Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

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Digital Military Collection

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MATURATIONOFTHECOMBATHEALTHCARESUPPORTSYSTEMINIRAQ OctoberDecember2008Perspective1MGRussellJ.CzerwTaskForce62MedicalBrigadeCombatHealthcareSupportSystem5intheMatureIraqTheaterofOperationsCOLPatrickD.Sargent,MS,USAHealthcareSystemPlanningAlongtheCombatTheaterMaturityContinuum:11TransitioninganExpeditionaryMedicalForcetoanIntegratedHealthcareSystemCOLDavidP.Budinger,MS,USAASystematicApproachtoCombatHealthcareImprovement:19TaskForce62MedicalBrigadeCombatHealthcareSupportSystemModelMAJAlanK.Ueoka,MS,USAMedicalCivil-MilitaryOperations:TheDeployedMedicalBrigadesRolein25CounterinsurgencyOperationsLTCJeffreyBryan,USA;CPTDanelleMiyamoto,MS,USA;LTCVincentHolman,MS,USATransitionoftheDetaineeHealthcareSystemtoaCorrectionalModel:29AnInteragencyApproachLTCVincentHolman,MS,USAEmploymentofaJointMedicalTaskForceinaCounterinsurgencyOperationalEnvironment35COLScottAvery,MS,USA;LTCVincentHolman,MS,USATheComplexityofMovingPatientsinTodaysMaturing41CounterinsurgencyEnvironment:Who,When,andHowLTCMichaelC.Richardson,MS,USAClinicalQualityManagementinaMatureCombatEnvironment51COLSuszClark,AN,USA;MSG(P)RichardBrewer,USAMedicalCapabilityTeam:TheClinicalMicrosystemfor57CombatHealthcareDeliveryinCounterinsurgencyOperationsCOLSuszClark,AN,USA;MAJJonK.VanSteenvort,MS,USATheDeployedElectronicMedicalRecord63MAJLeslieE.Smith,MS,USAMedicalEquipmentStandardizationinaMaturingCombatTheater68LTCBruceSyvinski,MS,USA;CPTJasonHughes,MS,USAAppliedEthicsinaCombatTheaterofOperations71MAJFrederickC.Jackson,MS,USAHealthFacilitiesPlanning:DeterminingInfrastructureRequirements79forFormandFunctionfromClinicalandOperationalCapabilitiesMAJDonChapman,MS,USA;LTCKristenL.Palaschak,AN,USAExpandingaProfessionalDentalCareSystem:ExperiencesofTaskForce26188MultifunctionalMedicalBattalionDuringOperationIraqiFreedom07-09LTC(P)FrankL.Christopher,MC,USA;etal

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LTGEricB.SchoomakerTheSurgeonGeneralCommander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneralUSArmyMedicalDepartmentCenterandSchool 0911102GEORGEW.CASEY,JRGeneral,UnitedStatesArmyChiefofStaff DISTRIBUTION:SpecialAdministrativeAssistanttotheSecretaryoftheArmyByOrderoftheSecretaryoftheArmy:Official: JOYCEE.MORROWOnlineissuesoftheAMEDDJournalareavailableathttp://www.cs.amedd.army.mil/references_publications.aspx AProfessionalPublicationoftheAMEDDCommunity TheArmyMedicalDepartmentJournal[ISSN1524-0436]ispublishedquarterlyforTheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN:MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078.CORRESPONDENCE:Manuscripts,photographs,officialunitrequeststoreceivecopies,andunitaddresschangesordeletionsshouldbesenttotheJournalattheaboveaddress.Telephone:(210)221-6301,DSN471-6301DISCLAIMER:TheJournalpresentsclinicalandnonclinicalprofessionalinformationtoexpandknowledgeofdomestic&internationalmilitarymedicalissuesandtechnologicaladvances;promotecollaborativepartnershipsamongServices,components,Corps,andspecialties;conveyclinicalandhealthservicesupportinformation;andprovideapeer-reviewed,highquality,printmediumtoencouragedialogueconcerninghealthcareinitiatives.Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUSArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeorsupersedeinformationinotherArmyPublications.TheJournalreservestherighttoeditallmaterialsubmittedforpublication(seeinsidebackcover).CONTENT:Contentofthispublicationisnotcopyrightprotected.Materialmaybereprintedifcreditisgiventotheauthor(s).OFFICIALDISTRIBUTION:ThispublicationistargetedtoUSArmyMedicalDepartmentunitsandorganizations,andothermembersofthemedicalcommunityworldwide. OctoberDecember2008TheArmyMedicalDepartmentCenter&SchoolPB8-08-10/11/12

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OctoberDecember20081Afewmonthsago,thestaffoftheArmyMedicalDepartmentJournalandIwerecontactedbythe62ndMedicalBrigade,thendeployedtoIraqasTaskForce62MedicalBrigade(TF62MED),whopresentedaproposalofsignificantrelevanceandvalue,notonlyforcurrentcombatoperations,butalsofortrainingandplanninginthelongterm.TF62MEDofferedacollectionofmanuscriptsdealingwiththevariousaspectsoftheirexperiences,initiatives,andlessonslearnedinIraq,allwrittenwhiletheauthorswereintheater.Therefore,theinformationisofimmediaterelevance,reflectingthesituationasitexistsinIraqrightnow,ratherthandiscussionsofexperiencesofatotallydifferentenvironment.WeareverypleasedtopresentthosearticlesinthiseditionoftheAMEDDJournal,andstronglyrecommendthattheinformationtheycontainbestudiedbyallcommandsandorganizationsinvolvedinmilitarymedicine,atalllevels.Thereareimplicationsforplanning,training,andmanagement,aswellasareasthatshouldbeaddresseddoctrinally,because,inalllikelihood,IraqandAfghanistanrepresenttheoperationalcombatenvironmentsoftheforeseeablefuture.Uponarrivalintheater,theleadershipofTF62MEDquicklyrecognizedthattheenvironmentwithinwhichtheywouldberequiredtoprovidehealthcaresupporthaddramaticallychangedfromthatencounteredbypreviousmedicalsupportunits.Obviously,duringhighintensitycombatoperations,themedicalsupportresourcesarefocusedonprovidingthoseservicesmostnecessaryinthetacticalenvironmenttosavethelivesofwoundedandinjuredWarriors.However,TF62MEDfounditselfinatotallydifferentsituation,amaturetheaterofoperationswithinwhichcasualtiesfromdirectcombathavebeensignificantlyreduced.However,evenmorecomplexchallengesweredevelopingastheUSmilitaryoperatesinacounterinsurgencyenvironment,whileassistingtheIraqistodevelopthecapabilitytoassumetheirownsecurityresponsibilities.TheroleofhealthcaresupporthadtobereevaluatedandtailoredtobecomeavaluablefactorintheoverallmissionofCoalitionforcesasitexiststoday.COLPatrickSargent,theCommanderofTF62MED,wasthedrivingforcebehindthedevelopmentandimplementationofaplantoprovidethehighestlevelofmedicalsupporttothemultinationalforcethroughoutIraq,includingCoalitionandIraqisecurityforces,whileassistingtheIraqigovernmentinthecreationofapublichealthcarestructure.Hisopeningarticledescribesthephilosophyandapproachthatestablishedtheoverallstructureforthisambitious,extensive,andcomplexadjustmentoftheexistingmedicalcapabilities.Subsequentarticlesdetailvariousaspectsoftheresultinghealthcaresupportsystem,providingaclearperspectiveontheextentoftheeffortinvolved,thedetailsandconsiderationsthatwereaddressed,andthesimple,dedicatedhardworkthattheprofessionalsacrosstheunitsofTF62MEDperformedintransformingCOLSargentsvisionintoreality.COLDavidBudingerfollowswithadetailed,carefullydevelopeddescriptionofthemany,oftendisparateelementsthatmustbeconsideredfortheprovisionofhealthcaresupportasacombattheatermatures.Insimpleterms,thatmaturityistheevolutionfromwidespread,noncontiguoushostilitiesintoanenvi-ronmentinvolvingfixedbases,functioninginfra-structure,andobligationstothehostnationasitstrugglestorecoverintoafunctioningnation-state.COLBudingersarticleconsolidatesthemajorelementsinvolvedinevolvinghealthcaresupportinconcertwiththechangingconditionsandsituationalfactorsassomemeasureofstabilityandorderareestablishedinincreasinglylargeareasofthecombattheater.Itisaneye-opening,thought-provokingarticlewhichshouldbeofgreatinteresttodoctrinedevel-opersandstrategicplanners.MAJAlanUeokapresentstheformalplanningprocessforTF62MEDscombathealthcaresupportsystemPerspectiveMajorGeneralRussellJ.Czerw

