Defense Health Care: Actions Needed to Define and Sustain Wartime Medical Skills for Enlisted Personnel
GAO-21-337
Published: Jun 17, 2021. Publicly Released: Jun 17, 2021.
Fast Facts
DOD's more than 73,000 enlisted medical personnel serve in roles ranging from paramedics to imaging technicians, and must be ready to use their wartime medical skills to care for injured and ill servicemembers.
However, DOD could do more to define, track, and assess wartime medical skills. For example, the Army does not consistently track skills training in its official system, and none of the services have developed targets for training completion. As a result, DOD lacks information on the preparedness of enlisted medical personnel to perform their lifesaving roles.
Our 30 recommendations are to help improve training, assessment, and more.
Army medical personnel conduct medical evacuation training
Highlights
What GAO Found
The military departments have not fully defined, tracked, and assessed wartime medical skills for enlisted medical personnel. The departments have defined these skills for 73 of 77 occupations. However, among other issues,
- the Army and the Air Force have not defined skills for numerous highly-skilled subspecialties that require additional training and expertise, such as Army Critical Care Flight Paramedics. Subspecialty personnel are key to supporting lifesaving medical care during deployed operations.
- The Army does not consistently track wartime medical skills training for enlisted medical personnel in its official system.
- The military departments are not able to fully assess the preparedness of enlisted medical personnel because, according to officials, they have not developed performance goals and targets for skills training completion.
As a result, the military departments lack reasonable assurance that all enlisted medical personnel are ready to perform during deployed operations.
The Department of Defense (DOD) has not fully developed plans and processes to sustain the wartime medical skills of enlisted medical personnel. While the Defense Health Agency (DHA) has initiated planning efforts to assess how the military departments' three primary training approaches sustain readiness (see figure), these efforts will not fully capture needed information. For example, DHA's planned metrics to assess the role of military hospitals and civilian partnerships in sustaining readiness would apply to a limited number of enlisted occupations. As a result, DHA is unable to fully assess how each training approach sustains readiness and determine current and future training investments.
Approaches to Train Enlisted Medical Personnel's Wartime Medical Skills
DOD officials have identified challenges associated with implementing its training approaches. For example, DOD relies on civilian partnerships to sustain enlisted medical personnel's skills, but DOD officials stated that licensing requirements and other issues present challenges to establishing and operationalizing civilian partnerships. DOD has not analyzed or responded to such risks, and may therefore be limited in its ability to sustain wartime medical skills.
Why GAO Did This Study
DOD has over 73,000 active-duty enlisted medical personnel who must be ready to provide life-saving care to injured and ill servicemembers during deployed operations, using their wartime medical skills.
Senate Report 116-48 accompanying a bill for the National Defense Authorization Act for Fiscal Year 2020 included a provision for GAO to review DOD's efforts to maintain enlisted personnel's wartime medical skills. This report examines, among other objectives, the extent to which (1) the military departments have defined, tracked, and assessed enlisted personnel's wartime medical skills, and (2) DOD has developed plans and processes to sustain these skills and assessed risks associated with their implementation. GAO analyzed wartime medical skills checklists and guidance; reviewed plans for skills sustainment; and interviewed officials from DOD and military department medical commands and agencies, and nine inpatient military medical treatment facilities.
Recommendations
GAO is making 30 recommendations, including that military departments fully define and implement wartime medical skills for enlisted medical personnel subspecialties, track skills training, and establish performance goals and targets for training completion, as appropriate; and that DOD develop metrics to assess how military medical treatment facility workload and civilian partnerships sustain these skills and assess risks to skills sustainment. DOD concurred and described some related actions, as discussed in the report.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of the Army | The Secretary of the Army should ensure that the Commanding General, U.S. Army Medical Center of Excellence, takes corrective action to define wartime medical skills for enlisted medical subspecialties with an expeditionary role. (Recommendation 1) |
The Army concurred with this recommendation. In a May 2024 status update, the Army stated that it had taken steps to implement this recommendation with an estimated completion date of June 2024. As of December 2024, the Army has not provided an update on the status of its efforts. We will update the status of this recommendation once we confirm what actions the Army has taken.
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| Department of the Air Force | The Secretary of the Air Force should ensure that the Surgeon General of the Air Force, in coordination with the Commander, Air Force Medical Readiness Agency, takes corrective action to define and implement wartime medical skills for enlisted medical subspecialties with an expeditionary role. (Recommendation 2) |
The Air Force concurred with this recommendation. In a May 2024 status update, the Air Force stated that it had implemented this recommendation but did not provide supporting documentation. As of December 2024, the Air Force has not provided this documentation. We will update the status of this recommendation once we determine what actions it has taken.
