditions that
if not treated are expected to result in dental
emergencies within the next 12 months) or 4 (patients
requiring a dental examination and whose dental
classification is unknown)
1Department of Defense Instruction 6025.19, Individual Medical Readiness
(Jan. 3, 2006).
2The assessment records general information such as blood pressure,
weight, height; screenings for hearing, vision, and depression; as well as
counseling on leading health indicators. In addition the assessment
includes testing and evaluations based on risk factors such as age, sex,
occupation, and personal habits such as smoking.
o Immunization Status: Required immunizations include hepatitis A,
tetanus-diphtheria, MMR (measles, mumps, and rubella), inactivated
poliovirus (IPV), hepatitis B, and influenza (once per season).
o Pass: all immunizations current
o Fail: overdue for one or more immunizations
o Medical Readiness Laboratory Tests: Includes human
immunodeficiency virus (HIV) testing and deoxyribonucleic acid
(DNA) sample on file.
o Pass: HIV testing, with one result on file within
the past 24 months and a DNA sample on file
o Fail: Missing or past-due HIV test or DNA sample
not on file
o Individual Medical Equipment: Core requirement is one pair of
gas mask inserts for all deployable personnel needing visual
correction.
o Pass: one pair of gas mask inserts for all
deployable personnel needing visual correction
o Fail: no gas mask inserts for all deployable
personnel needing visual correction
Servicemembers are then placed into one of the following four
readiness categories based on the pass/fail grades in the six
elements:
o Fully medically ready: current in all categories including
dental class 1 or 2
o Partially medically ready: lacking one or more immunizations,
readiness laboratory studies, or medical equipment
o Not medically ready: existence of a chronic or prolonged
deployment-limiting condition (per service-specific physical
standards guidelines), including servicemembers who are
hospitalized or convalescing from serious illness or injury, or
individuals in dental class 3
o Medical readiness indeterminate: inability to determine the
servicemember's current health status because of missing health
information such as a lost medical record, an overdue Periodic
Health Assessment or being in dental class 4
The minimum goal for overall medical readiness is to have more
than 75 percent of servicemembers fully medically ready for
deployment.
Appendix IV: Comments from the Department of Defense
Appendix V: GAO Contact and Staff Acknowledgments
GAO Contact
Brenda S. Farrell, (202) 512-3604 or [29][email protected]
Acknowledgments
In addition to the contact named above, Sandra B. Burrell,
Assistant Director; Alissa H. Czyz; Steve J. Fox; Wesley A.
Johnson; Susan J. Mason; Julie C. Matta; Terry L. Richardson; Kate
Robertson; Norris W. Smith; and John C. Wren made key
contributions to this report.
Related GAO Products
DOD Civilian Personnel: Greater Oversight and Quality Assurance
Needed to Ensure Force Health Protection and Surveillance for
Those Deployed. [30]GAO-06-1085 . Washington, D.C.: September 29,
2006.
Military Personnel: DOD and the Services Need to Take Additional
Steps to Improve Mobilization Data for the Reserve Components.
[31]GAO-06-1068 . Washington, D.C.: September 20, 2006.
Military Personnel: Top Management Attention Is Needed to Address
Long-standing Problems with Determining Medical and Physical
Fitness of the Reserve Force. [32]GAO-06-105 . Washington. D.C.:
October 27, 2005.
Defense Health Care: Improvements Needed in Occupational and
Environmental Health Surveillance during Deployments to Address
Immediate and Long-term Health Issues. [33]GAO-05-632 .
Washington, D.C.: July 14, 2005.
Defense Health Care: Force Health Protection and Surveillance
Policy Compliance Was Mixed, but Appears Better for Recent
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Military Personnel: DOD Needs to Address Long-term Reserve Force
Availability and Related Mobilization and Demobilization Issues.
[35]GAO-04-1031 . Washington, D.C.: September 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection
and Surveillance Processes. [36]GAO-04-158T . Washington, D.C.:
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Defense Health Care: Quality Assurance Process Needed to Improve
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Military Personnel: DOD Needs More Data to Address Financial and
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Washington, D.C.: September 10, 2003.
Defense Health Care: Army Has Not Consistently Assessed the Health
Status of Early-deploying Reservists. [39]GAO-03-997T .
Washington, D.C.: July 9, 2003.
Defense Health Care: Army Needs to Assess the Health Status of All
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VA And Defense Health Care: Military Medical Surveillance Policies
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Gulf War Illnesses: Research, Clinical Monitoring, and Medical
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5, 1998.
Gulf War Illnesses: Improved Monitoring of Clinical Progress and
Reexamination of Research Emphasis Are Needed.
[43]GAO/NSIAD-97-163 . Washington, D.C.: June 23, 1997.