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2www.cs.amedd.army.mil/references_publications.aspxPerspective(CHSS)inhiscarefullycraftedarticle.Heleadsthereaderthroughthesystematicapproachthattheplan-nersusedtoidentifytheparametersoftheeffort,thecategorizationofthoseparameters,theorganizationoftheapproachtoaddresstheparameters,andtheconsiderationsofresourcesandphilosophicalunder-pinningsthatwillsupportimplementationoftheplans.TheresultisanomnibusmapdepictingtheelementsoftheCHSS,theinterdependenciesofthoseelements,andtheflowofefforttosuccessfullyreachtheoverallobjectives.MAJUeokadescribeshowTF62MEDsuccessfulconvertedtheoryandideasintoactionoverawidearea,inaveryshortperiodoftime.Vitaltoasuccessfulcounterinsurgencystrategyarecivil-militaryoperations(CMO),asthesupport(orlackofopposition)bythelocalnationalpopulationdeniestheenemyconcealment,support,andfreedomofmovement.LTCJeffBryanandhiscoauthorshavecontributedanarticlewhichclearlyandsuccinctlydescribesthekeyrolethatmilitarymedicineplaysinasuccessfulCMOstrategy.Inadditiontoshelter,food,water,andameasureofsecurity,medicalcareisextremelyimportanttothelocalpopulation,mostofwhommayhavehadlittleinthewayofmedicalcarepriortohostilities.TF62MEDestablishedaproactive,vibrantprogramofmedicalCMO,integratedwithmedicalassetsofotherCoalitionforcesandtheIraqigovernment.ThisarticleismustreadingforthoseplanningandorganizingtheCHSSforallfuturedeploymentsintoIraq.Detaineesareanunavoidablebyproductofcombatorsecurityoperations.AlsounavoidableisthefactthathealthcareforthosedetaineesinIraqis,andhasbeen,theresponsibilityoftheUSmilitarymedicalsupportassets.AstheresponsibilitiesforsecurityareassumedbytheIraqis,thequestionofhowtotransitionthehealthcareresponsibilitytothehostnationremainsacomplexissue.LTCVincentHolmanproposesanapproachbywhichthedetaineehealthcaresystemcurrentlyinplaceshouldbetransitionedintoasystemappropriateforanationalcorrectionalcustodystructure.HiswellconceivedarticleproposesdrawingupontheexpertiseoftheUSDepartmentofPrisons,andtheNationalCommissiononCorrectionalHealthcarefordevelopmentofsuchamodel.Further,herecommendstheincorporationofmoretrainingintodetaineehealthcareinthecurriculumoftheAMEDDCenter&School.COLScottAveryandLTCVinceHolmandescribethereal-worldcomplexitiesanddetails,aswellasboththeobviousandsubtleconsiderationsthatTF62MEDhadtofactorintothedevelopmentandexecutionoftheirplantoestablishastandardizedstructureforforcehealthcareacrosstheIraqtheaterofoperations.TheirarticleprovidesinsightintothescopeofplanningthatwasrequiredwhenTF62MEDsleadersdecidedtochangethemedicalsupportlandscapeinkeepingwiththeevolvingrealitiesofthemilitary,political,andinfrastructureenvironments.Theanalysisofthesitu-ation,definitionoftherequirements,identificationofresources,developmentoftheplan,andsuccessfulimplementationaretestimonytotheprofessionalism,skills,dedication,andleadershipofthemedicalprofessionalswhoensurethattheyarethere,whereverandwheneverourWarriorsneedthem.Effectivemanagementofresourcesisaconstantconcernforeveryhealthcaredeliveryorganization.Itisespeciallyacuteforthosethatarerequiredtofunctionthousandsofmilesfromthesourcesofmanpower,supply,andassistance.LTCMichaelRichardsonwastheTF62MEDMedicalRegulatingOfficer(MRO)who,ashestatesinhisexcellentarticle,getstherightpatienttotherightplace,attherighttime,bytherightmeans.Indeed,emergencydispatchersinUSmetropolitanareashaveperformedasimilarfunctionforyears,routingcriticalcarepatientstoavailablefacilitiesbasedonproximity,capability,andspaceavailability.TheMROinIraqhastoperformthatfunctionforanentirecountry,whilemakingadditionaljudgmentsastothepatientsstatusdoesthepatientmeetthecriteriafortreatmentbyUS/Coalitionmilitaryresourcesaccordingtothemedicalrulesofeligibility,ormustanadequateIraqimedicalfacilitybelocated?LTCRichardsonsarticleprovidesinsighttothecomplexityofthemedicalregulatoryfunction,which,interestingly,hasbecomemorecomplicatedasthetheaterofoperationsmatures.OneofTF62MEDstopgoalswastheestablishmentoftheater-wide,standards-basedhealthcaredelivery.Crucialtoachievingthatgoalwastheimplementationofasystemtomeasureandensurethequalityofhealthcareservices,assesstheshortfalls,anddefinetheactionsnecessarytomeetthestandards.COLSuszClarkandMSG(P)RichardBrewerhaveprovidedacarefullyorganizedanddetaileddescriptionoftheTF62MEDprogramtocreatesuchaqualitymanagementsystemthroughouttheIraqtheater.Their

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OctoberDecember20083THEARMYMEDICALDEPARTMENTJOURNALarticleexplainstheconsiderationsinvolvedacrosseachaspectofclinicalcare,themetricsrequired,andthestepsnecessarytosupportthecontrolsystem.TheresultsensuredthataWarriorinIraqreceivesthesamequalityofcare,nomatterwhenorwherein-theateritisneeded.COLClarkalsocollaboratedwithMAJJonVanSteenvortinanarticleproposingthedevelopmentandimplementationofamodularmedicalorganizationalstructure.Thisconcept,centeredaroundwhattheytermthemedicalcapabilityteam(MCT),isinlinewiththecombatunitstructuretowhichtheArmyhasmovedinadaptingtotherealitiesofmodern,externalthreatstotheUnitedStates.Thegoalistheavailabilityofteamsofmedicalprofessionalswithspecificallyfocusedcapabilities,allowingmedicalsupporttobemoreeasilytask-organizedinkeepingwiththeforcestructurethatrequirestheirservices.Thearticleisawell-developed,thoroughlyresearchedpresentationoftheadvantagesandeffectivenessoftheMCTconcept.Theirproposalwilladdadditionalinsighttothecurrent,ongoingdiscussionsamongthosechargedwithplanningthefuturedoctrineandforcestructureofArmymedicine.ThebeginningofOperationsIraqiFreedomandEnduringFreedomin2003broughtwithitthefirstattempttofullydeployelectronicmedicalrecord(EMR)capabilityintoalargescale,extendedoperationalenvironment.Muchtimeandmoneyhadbeenspentondevelopinganelectroniccapabilitysince1991.Indeed,overtheyearstheAMEDDJournalhaspublishedanumberofarticlesdiscussingvariousaspectsofEMRdevelopmentandimplementation,aswellastheprosandconsofthesystemsthatAMEDDprofessionalshaveusedindeliveringhealthcareservices.MAJLeslieSmithaddsanarticlereflectingtheveryrecentexperienceofhealthcareprovidersintheIraqtheater.Hisarticleprovidesaninformativeoverviewoftheevolutionofhealthinformationsystems,andgivesanexcellentlookatthenumerousproblemsandobstaclesthatdevelopersfaceinattemptingtocreateasingle,all-encompassingmastersystemthatsolvesthemyriadofdisparaterequirementsformedicalinformationgathering,storage,movement,andretrieval.MAJSmithclearlydemonstrateshowthisseeminglystraightforwardrequirementisinfactoneofthemostcomplexdatamanagementpuzzlesfacedbysystemdevelopers.Theneedisprofound,butasatisfactorysolutionstilleludesus.Fortunately,theextensivelydocumentedexperi-encesfromreal-worldoperationaltheatersratherthantheoreticalsuppositionsandcannedfieldexercisereportsarenowontherecordforusebysystemplannersanddesigners.Hopefully,combatdeploy-mentsinthenearfuturewillhaveanintegrated,simplified,reliablesystemofmedicaldocumentationtosupporttheiroperations.Anotheraspectoftheeffectivemanagementofresourcessocriticaltoensuringhealthcaredeliverythroughoutanytheaterofoperationsistheavailabilityoffunctioningequipmentwithallthesuppliesnecessaryforitsuse.AsdescribedinthearticlebyLTCBruceSyvinskiandCPTJasonHughes,uponarrivalinIraq,TF62MEDimmediatelyinitiatedataskforcemedicalequipmentvalidationandstandard-izationreviewboardwhichimposedstandardizedequipmentcriteriaacrossalltaskforceunits.Equipmentrequirementswerevalidated,and,mostimportantly,thetaskforcelogisticsmanagershadcompleteknowledgeofwhatequipmentwaswhere,andthemaintenanceandsupplyrequirementsofeach.Thisarticleisatextbookonthecriteria,protocols,andprocedureswhichcreateacost-effective,responsive,andsupportablesystemtoensurethatfunctionalmed-icalequipmentisavailablewhereandwhenneeded.Earlyinthedeploymentperiod,theleadershipofTF62MEDrecognizedtheseeminglyincreasingoccurrencesofaproblemthat,unfortunately,hasalwaysbeenpresentwithinmilitaryorganizations,nomattertheeraorthenation.PersonalmisconductinviolationoftheethicsandvaluesthattheUSmilitarystrivestoinstillinourpersonnelisalwaysachallenge,which,regrettably,canoccurwithoutregardtoage,experience,orrank.Inresponsetoalarmingstatistics,theTaskForceCommanderdirectedthecreationofatrainingpackagetounambiguouslyaddresstheproblemareas,reemphasizingtheArmysexpectationsaswellastheconsequencesoffailure.MAJFrederickJacksonhaswrittenanexcellentarticledescribingtheprocessbywhichTF62MEDsAppliedEthicalFrameworktrainingpackagewasdeveloped.Especiallyrevealingishisdiscussionoftheresearchthatwasdoneinanefforttodiscovertheunderlyingreasonsforthevarioustypesofmisconduct.Armedwiththatinformation,theycreatedatrainingmoduleforeachcategoryofmisconduct,addressingthefactorsthatcontributedtotheproblem,butalsoexplicitlyrestatingtheregulatoryframeworkwithinwhichour