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| Department of the Air Force | The Secretary of the Air Force should ensure that the Surgeon General of the Air Force, in coordination with the Commander, Air Force Medical Readiness Agency, establishes guidance that requires the development of wartime medical skills for current and future enlisted medical subspecialties with an expeditionary role. (Recommendation 3) |
In June 2021, DOD concurred with this recommendation. In May 2024, DOD officials provided a revised version of Department of the Air Force Instruction 41-106, Air Force Medical Readiness Program, which requires the development of wartime medical skills for current and future enlisted medical subspecialties - including those with an expeditionary role. Specifically, the guidance requires the Air Force to develop skills for subspecialties as part of the same process by which it develops skills for general enlisted medical occupations. By updating this guidance, the Air Force has greater assurance that wartime medical skills are defined for occupational subspecialities on a continual basis.
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| Department of the Army | The Secretary of the Army should ensure that the Commanding General, U.S. Army Medical Center of Excellence, takes corrective action to fully incorporate joint wartime medical skills into Army wartime medical skills checklists. (Recommendation 4) |
The Army concurred with this recommendation and stated in May 2024 that implementing actions were underway, with an estimated completion date of June 2024. As of December 2024, the Army has not provided an update on the status of its efforts. We will update the status of this recommendation once we confirm what actions the Army has taken.
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| Department of the Air Force | The Secretary of the Air Force should ensure that the Surgeon General of the Air Force, in coordination with the Commander, Air Force Medical Readiness Agency, takes corrective action to fully incorporate joint wartime medical skills into Air Force wartime medical skills checklists. (Recommendation 5) |
The Air Force concurred with this recommendation. In a May 2024 status update, the Air Force stated that it had implemented this recommendation but did not provide supporting documentation. As of December 2024, the Air Force has not provided this documentation. We will update the status of this recommendation once we determine what actions it has taken.
|
| Department of the Air Force | The Secretary of the Air Force should ensure that the Surgeon General of the Air Force, in coordination with the Commander, Air Force Medical Readiness Agency, issues guidance requiring the incorporation of joint wartime medical skills into Air Force checklists. (Recommendation 6) |
In June 2021, DOD concurred with this recommendation. In May 2024, DOD officials provided a revised version of Department of the Air Force Instruction 41-106, Air Force Medical Readiness Program, which requires the incorporation of joint wartime medical skills into wartime medical skills checklists. Specifically, the guidance requires the Air Force to develop, maintain, refine, and validate wartime medical skills checklists, including by incorporating joint medical knowledge, skills, and abilities, where it is appropriate. By updating this guidance, the Air Force has greater assurance that its wartime medical skills checklists will be updated as joint skills are identified for common occupations and as changes are made to existing joint skills.
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| Department of the Air Force | The Secretary of the Air Force should ensure that the Surgeon General of the Air Force, in coordination with the Commander, Air Force Medical Readiness Agency, takes corrective action to review and update outdated wartime medical skills checklists for enlisted medical occupations. (Recommendation 7) |
The Air Force concurred with this recommendation. In a May 2024 status update, the Air Force stated that it had implemented this recommendation but did not provide supporting documentation. As of December 2024, the Air Force has not provided this documentation. We will update the status of this recommendation once we determine what actions it has taken.
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| Department of the Army | The Secretary of the Army should ensure that the Commanding General, U.S. Army Training and Doctrine Command, updates its guidance to require the specification of acceptable methods of sustainment training for wartime medical skills for enlisted medical personnel. (Recommendation 8) |
The Army concurred with this recommendation and stated in a May 2024 update that implementing actions were underway, with an estimated completion date of June 2024. As of December 2024, the Army has not provided an update on the status of its efforts. We will update the status of this recommendation once we confirm what actions the Army has taken.
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| Department of the Army | The Secretary of the Army should ensure that the Commanding General, U.S. Army Medical Center of Excellence, incorporates findings on skills degradation from DOD's project on highly perishable and mission-essential medical skills into its processes to identify appropriate training frequencies of wartime medical skills. (Recommendation 9) |
The Army concurred with this recommendation and stated in a May 2024 update that implementing actions were underway, with an estimated completion date of June 2024. As of December 2024, the Army has not provided an update on the status of its efforts. We will update the status of this recommendation once we confirm what actions the Army has taken.
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| Department of the Navy | The Secretary of the Navy should ensure that the Surgeon General of the Navy incorporates findings on skills degradation from DOD's project on highly perishable and mission-essential medical skills into its processes to identify appropriate training frequencies of wartime medical skills. (Recommendation 10) |
The Navy concurred with this recommendation and stated in a May 2024 status update that implementing actions are underway, with an estimated completion date of June 2024. As of December 2024, the Navy has not provided an update on the status of its efforts. We will update the status of this recommendation once we confirm what actions the Navy has taken.
