Military Personnel: Enhanced Collaboration and Process Improvements Needed for Determining Military Treatment Facility Medical Personnel Requirements

GAO found that the military services' continued focus on separate medical personnel requirements processes may not be consistent with the DOD strategic plan's vision of a more integrated approach, and the services may have missed opportunities to collaborate and develop cross-service manpower standards for common medical capabilities that are shared across military treatment facilities. In response to GAO's findings, DOD established the tri-service Medical Manpower Sub Working Group, under the Military Health System (MHS) Manpower and Personnel Operations Group. The sub working group's charter was issued in 2014 and states that its establishment supports and addresses findings in response to our July 2010 report. Furthermore, the activities outlined in the charter state that the sub working group will: (1) identify common medical capabilities that may benefit from a MHS-wide manpower staffing model, and (2) review and conduct analysis of existing manpower staffing model systems, which are used to develop medical manpower standards. DOD officials told us that the sub working group meets on a regular basis and has completed several efforts in response to our recommendation. Specifically, the group developed Staff Planning Factors to establish a consistent workload value for common medical capabilities shared across the services. After a series of trials and reviews, these factors were fully implemented in 2017 and are incorporated into each service's manpower tools to determine manpower requirements for all military treatment facilities. These efforts demonstrate a more collaborative approach to developing military medical personnel requirements, which more fully supports the MHS strategic planning goal of collaboration and has led to more opportunities to create department-wide benefits. For example, DOD officials told us that the sub working group performed a robust review of two military treatment facilities in the National Capital Region to identify redundancies and complete a tri-service requirements determination evaluation. We believe that DOD's actions meet the intent of our recommendation.

DOD concurred with this recommendation. We reported that, in certain cases, specialty modules within the Army's Automated Staffing Assessment Model contained obsolete assumptions and did not reflect the more advanced level of care being provided. Additionally, prior to 2008, the Army required a random sample of only 2 percent of the requirements models to be validated for reasonableness. However, in June 2018, Army medical officials told us that since 2013 the Army no longer has used the Automated Staffing Assessment model and said that it now uses a more stringent approach that requires all models to be validated by the US Army Manpower Analysis Agency. For example, we confirmed that the Army's largest requirements determination model-the Professional Services Model, which determines the provider and support staff requirements for 38 clinical specialties at 32 military treatment facilities (MTFs)-was validated for a period of five more years in June 2018. While the Army does not specifically use the Automated Staffing Assessment model that we reviewed and recommended changes to anymore, it has implemented a collection of models that covers a large amount of medical specialties across the Army medical infrastructure and which is routinely reviewed and validated by an independent Army agency to better ensure reasonableness and currency. Therefore, the Army's actions have met the intent of this recommendation and should be closed as implemented.

DOD concurred with this recommendation. We reported that according to Army officials, updates to Army medical requirements models were subject to a review process by the U.S. Army Manpower Analysis Agency (USAMAA), and to final approval by the Office of the Assistant Secretary of the Army for Manpower and Reserve Affairs. At the time of our review, Army documents indicated that the USAMAA completed validation of 4 of the 240 modules in 2009 and 2 more so far in 2010. In addition, 12 more modules have either been submitted for review and approval or are nearing submission. While Army Medical Command officials had been working with representatives from USAMAA to develop a specific time line and priorities for validation of the remaining modules, no definitive schedule had been set yet for completing the validation. Although the Army no longer uses the model we reviewed and recommended for which a validation schedule be developed and implemented, Army officials provided a schedule which shows the status of each of its currently used models and when they are due for review and validation/revalidation. Army officials noted that no more models will be submitted to USAMAA until the reorganization with the Defense Health Agency is complete. Therefore, because the Army has a schedule that tracks the review status of each of its models, the Army's actions have met the intent of this recommendation and it should be closed as implemented.

DOD partially concurred with this recommendation. We reported that all three services do not fully incorporate into their requirements processes the use of civilians who deliver health care at the same stage in the process where they determine their military medical personnel requirements. The services first determine their collective requirements. Then, at the local level, after all of the positions at a military treatment facility are staffed with the available military personnel, the commander of the local military treatment facility determines whether a position will be designated as civilian or contractor. In making determinations to use civilian personnel, local commanders use several factors, such as whether the position is military essential-to support readiness or operational missions-or inherently governmental-which would require the position be filled with a government employee. Upon closer review of Department of Defense Directive 1100.4, which requires that, for areas employing both military and civilian personnel, the requirements shall be determined in total and then designated as either military or civilian, but not both, we conclude that the Army's process for establishing its workforce mix is in accordance with this guidance. Therefore, we believe this recommendation should be closed as implemented. Further, the future of DOD's process is unclear because of the transfer of the services' military treatment facilities (MTFs) and associated civilian and contractor personnel to the Defense Health Agency as required by the 2017 National Defense Authorization Act..