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4www.cs.amedd.army.mil/references_publications.aspx conductasprofessionalWarriorsmustbestructured.Thescopeoftheresultingtrainingpackageisindeedimpressive.However,theeffectivenessofthiseffortwasundoubtedlyenhancedbythereal-worldcontextinwhichitwascreatedanddelivered.Thisisanotherexampleofperfectlytargeted,situationaltraining,ratherthangarrisonclassroomlectures,lists,theory,andtests.MAJJacksonsclear,detailed,wellorganizedarticleshouldbeoneveryleadersreadinglist,especiallythosetaskedwithleadingourSoldiersthroughextendeddeploymentsindistanttheaters.PerhapsnothingismoreindicativeofthematurationofthemilitarysituationinatheaterofoperationsthantheimprovementinthemedicalfacilitiesthatsupportourSoldiers.Everycombatcampaignbeginswithexpeditionarymedicalsupport;quicklyestablished,mobile,focusedontraumapatientstabilizationandevacuation.Asthesituationstabilizes,mobilityrequirementsdiminish,andthescopeofnecessarymedicalservicesincrease.Correspondingly,theneedforupgradedfacilitiesarisestoaccommodatetheevolvingmedicalsupportrequirements.MAJDonaldChapmanandLTCKristenPalaschakhavecontributedanarticledetailingtheprocessbywhichsuchupgradesarebeingaccomplishedintheIraqtheaterofoperations.Theirarticlehighlightsthestartingpoint,thecreationoftheclinicalconceptofoperations,thedefiningdocumentuponwhichtheplansfortheneworupgradedfacilityarebased.Assuch,theconceptofoperationsmustcaptureinformationfrommanyareas,someofwhichhavelittletodowithactualhealthcaredelivery.ThearticleusesacasestudyaboutreplacementofthemedicalfacilityatContingencyOperationsBaseSpeichertoillustratetheprocess.Thisisaninterestingpresentationofaprocessthatisbothlogicalandunique,becausetheIraqtheaterofoperationsisitselfanenvironmentthathaslittleprecedentinmodernUSmilitaryexperience.ThereadyavailabilityofdentalcarefordeployedWarriorsduringcombatoperationshaslongbeenrecognizedasasignificantforcemultiplier.Understandably,ascombatoperationsbeginandexpandthroughoutatheater,specialtyandcomplexdentalcarearenotusuallyavailableincloseproximity,mandatingevacuationtoafacilityinanothergeographicarea.However,inanexactparalleltothechangesinmedicalcareandfacilitiesthatarenecessaryinamaturingtheaterofoperations,sotoowilltheaterdentalcareevolveintoaprimarilyfixedfacilitymodel,withincreasedscopeofcarecapability.Suchanevolutionrequiresdetailedplanningandimplementationmanagement,employingmostoftheconsiderationsandstepsaddressedthroughoutotherarticlesinthisissuewithregardtotheoverallcombathealthcaresupportsystem.LTC(P)FrankChristopherandhiscoauthorshavewrittenacomprehensive,detailedarticlethatdescribestheworkdonebytheTaskForce261MultifunctionalMedicalBattalioninestablishingatheater-widedentalcaredeliverystructureinthecurrentenvironmentofIraq.Theyexaminedthegeographicdispersionoftherequirements,evaluatedthevariabilityintheproviderspecialtiesthatoccurintherotationsofdentalsupportunits,andprojectedthefacilities,bothexistingandrequired,thatwouldbenecessarytoprovidethelevelofdentalcarewhichshouldbeavailabletoourdeployedWarriors.Theresultisaflexible,integrateddentalcaresupportsystemthatmaximizesresources,includingprovider,equipment,andfacility,tocontendwiththechangesinbothpatientrequirementsanddentalpersonnel.ThearticlebyLTC(P)Christopheretalalsodiscussesthedentalcareaffordeddetainees,acomplexproblembecauseinmostcasesthedetaineemustbebroughttotheclinictoreceivethatcare.Also,ourdentalprofessionalsareheavilyinvolvedwithdentalcivil-militaryoperations,includingprogramsinthecommunitiesandacloseworkingrelationshipwithIraqidentalresourcesandgovernmentagencies.TF261establishedaseriesofcontinuingdentaleducationeventsforIraqidentalprofessionalstoassistwithdevelopmentoftheirknowledgeandskillsastheycontinuetodevelopaself-supportingcapabilitytoprovidedentalcaretotheirpopulation.Thisarticleisanothercasestudyofhowourmedicalanddentalprofessionalscallupontheireducation,training,initiative,andleadershiptorecognize,attack,andsolvethecomplexproblemstheyfaceinprovidingexcellentqualityhealthcaretoourWarriors,nomatterthelocationsorconditionsinwhichtheymustserve.Perspective

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OctoberDecember20085EVOLUTIONOFTHECOMBATHEALTHCARESUPPORTSYSTEMPorterwrites,Positionsbuiltonsystemsofactivitiesarefarmoresustainablethanthosebuiltonindividualactivities.1Historically,themedicaltaskforcehasfocusedalmostexclusivelyondeliveringrobustandaccessiblemedicalcareandforcehealthprotectionsupportsinceoperationsbeganinIraq5yearsago.Immediatelyuponassumingthemission,Inotedthemedicaltaskforcewaschargedtodeliver3essentialmedicaltasks:1.Combathealthsupport,whichwecallworld-classWarriorhealthcare,toUSandcoalitionforces.2.ProtectthehealthofUSandcoalitionforces.3.EnhancegovernmentofIraqcredibilitybysupportingself-reliantIraqipublichealthsystems.ToaccomplishthesetasksmystaffandIfusedtraditionalmilitarycampaignplanningwithabusiness-orientedstrategicplanningprocess.Theresultwasahybridmethodfocusedonoperatingahealthsystemprovidingmedicalsupporttoamultinationalcorpsdecisivelyengagedinacounterinsurgencyoperation.Wedevelopedandpublishedamedicalcampaignplanthatprovidedourmedicalforcewithanin-depthunderstandingofhowIvisualizedtheoperationalenvironment,describinghowwewouldprovidemedicalsupporttothecorpsWarriors.Themedicaltaskforcehadtheresponsibilityforprovidingmedicalcareto170,000USandcoalitionforces,150,000contractors,IraqArmyandIraqiSecurityForces(ISF),localnationals,and28,000detainees.Ourbeneficiarypopulationexceeded300,000peopleranginginagefrominfantstotheelderly.Ourpatientsmedicalconditionsrequiredcarerangingfromtraumacareforchildrenwithburnandblastinjuriestohospicecareforelderlydetaineeswithterminalillnesses.WequicklyrealizedthatinordertoeffectivelycommandandcontrolourmedicalresourcescaringforthevastnumberofSoldiersandciviliansacrossadiversityofmedicalconditions,wehadtobreakawayfromthetraditionalechelonedtacticalparadigmofmedicalcaredelivery.Weneededtobuildacombathealthsupportsystem(CHSS)thatpossessedtacticalagilitycapableofmeetingthecomplexityofthecounterinsurgency,whileestablishingthebestfeaturesofawell-managed,USqualityhealthcaresystem.Forthisreason,wedesignedaCHSScomprisedof3subsystems:aWarriorhealthcaresystem,forcehealthprotectionsystem,andmedicalcivil-militaryoperationssystem.Thesesystemscomplementandsynergizeeachotherinaccomplishingthecollectivemissionaswellastheirspecifiedtasks.OurCHSSmodel,illustratedinFigure1,hasthelookandfeelofTaskForce62MedicalBrigadeCombatHealthcareSupportSystemintheMatureIraqTheaterofOperationsCOLPatrickD.Sargent,MS,USA ABSTRACTLeadingadeployedcombathealthcaresystemisaverycomplextaskandrequiresacommandandcontrolstructurethatisauniqueblendoftechnicalandtacticalexpertisetoefficaciouslydeliverworld-classmedicalcaretoAmericassonsanddaughters.ThemedicaltaskforceinIraqhassuccessfullymanagedthetransformationofthemedicalfootprintfromatacticallyarrayedsetofdisparatemedicalunitstoanascentintegratedhealthcaresystemwithmanyfeaturessimilartothebesthealthcaresystemsintheUnitedStates.TheAmericanpublicdemands,andSoldiers,Marines,Sailors,Airmen,andCoastGuardsmendeserveUSqualitymedicalcare,whethertheyarebeingtreatedatamilitarymedicalcenterintheUS,oraUSmedicalfacilityinIraq.Thisarticlepresentsanoverviewofthe62ndMedicalBrigadesdevelopmentofthecombathealthcaresupportsystemduringitstenureleadingtheUSmedicaltaskforceinIraq.