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| Department of the Air Force | The Secretary of the Air Force should ensure that the Surgeon General of the Air Force, in coordination with the Commander, Air Force Medical Readiness Agency, incorporates findings on skills degradation from DOD's project on highly perishable and mission-essential medical skills into its processes to identify appropriate training frequencies of wartime medical skills. (Recommendation 11) |
The Air Force concurred with this recommendation. In a May 2024 status update, the Air Force stated that it had implemented this recommendation but did not provide supporting documentation. As of December 2024, the Air Force has not provided this documentation. We will update the status of this recommendation once we determine what actions it has taken.
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| Department of the Army | The Secretary of the Army should ensure that the Surgeon General of the Army requires the consistent tracking of training on wartime medical skills for enlisted medical personnel. (Recommendation 12) |
The Army concurred with this recommendation and stated in a May 2024 status update that it was taking steps to implement this action with an estimated completion date of June 2024. As of December 2024, the Army has not provided an update on the status of its efforts. We will update the status of this recommendation once we determine what actions the Army has taken.
|
| Department of the Army | The Secretary of the Army should ensure that the Surgeon General of the Army establishes performance goals and targets for the completion of training on wartime medical skills for enlisted medical occupations and tracks performance toward achieving the goals and targets. (Recommendation 13) |
The Army concurred with this recommendation and stated in a November 2024 status update that it was taking steps to implement this action. While the Army outlined efforts to track completion of training, it did not provide any evidence that it had established associated performance goals and targets. We will continue to engage with the Army on this topic and update the status of this recommendation as appropriate.
|
| Department of the Navy | The Secretary of the Navy should ensure that the Surgeon General of the Navy establishes performance goals and targets for the completion of training on wartime medical skills for enlisted medical occupations and tracks performance toward achieving the goals and targets. (Recommendation 14) |
The Navy concurred with this recommendation and stated in a May 2024 status update that implementing actions are underway, with an estimated completion date of June 2024. As of December 2024, the Navy has not provided an update on the status of its efforts. We will update the status of this recommendation once we confirm what actions the Navy has taken.
|
| Department of the Air Force | The Secretary of the Air Force should ensure that the Surgeon General of the Air Force, in coordination with the Commander, Air Force Medical Readiness Agency, establishes performance goals and targets for the completion of training on wartime medical skills for enlisted medical occupations and tracks performance toward achieving the goals and targets. (Recommendation 15) |
The Air Force concurred with this recommendation. In a May 2024 status update, the Air Force stated that it had implemented this recommendation but did not provide supporting documentation. As of December 2024, the Air Force has not provided this documentation. We will update the status of this recommendation once we determine what actions it has taken.
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| Department of Defense | The Secretary of Defense should ensure the Director, DHA, develops metrics to assess the contributions of MTF workload to sustaining wartime medical skills that include the medical care provided by enlisted medical personnel. (Recommendation 16) |
DOD concurred with this recommendation. The DHA has not yet implemented this recommendation. In a November 2024 status update, the DHA stated that it will address this recommendation through development of a metric and dashboard methodology for enlisted medical personnel, with an estimated completion date of January 2026.
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| Department of Defense | The Secretary of Defense should ensure the Director, DHA, develops the required inventory of civilian partnerships to include all partnerships in which enlisted medical personnel may participate. (Recommendation 17) |
DOD concurred with this recommendation. The DHA has not yet implemented this recommendation. In a November 2024 status update, the DHA stated that it will develop the required inventory by September 2025.
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| Department of Defense | The Secretary of Defense should ensure the Director, DHA, develops a process to identify opportunities to streamline or add military-civilian training partnerships. (Recommendation 18) |
DOD concurred with this recommendation. The DHA has not yet implemented this recommendation. In a November 2024 status update, the DHA stated that it is developing a process to identify opportunities to streamline or add military-civilian training partnerships. This effort has an estimated completion date of December 2025.
|
| Department of Defense | The Secretary of Defense should ensure the Director, DHA, develops metrics to assess the contributions of civilian partnerships to sustaining wartime medical skills that include the medical care provided by enlisted medical personnel. (Recommendation 19) |
DOD concurred with this recommendation. The DHA has not yet implemented this recommendation. In a November 2024 status update, the DHA stated that it will address this recommendation via the development of a set of metrics and corresponding dashboards for select enlisted medical personnel, with an estimated implementation date of January 2026.
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| Department of Defense | The Secretary of Defense should ensure the Director, DHA, performs the proposed assessment of available simulation programs, demand for them, and gaps in clinical training and simulation requirements. (Recommendation 20) |
DOD concurred with this recommendation. The DHA has not yet implemented this recommendation. In a November 2024 status update, the DHA outlined a series of actions to implement this recommendation, with an estimated completion date of June 2025.
