Theater Commanders Continually Assess Medical Personnel Requirements, but DOD’s Directive on Routine Medical Care for DOD Deployed Civilians Is Not Consistent with In-theater Guidance

Medical officials in theater continually assess the number and the types of  military medical personnel they need to support ongoing contingency  operations in Iraq and Afghanistan. In response to congressional interest about deployed civilians,  the Secretary of Defense reported to Congress in April 2010 that with each  new mission, the need for new civilian skills have resulted in an increase  in the number of deployed civilians and that these civilians are not  immune to the dangers associated with contingency operations. This ongoing assessment takes place in  theater and allows theater officials to identify new medical personnel  requirements and regularly reevaluate existing medical personnel  requirements. The Level of Care That Deployed DOD Civilian Employees Can Expect in Theater is Unclear

Although DOD primarily provides both emergency life-saving medical care  as well as routine medical care to U.S. military personnel in Iraq and  Afghanistan, it is unclear what level of routine medical care deployed DOD  civilian employees can expect in theater. Also, the  organizational design of these medical units used in theater, which  indicates the number and mix of skilled medical personnel these units  should have, has not been updated to reflect current practice in theater. In fact, studies show that for those severely injured  or wounded, 90 percent do not survive if advanced medical care is not  provided within 60 minutes of injury, thus creating urgency for rapid  access to the wounded. Specifically, officials with the Task Force  1st Medical Brigade told us these specialized personnel documents allow  for more up-to-date establishment of personnel requirements to address  gaps caused by splitting medical units. However, the process is difficult  and it came about because current doctrine and organizational design  were not sufficient to address the capabilities needed for splitting medical  units such as combat support hospitals and area support medical  companies. According  to an Army regulation, the Army maintains a lessons learned program to,  among other things, systematically update Army doctrine to enhance the  Army’s preparedness to conduct current and future operations. By  updating Army doctrine and organizational documents for the design of  medical units that could be used in other theaters, the Army could benefit  from incorporating its lessons learned, where appropriate, and be better  assured the current practice of splitting medical units to quickly provide  advanced life-saving emergency medical care to those severely injured or  wounded does not lead to unnecessary staffing challenges. According to medical officials in theater, when these gaps occur, Army  commanders have used two approaches to fill these gaps: backfilling and  cross-leveling. The Army’s 90-day rotation policy— while intended to ease the financial burden of deploying reserve medical  personnel and help retain them—has presented some challenges for the  Army in quickly filling these gaps when a medical provider is not able to  deploy. Although we found examples of the 915th Forward Surgical Team not  having all of its medical personnel before the end of each 90-day rotation,  Army data show the magnitude of these unfilled gaps or late arrivals for  the reserve components ranged from about 3 percent to 7 percent from  January 2008 to July 2010. Agency Comments and Our Evaluation

In written comments provided in response to a draft of this report, DOD  generally concurred with our findings and recommendations. DOD fully  concurred with our first recommendation that the department clarify the  level of care that deployed DOD civilian employees can expect in theater. Specifically, we evaluated the extent to which   (1) DOD has assessed its need for military medical personnel in Iraq and  Afghanistan, (2) the Army has adapted the composition and use of its  medical units to provide advanced medical care, and (3) the Army fills  medical personnel gaps that arise in theater. For the second objective—to evaluate the extent to which the Army has  adapted the composition and use of its medical units to provide advanced  medical care in Iraq and Afghanistan—we reviewed reports from the  medical task forces in theater, Army documentation of the composition of  medical units in Iraq and Afghanistan, theater-level publications regarding  medical care in Iraq and Afghanistan, Army medical doctrine, and Army  field manuals for medical units.
Why GAO Did This Study

For ongoing operations in Afghanistan and Iraq, military medical personnel are among the first to arrive and the last to leave. Sustained U.S. involvement in these operations has placed stresses on the Department of Defense's (DOD) medical personnel. As the U.S. military role in Iraq and Afghanistan changes, the Army must adapt the number and mix of medical personnel it deploys. In response to Congress' continued interest in the services' medical personnel requirements in Iraq and Afghanistan, GAO evaluated the extent to which (1) DOD has assessed its need for medical personnel in theater to support ongoing operations, (2) the Army has adapted the composition and use of medical units to provide advanced medical care, and (3) the Army fills medical personnel gaps that arise in theater. To do so, GAO analyzed DOD policies and procedures on identifying personnel requirements, deploying medical personnel, and filling medical personnel gaps in Iraq and Afghanistan, and interviewed officials.

What GAO Found

Medical officials in theater continually assess the number and the types of military medical personnel they need to support contingency operations in Iraq and Afghanistan and analyze the risks if gaps occur. Given congressional interest about deployed civilians, DOD reported to Congress in April 2010 that with each new mission, the need for new civilian skills has resulted in an increase in deployed civilians and that these civilians are not immune to the dangers associated with contingency operations. Although GAO did not learn of any DOD deployed civilians turned away for care in theater during this review, it is unclear the extent they can expect routine medical care in theater given that a DOD directive and theater guidance differ with regard to their eligibility for routine care. By clarifying these documents, DOD could reduce uncertainty about the level of routine care deployed DOD civilians can expect in theater and provide more informed insights into the military medical personnel requirements planning process. Army theater commanders have been reconfiguring or splitting medical units to cover more geographical areas in theater to better provide advanced emergency life-saving care quicker, but Army doctrine and the organizational design of these units, including needed staff, have not been fully updated to reflect these changes. Studies show that for those severely injured or wounded, 90 percent do not survive if advanced medical care is not provided within 60 minutes of injury. Officials in theater told GAO they are using specialized personnel documents to staff these medical units with more up-to- date personnel requirements to address gaps caused by splitting medical units, and that current doctrine and organizational design were not sufficient to address the capability needed for splitting medical units. According to an Army regulation, it maintains its lessons learned program to systematically update Army doctrine and enhance the Army's preparedness to conduct current and future operations. By updating Army doctrine and organizational documents for the design of medical units that could be used in other theaters, the Army could benefit from incorporating its lessons learned, where appropriate, and be better assured the current practice of splitting medical units to quickly provide advanced life-saving emergency medical care to those severely injured or wounded does not lead to unnecessary staffing challenges. Army commanders have used two approaches--cross-leveling and backfilling--to fill medical personnel gaps that arise in theater due to reasons such as illnesses, emergency leave, and resignations of medical personnel. When these gaps in needed medical personnel occur, the Army's 90-day rotation policy--while intended to ease the financial burden of deploying reserve medical personnel and help retain them--has presented some challenges in quickly filling these gaps in theater with reserve medical personnel when a medical provider is not able to deploy. However, Army data show the magnitude of these unfilled gaps or late arrivals for the reserve component medical providers ranged from about 3 percent to 7 percent from January 2008 to July 2010.

What GAO Recommends

GAO recommends that (1) DOD clarify the level of routine medical care that deployed DOD civilian employees can expect in theater and (2) the Army update its doctrine and the organizational design of split medical units. In response to a draft of this report, DOD generally concurred with the recommendations.