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6www.cs.amedd.army.mil/references_publications.aspx abalancedscorecard,2however,itisnotabalancedscorecardinthepuristsense.Althoughwehavedesignatedtraditionalends/outcomes,ways/deliverysystems,andmeans/applicationsandenablersandprograms,theonlyobjectivesweciteareintheendsportionofthemodel.TheprimarypurposeoftheCHSSmodelistoprovideanoperationalframeworkforthedeliveryandmanagementofqualityhealthcarethroughoutourhealthcaresystem.TheCHSSmodelallowedmetoclearlycommunicatethestrategic,operational,andtacticaleffortsofourmedicaltaskforcewithtaskforcemembers,customers,andstakeholders.Ultimately,theCHSSmodelfocusedourorganizationalenergyandengineeredwell-disciplinedsystemstoexecuteourmedicalcampaignplan.TheWarriorhealthcaresystem,forcehealthprotection,andmedicalcivil-militaryoperationsTaskForce62MedicalBrigadeCombatHealthcareSupportSystemintheMatureIraqTheaterofOperations E N D S W A Y S M E A N S O u t c o m e s D e l i v e r y S y s t e m s A p p l i c a t i o n s E n a b l e r s & P r o g r a m s Resources Force&HumanResourceManagement FiscalStewardship MedicalIM/ITMHSAcquisition,Research/Development,Infrastructure CustomerandStakeholderPerspective OptimizeReturntoDuty&ConserveCombatPower MaximizeWellPresentforDuty&ReduceDNBI ImprovedHealthStatus,PublicConfidence,IncreasedCapabilityandCapacity WarriorHealthcareSystem ForceHealthProtectionSystems MedicalCivil-MilitaryOperations Hospitalization,Surgery,Diagnostic&SpecialtyCare PreventiveMedicineSystems DetaineeHealthcareSystem Primary&DentalCareSystems VeterinaryCareSystems Pro-MEET,CooperativeMedicalEngagements Trauma&ChronicCareCPGs MentalHealthCareandBuildingResiliency FacilitateImprovedAccesstoIraqiHealthServices MedicalRegulationandClinicalIntegration FacilitateTimelyIraqiPatientTransfers/DischargesfromUStoIraqiFacilities InternalProcessesandSystems LearningandGrowth ClinicalQualityManagement ElectronicClinicalDocumentation DevelopAdaptiveLeaders ContinuingEducation&Training OrganizationalAssessment ComprehensiveRiskManagement Logistics&MaintenanceManagement HealthFacilitiesPlanning&Management MoralCompass,EthicalSystemFramework AgileJoint/MultinationalC2Structure&Methods Efficiency,Effectiveness,OutcomeMeasurement&AccountabilitySystemsAmbassadorshipFamilyLeadershipGrowth ProtecttheHealthofUS&CoalitionForcesEnhanceGOICredibilitybySupportingSelf-reliantIraqiPublicHealthSystemsProvideWorld-ClassWarriorHealthcaretoUS&CoalitionForces Figure1.TheTaskForce62MedicalBrigademodelfordevelopmentandexecutionoftheCombatHealthcareSupportSystem.Themodelwasconceivedanddesignedtooptimizehealthcaresupportinthematurecombattheaterwhileoperatinginacounterinsurgencyenvironment.

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OctoberDecember20087THEARMYMEDICALDEPARTMENTJOURNALsubsystemsareeachdirectlyinsupportofour3coremissions:providingworld-classWarriorhealthcaretoUSandcoalitionforces;protectthehealthofUS&coalitionforces;andenhancethecredibilityofthegovernmentofIraqbysupportingself-reliantIraqipublichealthsystems.Eachsystemhascomponentdeliverysystems,orways,withtheirowndefinedobjectivesandmeasuresofeffectiveness(MOE)thatallowustodefinesuccessandobjectivelymeasureourprogress.ThedevelopmentanduseofMOEsarecriticaltohelpdisciplineourprincipalmanagementfocusandenergyonthoseelementsofourorganizationalperformancemostimportanttoourpatientsandstakeholders.Asyoucanimagine,asamedicalbrigade,allofourMOEseitherdirectlyorindirectlysupportedthecareorprotectionofthecoalitionforcesanddetaineesorsupportedtheGovernmentofIraqscarefortheircitizenshealth.Visuallyandpractically,thefoundationofthebrigadesCHSSmodelisourvaluesystem.OurmoralcompassandethicalframeworkincorporatetheArmyvaluesandWarriorethos.TaskForce62MedicalBrigadesvaluesaretheembodimentoftheConstitutionandtheAmericanflag,whichiswhyIcoinedtheacronym:F.L.A.G.forFamily,Leadership,Ambassadorship,andGrowth.Thesesimpletenets,presentedinFigure2,havesustainedusthroughsometoughtimesandallowedustosuccessfullyserveasambassadorsfortheArmyMedicalDepartmentandourgreatNation.WARRIORHEALTHCARESYSTEMPhysiciansaretheclinicalleadersofcareinthehealthcareorganization.3Asthemedicaltaskforcecommander,Ifundamentallyvaluethephysiciansroleinthemedicaltaskforce.Overthecourseofthisdeployment,itbecameincreasinglycleartomethatdeliveringqualitymedicalcarerequiredamultidisciplinaryteamapproachandweavingtogetherthetalentsofthevarioushealthcareprofessionals.Reflectingontheincreasinglymatureoperationalenvironmentweinstitutedinterdisciplinarypatientsafety,riskmanagement,andclinicalqualitymanagementprogramsacrossthemedicaltaskforceinIraqtoenhancethecommunicationandteamworkbetweenourvariousprofessionalsandsupportstafftoimprovepatientsafety.Afterinstitutingtheseprograms,wewitnessedquantitativeandqualitativeimprovementsinourpatientsafetyandclinicalqualitymanagementprogramsinsidethemedicaltreatmentfacilities.Wewidelyimplementedandprovidedrecurringinputtothejointtheatertraumasystemstraumaclinicalpracticeguidelines(CPGs),andweimplementedseveralchroniccareCPGs.Theseguidelineswereastartingpointinstandardizingthedeliveryofmedicalcare,buttheydidnotunnecessarilyrestrictourphysiciansfrompracticingmedicineusingtheirclinicaljudgment.TheyretainedtheprofessionalautonomytonotusetheCPGiftheirclinicaljudgmentledthemtoabetterplanofcare.Thejointtheatertraumaregistryanddeployedcombatcasualtycareresearchteamplayedanintegralroleinthesuccessofthetaskforcesmedicalmission.Theireffortswereinstrumentalinourabilitytocontributetothemilitaryhealthcaresystemseffortstouseourtrauma-richenvironmenttoadvanceevidenced-basedmedicine.ThebrigadeinstitutedaQuality-HealthcareAssess-mentVisit(Q-HAV)ProgrammodeledinthespiritoftheJointCommissions*patienttracermethodology.ThisallowedourcombatsupporthospitalstoreceiveanobjectiveassessmentoftheirhospitalandenabledtheQ-HAVTeamtoobserveanddisseminatethebestpracticesofeachorganizationthroughoutthemedicaltaskforce.Thiswasaparadigmshiftawayfromthetraditional,checklist-basedorganizationalassessmentprogramsfocusedonreviewingpoliciesandstandardoperatingprocedures.Overthepast15months,wehavesustaineda98%survivabilityratefortraumapatientswhoarriveatour7hospitals.Throughoutourdeployment,duringandafterthesurge,wehaveseenaprecipitousdeclineincasualtiesandtraumaandhaveusedthistimeofimprovedsecuritytoimprovetheintegrationoftheelectronicmedicalrecord,radiologyandlabservices,primaryandspecialtycare,andclinicalintegration.FocusingonimprovingtheIraqtheatersradiologyinfrastructurebyworkingwithDefenseHealthInformationManagementSystem,weupgradedtheMedweb(667FolsomSt,SanFrancisco,CA)capacityallowingradiographstakenatlevelIIclinicstobereadbyaradiologistatalevelIIIhospital. *JointCommissiononAccreditationofHealthcareOrganizations,OneRenaissanceBlvd,OakbrookTerrace,Illinois.