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| Department of the Army | The Secretary of the Army should ensure the Surgeon General develops and implements a consistent clinical readiness assessment process for wartime medical skills maintenance to identify and address gaps in training. (Recommendation 21) |
The Army concurred with this recommendation. The Army has not yet implemented this recommendation. In a May 2024 status update, the Army stated that this recommendation would be addressed through a future enterprise operations, analytics, and data management platform. The Army provided an estimated completion date of June 2024 for this effort. As of December 2024, the Army has not provided an update on the status of its efforts. We will update the status of this recommendation once we determine what actions the Army has taken.
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| Department of the Navy | The Secretary of the Navy should ensure the Surgeon General develops and implements a consistent clinical readiness assessment process for wartime medical skills maintenance to identify and address gaps in training. (Recommendation 22) |
The Navy concurred with this recommendation. The Navy has not yet implemented this recommendation. In a May 2024 status update, the Navy stated that it will take steps to implement this recommendation by June 2024. As of December 2024, the Navy has not provided an update on the status of its efforts. We will update the status of this recommendation once we determined the steps the Navy has taken.
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| Department of Defense | The Secretary of Defense should ensure the Director, DHA, in conjunction with the Surgeons General of the Army, the Navy, and the Air Force analyzes and responds, as appropriate, to risks to sustaining enlisted personnel wartime medical skills associated with: (1) staffing challenges at MTFs; (2) managing rotations of non-MTF personnel to MTFs; (3) barriers to civilian partnerships; and (4) challenges in providing enlisted medical personnel opportunities to train on expeditionary medical equipment. (Recommendation 23) |
DOD concurred with this recommendation. DOD has not yet implemented this recommendation. In a November 2023 status update, DOD outlined a series of steps to implement this recommendation, with an estimated completion date of September 2027. As of December 2024, the DOD has not provided an update on the status of its efforts. We will update the status of this recommendation once we determine what steps DOD has taken.
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| Department of the Army | The Secretary of the Army should develop annual retention goals, by skill level, for enlisted medical personnel. (Recommendation 24) |
The Army concurred with this recommendation. However, in a November 2024 update the Army stated that annual retention goals are inflexible and did not outline any steps to implement this recommendation. We will continue to engage with the Army on this topic.
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| Department of the Navy | The Secretary of the Navy should develop annual retention goals, by skill level, for enlisted medical personnel. (Recommendation 25) |
The Navy concurred with this recommendation. However, in a November 2024 update the Navy stated that its current system more effectively serves the objective of managing personnel levels and did not outline any steps to implement this recommendation. We will continue to engage with the Navy on this topic.
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| Department of the Air Force | The Secretary of the Air Force should develop annual retention goals, by skill level, for enlisted medical personnel. (Recommendation 26) |
The Air Force concurred with this recommendation. In a May 2024 status update, the Air Force stated that it had implemented this recommendation but did not explain how or provide any supporting documentation. As of December 2024, the Air Force has not provided this documentation. We will update the status of this recommendation once we determine what actions it has taken.
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| Department of the Army | The Secretary of the Army should consider incorporating data on civilian pay for comparable occupations in the Army's decision-making processes for awarding retention bonuses. (Recommendation 27) |
The Army concurred with this recommendation. However, in a November 2024 update the Army did not outline any steps to implement this recommendation. We will update the status of this recommendation once we confirm what actions, if any, the Army has taken.
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| Department of the Navy | The Secretary of the Navy should consider incorporating data on civilian pay for comparable occupations in the Navy's decision-making processes for awarding retention bonuses. (Recommendation 28) |
The Navy concurred with this recommendation. However, in a November 2024 update the Navy stated that it believes its current system effectively serves the objective of managing retention bonuses and did not outline any steps to implement this recommendation. We will continue to engage with the Navy on this topic.
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| Department of the Air Force | The Secretary of the Air Force should consider incorporating data on civilian pay for comparable occupations in the Air Force's decision-making processes for awarding retention bonuses. (Recommendation 29) |
The Air Force concurred with this recommendation. In a May 2024 status update, the Air Force stated that it had implemented this recommendation but did not explain how or provide any supporting documentation. As of December 2024, the Air Force has not provided this documentation. We will update the status of this recommendation once we determine what actions it has taken.
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| Department of the Navy | The Secretary of the Navy should include information on the cost of training in its decision-making process for awarding retention bonuses. (Recommendation 30) |
The Navy concurred with this recommendation. In a May 2024 update, the Navy stated that it had implemented this recommendation but did not provide supporting documentation. We will continue to engage with the Navy and will update this recommendation once we determine what actions it has taken.
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