Defense Infrastructure: Documentation Lacking to Fully Support How DOD Determined Specifications for the Landstuhl Replacement Medical Center
Highlights
What GAO Found
Department of Defense (DOD) officials considered current beneficiary population data, contingency operations, and most of the expected changes in troop strength when planning for the replacement medical center. However, recently announced posture changes in January 2012 have yet to be assessed for their impact on the facility. DOD estimates that the replacement medical center will provide health care for nearly 250,000 beneficiaries. A majority of those who are expected to receive health care from the center come from within a 55-mile radius of the facility. DOD officials told us that because the replacement medical center was designed for peacetime operations—with the capacity to expand to meet the needs of contingency operations—reductions in ongoing contingency operations in Afghanistan would not have an impact on facility requirements. At the time of this review, DOD officials said they were in the process of assessing proposed changes in posture to better understand their possible impact on the sizing of the replacement medical center.
DOD officials incorporated patient quality of care standards as well as environmentally friendly design elements in determining facility requirements for the replacement medical center. DOD also determined the size of the facility based on its projected patient workload. Internal control standards require the creation and maintenance of adequate documentation, which should be clear and readily available for examination to inform decision making. However, GAO’s review of the documentation DOD provided in support of its facility requirements showed (1) inconsistencies in how DOD applied projected patient workload data and planning criteria to determine the appropriate size for individual medical departments, (2) some areas where the documentation did not clearly demonstrate how planners applied criteria to generate requirements, and (3) calculation errors throughout. Without clear documentation of key analyses—including information on how adjustments to facility requirements were made—and without correct calculations, stakeholders and decision makers lack reasonable assurances that the replacement medical center will be appropriately sized to meet the needs of the expected beneficiary population in Europe.
DOD’s process for developing the approximately $1.2 billion cost estimate for the replacement medical center was substantially consistent with many cost estimating best practices, such as cross-checking major cost elements to confirm similar results. However, DOD minimally documented the data sources, calculations, and estimating methodologies it used in developing the cost estimate. Additionally, DOD anticipates that the new facility will become the hub of a larger medical-services-related campus, for which neither cost estimates nor time frames have yet been developed. Without a cost estimate for the facility that includes detailed documentation, DOD cannot fully demonstrate that the proposed replacement medical center will provide adequate health care capacity at the current estimated cost. Further, DOD and Congress may not have the information they need to make fully informed decisions about the facility.
Why GAO Did This Study
Landstuhl Regional Medical Center (LRMC) is DOD’s only tertiary medical center in Europe that provides specialized care for servicemembers, retirees, and their dependents. Wounded servicemembers requiring critical care are medically evacuated from overseas operations to the 86th Medical Group clinic at Ramstein Air Base to receive stabilization care before being transported to LRMC for intensive care. According to DOD, both facilities were constructed in the 1950s and are undersized to meet current and projected workload requirements. DOD plans to consolidate both facilities into a single medical center at an estimated cost of $1.2 billion. In this report, GAO (1) describes how DOD considered changes in posture and the beneficiary population when developing facility requirements, (2) assesses DOD’s process for determining facility requirements, and (3) reviews DOD’s process to develop the facility’s cost estimate. GAO examined posture planning documentation, beneficiary demographic data, plans for the replacement medical center, and relevant DOD guidance, as well as interviewed relevant DOD officials.
Recommendations
GAO recommends that DOD provide clear and thorough documentation of how it determined the facilitys size and cost estimate, correct any calculation errors, and update its cost estimate to reflect these corrections and recent posture changes. In commenting on a draft of this report, DOD concurred with GAOs recommendations and stated that it has conducted a reassessment of the project that will be released once approved by the Secretary of Defense.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | To ensure that the replacement medical center is appropriately sized to meet the health care needs of beneficiaries in a cost-effective manner, as part of the facility's recertification process, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to provide sufficient and clear documentation on how medical planners applied DOD criteria to determine the facility's requirements, including how and why medical planners made adjustments to the criteria. | DoD acknowledged that there were some deficiencies in the documentation of the HCRA, including deviations from published criteria. While the planning team may have had legitimate reasons for making adjustments, assumptions and data used to draw conclusions about facility sizing were not always clearly documented. DoD stated that it had recently conducted a reassessment of the original $1.2 billion project submitted in the FY12 President's Budget request. This new analysis was conducted in a manner separate and independent of the analysis reviewed by GAO. The Department believes this new analysis (called the Recertification Report) responds to GAO's recommendations by utilizing the most... current data including recently announced force structure changes and by providing a documented audit trail of how the scope, size, and costs were developed. Specifically DOD stated that the assumptions that serve as the basis for sizing three courses of action (COA) are clearly stated. Data trails are explicit and when there are deviations from existing criteria, a rationale is provided. At the time of our review DOD had not yet made the Recertification Report available for our review. Subsequently, DOD provided GAO with a copy of the Recertification Report for review and on April 1, 2013 DOD officials met with GAO to discuss details of the new analysis. According to DOD officials, specific steps were taken to ensure that there was sufficient and clear documentation on how medical planners applied DOD criteria to determine the facility's requirements, based on our recommendation. In addition to the depth of documentation in the Recertification Report itself, DOD officials provided us with supplemental documentation used to generate the requirements. For example, DOD provided GAO with a spreadsheet that showed a summary of the process for moving from requirements, to space, to cost. Additionally, as a specific example, they provided documentation that showed the process used to generate requirements for primary care exam rooms. As a result of the details contained in the Recertification Report as well as the supporting documentation, we believe DOD has implemented the intent of the recommendation and provided a much clearer link between criteria and the resulting facility's requirements than the original HCRA.
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| Department of Defense | To ensure that the replacement medical center is appropriately sized to meet the health care needs of beneficiaries in a cost-effective manner, as part of the facility's recertification process, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to correct any calculation errors and show what impact, if any, these errors had on the sizing of the facility. | DoD acknowledges that the HCRA contained some calculation errors. DOD stated in its Agency comments that all calculations Had since been re-computed as part of the recently completed re-assessment and efforts had been made to ensure their accuracy and consistency. DoD stated that it had recently conducted a reassessment of the original $1.2 billion project submitted in the FY12 President's Budget request. This new analysis was conducted in a manner separate and independent of the analysis reviewed by GAO. The Department believes this new analysis responds to GAO's recommendations by utilizing the most current data including recently announced force structure changes and by providing a...
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| Department of Defense | In light of recently announced posture changes and potential adjustments that may need to be made in facility requirements based on correcting identified calculation errors in the original documentation, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to revise the cost estimate for the center, incorporating the best practices outlined in the GAO Cost Estimating and Assessment Guide to (1) reflect these potential posture changes, (2) update it with the revised calculations as part of the recertification process, and (3) more thoroughly document the data, assumptions, calculations, and methodology used to develop specific cost elements. | According to DOD officials, DOD has taken steps to incorporate posture changes, verify requirement calculations, and provide thorough documentation of the steps taken in submitting its revised cost estimate of the Landstuhl replacement facility. DOD's reassessment of the original $1.2 billion project submitted in the FY12 President's Budget is referred to as the Recertification Report. According to DOD, this report was conducted in a manner separate and independent of the analysis reviewed by GAO. The Department believes this new analysis responds to GAO's recommendations by utilizing the most current data including recently announced force structure changes and by providing a documented...
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