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8www.cs.amedd.army.mil/references_publications.aspxGiventheUS,Coalition,andISFsuccessesoverthepast15monthswhichsignificantlyimprovedthesecuritysituation,wehaveseenaprecipitousdeclineinthenumberofcasualties,promptingustoreevaluatethedistributionandcontentofourmedicalfootprint.AsthecombatforceinIraqshrinks,combatunitcommandersarechallengedtomaximizetheirwell-presentfordutystrengthasthemissionhasnotsubsided.Insupportoftheirneeds,myobjectiveistoreducethenumberofSoldiersrequiringevacuationoutoftheaterforspecialtycare,andreduceturnaroundtimetogetSoldiersbacktotheirunits.Wearepresentlydevelopingaspecialtycarereferralclinic,firstfocusingongastroenterology,andplanningtoexpandtoscreenandtreatpatientswithinthespecialtiesthathavethehighestrateofevacuationoutoftheater.Lastly,weareleveragingthedeclineintraumapatientstorefineouroutpatientbusinesspracticestoimprovetimelyaccesstocareandoptimizingtheutilizationofourproviders.FORCEHEALTHPROTECTIONThemedicaltaskforcehasachievedthelowestdisease-nonbattleinjuryrateinthehistoryoflandwarfare.Thisislargelyaresultofthepreventivemedicineandveterinarymedicineteamsthataredispersedacrossthebattlefield,conductingapplicableinspectionsintheirrespectiveareasandcoachingSoldiersandleadersaboutkeepingtheforcehealthy.Ihavebeenextremelyimpressedwiththelevelofprofessionalismdisplayedbytheseteams,whichgenerallyconsistofjuniorenlistedSoldiersandjuniorofficers.TheseSoldiersepitomizetheconceptofthestrategiccorporalandaregreatambassadorsfortheArmyMedicalDepartment.Theveterinarianshaveplayedacrucialroleinreducingtheferalanimalpopulationaroundourforwardoperatingbasesandcontingencyoperatingbases.TheCorpsCommanderestablishedaforceprotectiondogprogramthatallowsunitstoacquireadogfortheexpresspurposeofsecurity.Therefore,whenregistered,thesedogsareeligibleforthesamecareprovidedtoourmilitaryworkingdogs.Theveterinarianmedicineteamshavesustainedaveryimpressivesurvivabilityrateformilitaryworkingdogsundertheircare.Wehavemadetremendousprogressintheaccessibilityandqualityofbehavioralhealth(BH)servicesinIraqaswell.Thetaskforcehasachieveda99.3%return-to-dutyrateforallSoldierstreatedbyourBHpersonnel.Thesededicatedprofessionalsconductprevention,consultation,andrestorationcareinsidethedivisionandbrigadeareasofoperations,largelybymovinginandaroundtheoperationalareaswiththesupportedunits.TheprimarycauseofoperationalstressorsistheSoldiersinabilitytocopewithissuesonthehomefront.OurBHpersonnelfocustheirpreventiveandrestorationservicesontheskillsrequiredtosufficientlycopewithstressorsfromhome:angermanagement,relationshipbuilding,andcommunication.Generally,aftera3-dayvisittoourrestorationcenters,Soldiersreturntodutymorecapableofdealingwiththeirstressors.TaskForce62MedicalBrigadeCombatHealthcareSupportSystemintheMatureIraqTheaterofOperations Figure2.Reproductionofthein-theaterposterdisplayingthetenetsoftheF.L.A.G.institutionalphilosophydevelopedbytheTF62MedicalBrigadeasthefoundationforthecombathealthcaresupportsystem. IwillneverleaveafallencomradeWenotonlyfightfortheConstitutionandourDemocracy,Wefightforeachother.Familiestakecareofeachotherandtreatoneanotherwithdignityandrespect.YouenlistSoldiers,Sailors,Airmen,andMarines,butreenlistFamilies.IwillneveracceptdefeatNooneismoreprofessionalthanI.Leadfromthefrontwithpersonalandorganizationalintegrity.LeadershipisaTEAMsport-counsel,coach,andmentor.IwillalwaysplacethemissionfirstDuty,Honor,Country!Yourcharactermusthonorournation,yourservice,unitandFamily.Ethicalconductandmedicaldiplomacyareforcemultipliers.IwillneverquitKnowyourjob,doyourbest,anddevelopyourabilitiestotheutmost.Alwaysseektoimproveyourphysicalandspiritualfitness.Wearealearningorganizationandmustmaintainaperpetualquestforknowledge.SOHELPMEGOD! Family,Leadership,Ambassadorship,andGrowth Yourlifeisnotimportantexceptfor theimpactithasonanotherlifeJackieRobinson

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OctoberDecember20089THEARMYMEDICALDEPARTMENTJOURNALAsaresultoftheMentalHealthAdvisoryTeamsrecommendationthatthebrigadebecomemoreinvolvedinthesuicidepreventionaspectsofmentalhealthcare,wedevelopedsuicideriskmanagementteamsinseveralofthebrigades.Theseteamsconsistofthecommander,chaplain,andabehavioralhealthcareadvocate.ThisinnovativeapproachtoprovidingbehavioralhealthcaredemonstratedthecommandsconcernfortheirSoldierswhohavebehavioralhealthcareneeds.WeconductedaninformalsurveythatrevealedSoldierswantedtheircommandinvolvedmoreintheircare;thus,thisprogramprovidesustheopportunitytoconnecttheSoldierandcommandwhilerespectingtheSoldiersdesireforprivacy.Ourcombatstresscontrolunitstreatover6,400patientsmonthly,andeachencounteriscapturedelectronicallyusingthecombatandoperationalstresscontrolworkloadandactivityreportingsystem(COSC-WARS).ElectronicdocumentationoftheCOSC-WARShasprovenbeneficialandaffordsprimarycaredoctorstheabilitytoevaluateourSoldiersinaholisticmanner.ThebehavioralhealthcarepersonnelprovidestealthmentalhealthcirculatingwithSoldiers,andaretrulycombatmultipliers.MEDICALCIVIL-MILITARYOPERATIONSDetaineehealthcareisthemedicaltaskforcesmoststrategicallyimportantmission.Thetaskforcehastheresponsibilityforprovidingcaretoover28,000detainees.ThequalityofmedicalcarethedetaineesreceiveisidenticaltothatprovidedtoUSandcoalitionforces.Thedeliveryofmedicalcaretodetaineesisuniquelychallengingduetothephysicallayoutofthedetentionfacilitiesandthesecurityrequirements.Themajorityofmedicalcareprovidedtodetaineesisdoneatthewirefenceofthecompounds,hencethetermwiremedicine.Themedicistheprimarypersonconductingtriageatthewireusinganalgorithmdirectedmodelofcare.Formedicalconditionsbeyondthescopeofthemedic,detaineesaremovedtothecompoundtreatmentareawheretheyareseenbyaprimarycareprovider.Eachcompoundiscoveredbyanursecasemanagertoensurethedetailedplanofcareisimplementedforthedetaineepatients.Amajorchallengeinthedetaineepopulationisthedocumentationofcare;however,wehaverecentlyimplementedtheBattlefieldMedicalInformationSystem-Tactical(BMIST)astheprimarymeansofdocumentingthemedicalscreeningwithinthedetaineepopulationatthewire.Thisensuresthereisnotabreakinthecommunicationanddeliveryofcare.Forsecurityreasons,thedetaineesareroutinelymovedbetweencompounds,creatingasignificantchallengetomanagetheirmedicalcarerequirements.Thustheelectronicmedicalrecordassistsinensuringcontinuityofcareaswell.Detaineenursecasemanagementensuresqualityandstandardizationacrossthedetaineehealthcarecontinuum.Nursecasemanagershavealsoeffectivelyassistedinthemanagementofchronicconditions.Diabeticdetaineeshavemorefavorablemanagementoftheirconditions,asmeasuredbyhemoglobinA1C,thanotherdiabeticsinsimilardiseasemanagementprograms.Professionalmeetings,engagement,education,andtraining,andcooperativemedicalengagementshaveaffordedthemedicaltaskforcetheabilitytodirectlyinfluencethestrategiclinesofoperationswithintheMulti-NationalForceandCorps.Asthesecuritysituationbegantoimprove,ourmedical,dental,andveterinaryteamswerehighlysoughtafterbycombatunitcommanderstoprovidecooperativemedicalengagements(CMEs)withtheirIraqicounterparts.Throughoutourdeployment,wehavesupportedCMEsinsupportofprovincialreconstructionteams,Iraqimilitarytrainingteams,andcoalitionbrigadecombatteams.OurtaskforcesinvolvementenabledtheseorganizationstobuildrapportwithlocalProvincialleadersandcitizens.Throughthecooperativemedicalengagementwehaveleveragedourassetstoemploymedicaldiplomacyacrossthebattlefield.OurveterinaryofficershaveprovidedtheIraqveterinarianswithtrainingonartificialinsemination,rabiessurveillance,andfoodprocurementguidelines.Asthesecurityimproves,sodoestheIraqieconomy.OurveterinarianshaveassistedIraqiswithinspectingsodabottlingandcanningplantspriortobeingawardedcontractstosellsodatocoalitionforces.AttherequestoftheIraqiMinisterofHealthandtheMultinationalForce-IraqSurgeon,thetaskforcerecentlydevelopedhealthprofessionstrainingcoursesfocusedonphysicians,nurses,andhealthcareadministrators.TheprogramwillenableourhealthcareprofessionalstotrainIraqihealthcarepersonnelmanagingahospitalinthecontextofalargerhealthcaresystem.Theprogramspanstherangeof