Defense Health Care: Medical Surveillance Improved Since Gulf War,
but Mixed Results in Bosnia. [44]GAO/NSIAD-97-136 . Washington,
D.C.: May 13, 1997.
Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet
Medical and Physical Fitness Standards. [45]GAO/NSIAD-94-36 .
Washington, D.C.: March 23, 1994.
Operation Desert Storm: War Highlights Need to Address Problem of
Nondeployable Personnel. [46]GAO/NSIAD-92-208 . Washington, D.C.:
August 31, 1992.
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Highlights of [63]GAO-07-831 , a report to the Ranking Member,
Subcommittee on National Security and Foreign Affairs, Committee on
Oversight and Government Reform, House of Representatives
June 2007
DEFENSE HEALTH CARE
Comprehensive Oversight Framework Needed to Help Ensure Effective
Implementation of a Deployment Health Quality Assurance Program
Overseas deployments expose servicemembers to a number of potential risks
to their health and well-being. However, since the mid-1990s, GAO has
highlighted shortcomings with respect to the Department of Defense's (DOD)
ability to assess the medical condition of servicemembers both before and
after their deployments. Following GAO's May 1997 report, Congress enacted
legislation (10 U.S.C. S 1074f) that required the Secretary of Defense to
establish a medical tracking system for assessing the medical condition of
servicemembers before and after deployments. GAO was asked to determine
(1) whether DOD has established a medical tracking system to comply with
requirements of 10 U.S.C. S 1074f pertaining to pre- and postdeployment
medical examinations, and (2) the extent to which DOD has effectively
implemented a deployment health quality assurance program as part of its
medical tracking system. In conducting this review, GAO analyzed pertinent
documents and interviewed DOD officials.
[64]What GAO Recommends
GAO is recommending that DOD develop a comprehensive oversight framework
with reporting requirements and results-oriented performance measures to
improve the implementation of its deployment health quality assurance
program. In reviewing a draft of this report, DOD concurred with GAO's
recommendations.
DOD has established a system to comply with the requirements of 10 U.S.C.
S 1074f to perform predeployment and postdeployment medical examinations
through a variety of deployment health activities. For example, DOD's
system includes the use of pre- and postdeployment health assessment
questionnaires along with reviews of servicemembers' medical records. The
pre- and postdeployment health assessment questionnaires ask
servicemembers to respond to a series of questions about their current
medical and mental health conditions and any medical concerns they might
have. Prior to deploying, the predeployment questionnaire and
servicemembers' medical records are to be reviewed by a health care
provider to confirm whether servicemembers have met applicable deployment
health requirements. Also, prior to or after redeploying, the
postdeployment questionnaires are to be reviewed by a health care
provider, along with servicemembers' medical records, to determine whether
additional clinical evaluation or treatment is needed.
DOD has established a deployment health quality assurance program as part
of its medical tracking system, but does not have a comprehensive
oversight framework to help ensure effective implementation of the
program. Thus, DOD does not have the information it needs to evaluate the
effectiveness and efficiency of its deployment health quality assurance
program. DOD policy specifies four elements of the program: (1) monthly
reports on active and reserve component servicemembers' deployment health
data from the Army Medical Surveillance Activity (AMSA), (2) quarterly
reports on service-specific quality assurance programs, (3) DOD site
visits to military installations, and (4) an annual report on the program.
DOD guidance requires each of the services to create their own quality
assurance programs based on these elements. However, GAO found weaknesses
in each of these elements. For example, DOD's policy does not contain
specific reporting requirements or performance measures that require AMSA
to provide critical information needed to assess departmentwide compliance
with deployment health requirements, such as tracking the total number of
servicemembers who deploy overseas or return home during a specific time
period. Also, DOD does not have quality controls in place to ensure the
accuracy or completeness of the information it collects during site visits
to military installations. Without a comprehensive oversight framework,
DOD is not well-positioned to determine or assure Congress that active and
reserve component servicemembers are medically and mentally fit to deploy
and to determine their medical and mental condition upon return. Having an
effective deployment health quality assurance program is critically
important given DOD's long-standing problems with assessing the medical
condition of servicemembers before and after their deployments. Such a
program has become even more important in the current environment, where
active and reserve component servicemembers continue to deploy overseas in
significant numbers in support of ongoing military operations in
Afghanistan and Iraq.
References
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46. http://www.gao.gov/cgi-bin/getrpt?GAO/NSIAD-92-208
47. http://www.gao.gov/
48. http://www.gao.gov/
49. http://www.gao.gov/fraudnet/fraudnet.htm
50. mailto:[email protected]
51. mailto:[email protected]
52. mailto:[email protected]
53. http://www.gao.gov/cgi-bin/getrpt?GAO-03-1041
54. http://www.gao.gov/cgi-bin/getrpt?GAO-04-1031
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63. http://www.gao.gov/cgi-bin/getrpt?GAO-07-831
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