DOD partially concurred with this recommendation. We found that the Navy had not utilized a standardized approach or model to determine its medical personnel requirements for its fixed military treatment facilities (MTFs). Instead, the Navy's process was to use current manning as a baseline and adjust the figure based on emerging needs or manor changes in its medical mission and have MTF commanders prepare annual business case analyses for their facilities to be submitted and reviewed through the chain of command and approved as medical resources allowed. While the Navy routinely employed this approach, it was not a validated or verified methodology as required by DOD guidance. To better assess its medical personnel requirement needs, Navy Medical Department revised that approach and began using in 2011 the Navy Requirements Determination (NAVMED REDE) tool to identify total manpower requirements for all of its shore-based activities. According to Navy officials, when this tool was developed, it went through a standardized vetting process that involves research, data collection, model development and review. However, it was not submitted beyond the Navy Medical Department for any line-level formal approval as the Navy considers it more of a tool and a collection of data vice an official model or standard which would be required by DOD guidance to undergo verification and validation throughout its lifecycle. That said, this tool underwent and continues to undergo internal verification and validation. The NAVMED REDE tool primarily combines clinical and non-clinical workload data to determine its medical manpower requirements for 45 selected outpatient clinical specialties such as Family Medicine, Dermatology, but not some other unique functions like Dental Services, Industrial Hygiene, etc as those have their own standards and review processes. According to Navy officials, the NAVMED REDE tool methodology can be applied across specialties. In addition, the workload inputs to the tool are reviewed and revised annually most typically as a result of periodic MTF validation visits. These inputs are also reviewed, validated and approved annually as part of the MHS Governance process via the Manpower and Personnel Operation Group. Thus, with the Navy's change from using decentralized business case analyses to using a more structured approach-although not formally validated, but regularly reviewed-for determining its medical requirements, the Navy's actions meet the intent of this recommendation and it should be closed as implemented.

DOD partially concurred with this recommendation. We found that all three services do not fully incorporate into their requirements processes the use of civilians who deliver health care at the same stage in the process where they determine their military medical personnel requirements. The services first determine their collective requirements. Then, at the local level, after all of the positions at a military treatment facility are staffed with the available military personnel, the commander of the local military treatment facility determines whether a position will be designated as civilian or contractor. In making determinations to use civilian personnel, local commanders use several factors, such as whether the position is military essential-to support readiness or operational missions-or inherently governmental-which would require the position be filled with a government employee. Navy officials stated that it has always taken a Total Force approach to include not just Active Duty, but Reserve, Civilian, and Contractor personnel and the Navy Surgeon General will continue with this emphasis in all future planning and programming for medical personnel. Upon closer review of Department of Defense Directive 1100.4 which requires that, for areas employing both military and civilian personnel, the requirements shall be determine in total and then designated as either military or civilian, but not both, we conclude that the Navy's process for establishing its workforce mix is in accordance with this guidance. Therefore, we believe this recommendation should be closed as implemented. Further, the future of DOD's process is unclear because of the transfer of the services' military treatment facilities (MTFs) and associated civilian and contractor personnel to the Defense Health Agency as required by the 2017 National Defense Authorization Act.

DOD concurred with this recommendation. In 2010, the Air Force activated the 7th Manpower Requirements Flight to independently support the Air Force Surgeon General's and the Air Force Medical Services' effort to develop its medical personnel standards. As of April 2017, this organization was realigned as a direct component of the Air Force Manpower Analysis Agency with the sole responsibility of systematically and methodically identifying essential medical personnel determinants. With the institution of this organization and its implementation of standardized processes, the Air Force currently has a verifiable and validated method to determine its medical personnel requirements. The Air Forces' actions address this recommendation which should be closed as implemented.

DOD partially concurred with this recommendation. We reported that all three services do not fully incorporate into their requirements processes the use of civilians who deliver health care at the same stage in the process where they determine their military medical personnel requirements. The services first determine their collective requirements. Then, at the local level, after all of the positions at a military treatment facility are staffed with the available military personnel, the commander of the local military treatment facility determines whether a position will be designated as civilian or contractor. In making determinations to use civilian personnel, local commanders use several factors, such as whether the position is military essential-to support readiness or operational missions-or inherently governmental-which would require the position be filled with a government employee. Air Force officials stated the Air Force Medical Service personnel standards include the identification of civilian equivalents for those positions that are not deemed military essential. Civilian requirements are also reviewed and determined through the Inherently Governmental/Commercial Activity process. Upon closer review of Department of Defense Directive 1100.4 which requires that, for areas employing both military and civilian personnel, the requirements shall be determine in total and then designated as either military or civilian, but not both, we conclude that the Air Force's process for establishing its workforce mix is in accordance with this guidance. Therefore, we believe this recommendation should be closed as implemented. Further, the future of DOD's process is unclear because of the transfer of the services' military treatment facilities (MTFs) and associated civilian and contractor personnel to the Defense Health Agency as required by the 2017 National Defense Authorization Act.