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10www.cs.amedd.army.mil/references_publications.aspxlectures,one/two-dayseminarstoprovidingdidacticandpracticaltrainingwithmultidisciplinaryteamsofhealthcareprofessionalsintheUSmilitarytreatmentfacilities.LocalnationalsfilledadisproportionatelylargeshareoftheUShospitalbedsinthemedicaltaskforceatthebeginningofourtour.Therefore,weaddressedthisprogramwiththefollowinggoalsinmind:reducetheIraqisdependencyonourmedicaltreatmentfacilitiesandincreasetheirconfidenceintheIraqihealthcaresystem.AsecondaryreasonforthenumberofIraqisenteringourmedicaltreatmentfacilitieswastheUSandcoalitionforcesmisunderstandingofthemedicalrulesofeligibility(MROE).AdherencetotheMROEisasignificantchallenge,butvitallyimportanttoensureourlimitedmedicalresourcesarereadilyavailableforthecareofUSandcoalitionforces.ImprovementintheseareashaveledtoasignificantreductionintheproportionandoverallnumberofUShospitalbedsoccupiedbyIraqipatients.TheMedicalTaskForcehastheresponsibilityforover180casemanagementliaisonofficers,biculturalbilingualadvisorsandIraqiadvisortaskforcepersonnel.TheseareIraqi-AmericansorhighlyskilledformermilitarypersonnelthatareexpresslyfocusedonprovidingtheCorpswithmedicalinformation,oratmospherics,describingthestatusofmedicalcareandfacilitiesthroughoutIraq.TheirreportinghasshapedtheCorpsfocusandguidedtheforceseffortstoassistinbuildingthequalityandcapacityofIraqsmedicalsystems.CONCLUSIONThemedicalinfrastructurewithintheIraqtheaterofoperationshasmaturedoverthecourseofthepast15months.TheCHSSmodelhassufficientlyallowedmetodevelopandmaintainapreciseunderstandingofmymedicalwarfightingfunctions.TheCHSStranslateddataintouseableinformationthatallowedmetomakeinformeddecisionsontheeffectivenessofourinternalprocessesandsystems.Moreover,theCHSSprovidedastructuredwayofdefiningandmeasuringmedicalqualityinatacticalenvironment,specifically,our3coremissionsofprovidingworld-classWarriorhealthcaretoUSandCoalitionForces;protectingthehealthoftheUSandCoalitionForces,andenhancingtheGovernmentofIraqscredibilitybysupportingself-reliantpublichealthsystems.REFERENCES 1.PorterME.CompetitiveStrategy:TechniquesforAnalyzingIndustriesandCompetitors.NewYork,NY:TheFreePress;1980.2.BalancedScoreboardInstitute.Whatisthebalancedscoreboard?.Availableat:http://www.balancedscorecard.org/BSCResources/AbouttheBalancedScorecard/tabid/55/Default.aspx.AccessedOctober6,2008.3.GriffithJR,WhiteKR.TheWell-ManagedHealthcareOrganization.6thed.Chicago,IL:HealthAdministrationPress;2006:203.AUTHOR Atthetimethisarticlewaswritten,COLSargentwastheCommander,62ndMedicalBrigade,deployedtotheIraqtheaterasTaskForce62MedicalBrigade.TaskForce62MedicalBrigadeCombatHealthcareSupportSystemintheMatureIraqTheaterofOperations Crestofthe62ndMedicalBrigade

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OctoberDecember200811Thesubjectofapieceofmosaicartcannotbeseenwhenviewingitfromtoocloseofavantagepoint.Likewiseinhistoryandlife,weoftenmissthesignificanceofwhatishappeningwhenweareinthemiddleofmajorchanges.Itisonlybysteppingbackandgainingperspectivethatweareabletodiscernwherewehavebeenandgainwisdomabouthowtoproceed.ThewarinIraqhasbeenacrucibleforcountlessadvancesinscience,technology,counterinsurgencytactics,andmedicalpractice.Manyoftheadvancesweredesignedpriortoapplication,whileotherswerecreatedthroughpracticalimprovisation,andstillotheradvancesresultedfromfacinglife-or-deathcrises.Someofthechangeswereimmediateandrevolutionarywhileotherswereincrementalandevolutionary.Theseadvancesareinterwovenwiththepassageoftime,andtogetherresultincombattheatermaturation.Thoughspaceconstraintsnecessitatesomeoversimplification,thisarticleintroducesbothconditionswhichshouldpromptanalysisanddecision-making,andseveraldimensionsofahealthcaresystemwhichdevelopasacombattheatermatures.ThematurationoftheIraqtheaterofoperationsiscelebratedbySoldiersreturningtoIraqfortheirsecondorthirddeploymentsbecauseofthetangibleimprovementsinsecurityandcreaturecomforts.Theatermaturityaffectscommandandcontrol,communications,logisticsphysicalplantfacilities,utilities,security,forceprotectiontechnology,nationalandprovincialgovernment,andhealthcare.MedicalpracticeadvancesintheUSmilitaryhealthsysteminIraqareveryobviousinthehistoriclowratesofbothdeathduetowoundsandlossofmanpowerduetodiseaseandnonbattleinjury.GermanyandKoreatodayprovideexcellentexamplesoftheendstateofUSmilitaryhealthsystemsinamaturetheaterofoperations.TheUSmilitarytreatmentfacilitiesinbothofthesetheatersarepartofsophisticated,integratedhealthcaresystemswelladaptedtotheirenvironments.Combathealthcareorganizationsmustbeeffective,whateverthecost.Healthcareorganizationsinmaturetheatersmustbeeffectiveandefficientinmanagingthecareoftheirsupportedpopulations.AtsomepointinhistorythedeployablehospitalsoperatingoutoftentsinGermanyandKoreawerereplacedbytemporarybuildings.Thesehospitalseventuallymovedintopermanentlyconstructedfacilities.Likewise,themedicalservicesprovidedwithinthesefacilitieswereadjustedovertime,shiftingfromabattleinjuryandtraumafocusduringcombatoperationstoadiseaseandnonbattleinjuryfocuswhichtodayplacesfirstemphasisonprimarycare,aspecialtycarenetwork,andcommunityhospitals.Itisimpossibletoseparatetechnologicaladvancesfromchronologicmaturationinhistoricormoderntheatersofoperationsastechnologyimprovementandtimeareinterwoven.HistorianscancombtherecordstofindtheenvironmentalandtechnologicalconditionsandtheoperationalfactorswhichresultedintheestablishmentofthefirstpermanentfacilitiesinGermanyandKorea.Thesechangesinconditionsandfactorswere,ineffect,decisionpoints.Untilveryrecently,mainstreamcampaignplanningintheUSArmylargelyneglecteddetailedplanningforstabilityorcounterinsurgencyoperationsinthetheateraftermajoroffensiveordefensiveoperationshaveended.Theoperationalcampaignplanningcurriculuminourprofessionalmilitaryeducationinstitutionshistoricallyinvolvedplanningandwargamingthemajormusclemovementsofreception,staging,onwardmovementandintegration,combatoperationsindetailthroughtheactionsontheobjective,andthentheinstructorswoulddeclaretheendoftheexerciseHealthcareSystemPlanningAlongtheCombatTheaterMaturityContinuum:TransitioninganExpeditionaryMedicalForcetoanIntegratedHealthcareSystemCOLDavidP.Budinger,MS,USA

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12www.cs.amedd.army.mil/references_publications.aspx(ENDEX).Eachoftheseelementsinvolvedpreparationofverydetailedplanswhichincludedmajordecisionbranches,sequels,anddecisionpointsforthecombatantcommanderandsustainmentforceleaders.Planningforhealthcaresupportfollowedthisparadigmaswell.HealthcareplanningexercisestraditionallydeclaredENDEXafterthecombatobjectiveswereachievedwithoutregardtotheenduringrequirementsandchanges6months,12months,or36monthsaftermajorcombatoperationsended.TheUSmilitarysmorethan5-yearengagementinIraqhaspromptedthedevelopmentofrevolutionarydoctrinechangesforoperationsingeneral,andcounterinsurgencyoperationsinparticular.LearningfromthepracticalexperiencesofthematuringIraqtheaterofoperations,weareintheoptimalpositiontostepbackandgainthenecessaryperspectivetoassessourprogressandthenguideourstrategicdecisionsaboutthefuturedesignandestablishmentofhealthservicesandfacilitiesinamaturingtheaterofoperations.Thisarticleisaninitialattempttocreateaconstructfordevelopingamilitaryhealthsystemthroughoutthelifecycleofatheaterofoperations.ThefollowingparagraphsdescribeseveraldecisionpointsanddimensionsofthehealthcaresystemswhichshouldbeconsideredinplanningacrossthestrategictimelinewhichIcallthetheatermaturitycontinuum.Figure1isanoversimplifieddepictionofselectmaturationmilestonesfortheUSmilitaryhealthsysteminIraqalongaroughtimelinetohelpillustratethisconcept.DECISIONPOINTSFORMILITARYHEALTHCARESYSTEMMATURATIONEstablishingfirmdecisionpointsforadding,removing,orchangingthemedicalsupportresourcesinatheaterofoperationscanbemoredifficultthanestablishingdecisionpointsforcombatoperations.Therearerarelydistincttimes,locations,oreventstopromptactionsordecision-making.Thereare,however,environmental,organizational,political,andphysicalfactorsforthehealthcareleadertoconsiderwhichmayprompthisdecisionstodeliberatelyadvance,reduce,orchangeclinicalprocesses,organizationalandsupportstructures,orphysicalplants.Manyofthesearecommonfactorswhichhealthcareleadersinnoncombattheatersettingsconsideraswell.Theymaybeeitherexternallyorinternallygenerated.Belowarelistedseveralpotentialdecisionpointsorvariables:Changesintheoperationalsecurity,threatlevelorenemycompositionandactivitiesGeographicoroperationalchangesinsupportedunitsorpopulationsHighercommandorderstoestablish,discontinue,ormodifyaparticularlevelofsupportorclinicalserviceRequestsordemandfromsupportedcustomersorunitsMonthlyanalysisofinjurypatterns,diseaseprevalence,andevacuationsoutoftheaterforspecialtyconsultation,tohigherlevelsofcare,orforrehabilitativeservicesAnalysisofdiagnosesorcausesforlostdutytimeHealthcareprofessionalobservationsandrecommendationsAcquisitionorlossofessentialequipmentorothertechnologyAcquisitionorlossofphysiciansorsupportstaffmanpowerwithaparticularskillsetRatesofshipmentoflabspecimensortransmissionofradiographicimagesoutoftheaterAdvancesinmedicalpracticeandmedicaltechnologyIncreasesordecreasesinfunding,changesinfundingmethodologies,orinvalidationofassumptionsorprojectionsinbusinesscases,oreconomicbreakevenpointsFindingsandrecommendationsfromconsultants,audits,externalagencies,orinvestigationsChangesinsupplycontent,vendors,ordistributionsystemsChangesinroutinepersonneltransportationcircuits,strategicortacticalMEDEVACassetdensityorflightpatternsPublicsentiment(bothUSandlocalnational)aboutlongevityofthemissionChangesinpublic,media,orpoliticalsensitivityaboutspecificdiseases,conditions,ortechnologyHealthcareSystemPlanningAlongtheCombatTheaterMaturityContinuum:HowanExpeditionaryMedicalForceTransitionstoanIntegratedHealthcareSystem

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OctoberDecember200813THEARMYMEDICALDEPARTMENTJOURNALRequirementstosupporthost-nationstabilitydirectlyorindirectlythroughcooperativemedicalengagements,educationalprograms,medicaldiplomacy,orhumanitarianassistanceDIMENSIONSOFHEALTHCARESYSTEMSWHICHVARYWITHTHEATERMATURATIONAccordingtoArmyFieldManual3-0:CampaigncapabilityistheabilitytosustainoperationsaslongasnecessarytoconcludeoperationssuccessfullyItisanabilitytoconductsustainedoperationsforaslongasnecessary,adaptingtounpredictableandoftenprofoundchangesintheoperationalenvironmentasthecampaignunfolds.Armyforcesareorganized,trainedandequippedforendurance.1RelativelyfewdimensionsoftheUSmilitaryhealthcaresystemremainstaticasatheaterofoperationsmatures.Historyrevealscountlessexamplesofmilitaryhospitalsandmedicalcompaniesmovingwithorshadowingtheadvanceofcombatforcesduringexpeditionarycampaigns.Asthecampaignextendsindurationandmissionvariableschange,medicalsystemleadersmustconsiderseveralphysical,manning,andoperationalelementsinordertoadaptthehealthsystemtothenewenvironment.Manyofthesedimensionsarebrieflydescribedbelow:HospitalandClinicPhysicalPlants:Themostvisibledimensionofmilitaryhealthsystemmaturationisinthephysicalplantsofhospitalsandclinics.Inanexpeditionaryphaseofacampaignthetentsandexpandabletrailers(ISOshelters)ofthedeployablemedicalsystem(DEPMEDS)areanappropriatehospitalphysicalplant,giventhattheyarerelativelymobileandcanbemodularlycustomizedtofitmissionrequirementsandenvironmentalconstraints.Thesesystemsarenot,however,optimalforuseinextendedcampaignswhenthehospitalwillbeemployedinastaticlocationforseveralyears.TheArmysHealthFacilityPlanningAgencyprovidesthemedicalleaderwithexpertconsultantstoassistinanalyzingtherequirements,designing,contracting,andbuildinghardenedfacilitiesforlongdurationcampaigns.Itisnotuncommontodesignmedicalfacilitiesforusebetweenoneand10yearsintegratingacombinationofexistingpermanentbuildings,plywoodstructures,DEPMEDSISOshelters,ormultisectiontrailersonthenewhospitalsite.Securitythreatsmaynecessitatetheadditionofconcretet-wallsandmortar-protectiveoverheadsheltersorentirelyhardenedstructuresinordertomeetforceprotectionrequirements.Thefacilitiesintendedforuselongerthan5to10yearsaremuchmoreexpensiveandincorporatemoreelaborateutilities,medicalgas,communication,andlife-safetysystems.CommandandControl/Governance:Duringtheexpe-ditionaryphase,themedicalbrigadesormedicalcommandsarefocusedonamorevolatileanddynamicsupportedcombatforce.Theirpriorityeffortsareprimarilywrappingthemedicalforcescapabilitiesaroundtheoperationalforcesrequirements.Asthetheatermatures,thehospitalsandclinicsestablishmanyofthefunctionalcommitteestructuresthatarefoundinmedicalfacilitiesintheUnitedStatestoassistwiththemanagementofthehospital.Themedicalcommandandcontrol(C2)orgovernancestructureinthemedicalbrigademustbesignificantlyexpandedinordertoconducthealthsystemmanagementfunctionsasthetheatermatures.ThetheatermedicalC2headquartershasatraditionalbattlestaff,butrequiresaugmentationpersonneltomantheclinicaloperationssection,includingtheatersurgical,behavioralhealth,andpreventivemedicineconsultants.Recognizingtheneedtotransformthetacticallyposturedmedicalforceintoahealthsystem,themedicaltaskforceinIraqaddedahealthcareadministratortohelpincorporatestrategicmanagementsystemsandfurtherintegratethehealthsystemusingmodernbusinesstoolsandmethods.Inthemostmaturetheaters,themedicalC2structurefunctionallytransformsintoaregionalmedicalcommand-typeconfigurationasseenintheUnitedStatesandEurope.HealthcareContinuum:Theexpeditionarymedicalsystemusesthetraditionalechelonsofcombathealthcare,whichgenerallyincludeprimaryandacutecaresupportedbyverylimitedmedicaltechnologyandmanningfromthemaneuverbattalionslevelIbattalionaidstations.TheareasupportmedicalcompaniesofthebrigadecombatteamsandmultifunctionalmedicalbattalionsoperatelevelIIfacilitieswhichpossessslightlyexpandeddiagnosticandpatientholdingcapabilities.Insettingswheretacticalriskincreasesandevacuationdistancesorweatherconditionswilllikelyimpedetheuseofrotarywingmedicalevacuation(MEDEVAC),itiscommontoaddaforwardsurgicalteamtotheselevelII

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14www.cs.amedd.army.mil/references_publications.aspxHealthcareSystemPlanningAlongtheCombatTheaterMaturityContinuum:HowanExpeditionaryMedicalForceTransitionstoanIntegratedHealthcareSystem F i g u r e 1 : S e l e c t e d U S m i l i t a r y h e a l t h s y s t e m a d v a n c e s a c r o s s t h e c o n t i n u u m o f c o m b a t t h e a t e r m a t u r i t y i n I r a q T a b l e o f O r g a n i z a t i o n a n d E q u i p m e n t : D e f i n e s t h e s t r u c t u r e a n d e q u i p m e n t f o r a m i l i t a r y o r g a n i z a t i o n o r u n i t T a b l e o f D i s t r i b u t i o n a n d A l l o w a n c e s : P r e s c r i b e s t h e o r g a n i z a t i o n a l s t r u c t u r e p e r s o n n e l a n d e q u i p m e n t a u t h o r i z a t i o n s a n d r e q u i r e m e n t s o f a m i l i t a r y u n i t t o p e r f o r m a s p e c i f i c m i s s i o n f o r w h i c h t h e r e i s n o a p p r o p r i a t e t a b l e o f o r g a n i z a t i o n a n d e q u i p m e n t C o m m a n d a n d c o n t r o l T a c t i c a l f o c u s M o v e a n d s h i f t w i t h s u p p o r t e d f o r c e E n d u r i n g b a s e s w i t h o u t p o s t s F i x e d b a s e s a n d c o m m u n i t i e s C l i n i c a l f o c u s T r a u m a a n d p r i m a r y c a r e v e r y l i m i t e d s p e c i a l t y c a r e E a r l y i n t e g r a t i o n o f h u b a n d s p o k e s y s t e m : p r i m a r y c a r e r o b u s t e m e r g e n c y / t r a u m a c a r e a n d l i m i t e d s p e c i a l t y c a r e c e n t e r s a n d c i r c u i t r i d e r s I n t e g r a t e d h e a l t h s y s t e m w i t h f o c u s o n p r i m a r y a n d t r a u m a c a r e p o p u l a t i o n a n d d e m a n d b a s e d s p e c i a l t y c a r e s o m e a p p o i n t e d c a r e P r i m a r y d e f i n i t i v e s p e c i a l t y t r a u m a c a r e w i t h c o m m u n i t y h o s p i t a l s ; p o p u l a t i o n h e a l t h f o c u s ; a p p o i n t e d c a r e E v a c u a t i o n p o l i c y R e q u i r i n g 7 d a y s o r l o n g e r a c c o m m o d a t i n g m o r e t i m e f o r r e c o v e r y a n d r e h a b i l i t a t i o n ; a l s o T h e a t e r T e m p o r a r y H o l d i n g D e t a c h m e n t s O v e r s e a s A r m y c o m m u n i t y h o s p i t a l s t a n d a r d s F a c i l i t i e s D e p l o y a b l e m e d i c a l s h e l t e r s a n d h y b r i d s s e m i p e r m a n e n t a n d u s e o f s e i z e d p e r m a n e n t s t r u c t u r e s S e m i p e r m a n e n t c o n s t r u c t i o n P e r m a n e n t c o n s t r u c t i o n t o U S s t a n d a r d s E q u i p m e n t M o d i f i e d T O & E e q u i p m e n t r e p l a c e d w i t h d u r a b l e U S e q u i p m e n t w i t h a u g m e n t a t i o n T h e a t e r p r o v i d e d U S s t a n d a r d e q u i p m e n t U S s t a n d a r d M e d i c a l d o c u m e n t a t i o n P a p e r a n d l i m i t e d e l e c t r o n i c m e d i c a l r e c o r d s S t a n d a r d i z e d u s e o f e l e c t r o n i c m e d i c a l r e c o r d S u p p l y s y s t e m M o d i f i e d T O & E s t a n d a r d w / e n h a n c e m e n t s R e g i o n a l h u b s a u g m e n t e d b y c o m m e r c i a l s u p p l i e r s P r i m e v e n d o r U t i l i t i e s O r g a n i c p o w e r a n d w a t e r b a s e p r i m e o r c i t y p o w e r a n d w a t e r / s e w a g e s y s t e m B a s e / c i t y u t i l i t i e s F u n d i n g R e q u i r e m e n t s b a s e d P o s s i b l y b u d g e t e d W o r k l o a d a d j u s t e d b u d g e t Q u a l i t y p a t i e n t s a f e t y a n d p e r f o r m a n c e i m p r o v e m e n t U n i t b a s e d q u a l i t y a n d p a t i e n t s a f e t y e f f o r t s C o m m a n d w i d e q u a l i t y m a n a g e m e n t s t a n d a r d s s t r i v i n g t o w a r d s U S / J C s t a n d a r d s w h e r e p r a c t i c a l ; u s e e x t e r n a l v i s i t s a n d p a t i e n t / s y s t e m t r a c e r m e t h o d o l o g y J o i n t C o m m i s s i o n a c c r e d i t e d O n b a s e E M S T a c t i c a l m e d i c a l e v a c u a t i o n B a s e e m e r g e n c y s e r v i c e s 9 1 1 S y s t e m I n t e g r a t e d 9 1 1 S y s t e m w i t h s e c u r i t y f i r e a n d a m b u l a n c e U n i t m a n n i n g O r g a n i c m o d i f i e d T O & E m a n n i n g a u g m e n t e d m o d i f i e d T O & E m a n n i n g d o c u m e n t A u g m e n t e d M T O E a n d / o r M a n n i n g D o c u m e n t / T D A w i t h c i v i l i a n s a n d c o n t r a c t o r s T D A w i t h m i l i t a r y c i v i l i a n s a n d c o n t r a c t o r s ; J o i n t m a n n i n g C 2 / g o v e r n a n c e T O & E M e d i c a l B r i g a d e o r M e d i c a l C o m m a n d / M e d i c a l S u p p o r t C o m m a n d R e g i o n a l m e d i c a l c o m m a n d C a m p a i g n p h a s e E x p e d i t i o n a r y E n d u r i n g C a m p a i g n w i t h I m p r o v i n g S e c u r i t y S t a b l e e n v i r o n m e n t 2 0 0 3 2 0 0 6 2 0 0 7 2 0 0 9 2 0 0 9 U n k n o w n F u l l y m a t u r e C O M B A T T H E A T E R H E A L T H S Y S T E M M A T U R I T Y L O W L E V E L F U L L Y M A T U R E

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OctoberDecember200815THEARMYMEDICALDEPARTMENTJOURNALfacilitiestoprovidetraumaandresuscitativesurgery.Asthecombattheatermatures,thelevelsIandIIfacilitiesfunctionastroopmedicalclinicswhichalsoprovideemergencymedicaltreatmentcapabilityonanareasupportbasis.Inthemorematuretheaterthecombatsupporthospital(CSH)addsmoresophisticateddiagnostic,surgical,andspecialtycarecapabilities.Todayitisnormalforthematurecombatsupporthospitaltohavefluoroscopy,a16-sliceCT(computerizedtomography)scanner,andagreatervarietyoflaboratorycapabilities.TheclinicalworkloadintheCSHinthematuretheatershiftsfrombeingdominatedbytraumatoanoutpatientcarefocus.Overtime,thesupportedcombatantcommandersplaceincreasedemphasisonpreservingtheirwell-presentfordutystrengthanddesiretohavetheirSoldiersreturnedtodutymorequickly.ThisisoftenattributabletoreductionsincombattroopstrengthanddifficultyobtainingreplacementSoldiers.Inresponsetotheseexpectations,themedicalleadershouldconsideraddingwomenshealth,gastroenterology,cardiology,andneurologyservices.Itisalsoprudenttoconsiderpediatricservicestoo,iftheorganizationisexpectedtoperformhumanitarianassistancesupportorcareforthelocalnationalpopulationinthetheater.Whenplanninghealthservicesinthematuretheater,itisimportanttoconsiderthehighdensityofUScontractorswhousethehealthsystem.ThehealthscreeningprocessforcontractorsismuchlessrigorousthanforSoldiers,thusthesepatientsaregenerallyolderandhavemorechronichealthconditions.Inthemorematuretheater,itisappropriateforthemedicalleadertoencouragetheestablishmentofcontractoroperatedhealthcarefacilitiesonthemajorbasesifthedeployedhealthcaresystemdesirestoreducecontractordependencyontheUSmilitaryhospitals.ClinicalIntegrationandMedicalRegulationandEvac-uationResources:Inordertogetpatientsintheexpe-ditionarytheatertotherightlevelofcareinatimelyfashion,unitprovidedcasualtyevacuationvehiclesorgroundambulancesandMEDEVAChelicoptersevacuatepatients,inaccordancewithdoctrine,totheclosestfacilitywiththeappropriatelevelofcare.Asthetheatermaturesandtherelativeproportionofroutineoutpatientcareorrule-outconsultationsandreferralsincrease,thehealthsystemleadermustestablishaspecialtyconsultantsystemtoenabletelephonicoremailconsultations,and,ifappropriate,patientreferrals.ItisalsoappropriatetoworkwiththeMEDEVACsystemleaderstoestablishroutineMEDEVACringroutestoflyonregulardaysoftheweek.Thehighdensityofspecialistsandsubspecialistsinthemedicalcorpsrelativetotheneedforprofessionalfillersystem*generalmedicalofficers(GMOs)inlevelIandIIfacilitiesresultsinaseveralspecialistsandsubspecialistsfillingGMOrolesinthematuretheater.Thoughthisisnotanoptimalwaytomeetthedeployedforcesprimarycareneeds,thissubstitutionpracticedoesyieldthesecondarybenefitofhavingaricharrayofspecialistsavailableintheaterforconsultation.Themedicalleaderinthematuretheatershouldcloselymonitortheassignmentofthesespecialists,andplacesomeofthemincliniclocationsneartransportationhubsinordertocapitalizeontheirabilitytoserveindualroles,usingtheirspecialtyskillswhentheyarenotperformingtheirGMOfunctions.Inthematuretheateritisappropriatetoregularlymonitorevacuationsanddiagnosesbymedicalspecialtytoguidedecisionsonestablishingdedicatedspecialtycareclinicseitheratthehospitalsoronthemajortransportationcross-roadsatairport-basedhealthclinics.On-baseEmergencyMedicalServiceor911PhoneSystem:Oncetheexpeditionaryforceispositionedonlongertermbases,itisappropriateforthemedicalleadertoestablishanon-baseemergencymedicalserviceor911phonesysteminordertospeedambulanceresponsivenessandaccesstoprehospitalcare.FouryearsaftertheestablishmentofamajorbaseinBosnia,aSoldiersufferedcardiacarrestatthegymonemileawayfromthecombatsupporthospital.TheSoldiersbuddiesandthegymstaffdidnothaveaccesstoa911phonesystem,sotheycalledforhelpusingtheirunitsMEDEVACrequestprocedures.It *Theprofessionalfillersystem(PROFIS)predesignatesqualifiedActiveDutyhealthprofessionalsservinginTableofDistributionandAllowanceunitstofillActiveDutyandearlydeployingandforwarddeployedunitsofForcesCommand,WesternCommand,andthemedicalcommandsoutsideofthecontinentalUnitedStatesuponmobilizationorupontheexecutionofacontingencyoperation.2Prescribestheorganizationalstructure,personnelandequipmentauthorizations,andrequirementsofamilitaryunittoperformaspecificmissionforwhichthereisnoappropriatetableoforganizationandequipment(thedocumentwhichdefinesthestructureandequipmentforamilitaryorganizationorunit).

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16www.cs.amedd.army.mil/references_publications.aspxtookalmost20minutesfortheambulancetoarriveatthegym.TheSoldierdiedandthemedicalleadersquicklyestablisheda911telephonenumberforthebaseinjust2weeks.QualityManagementandPerformanceImprovement:Medicalunitsinthelessmaturetheaterstraditionallyestablishtheirownqualitystandardsandoperatewithinthescopeofprivilegesoftheassignedhealthcareproviders.Inthesetheaters,therearenotconsistenteffortstoassessordocumentcompetenciesorscopesofpracticeforthenursingstafformedics.BasiccombatskillscallforSoldierstoconstantlyimprovetheirfoxhole.Themedicalforceshouldbenodifferentinconstantlyimprovingthequalityandreliabilityofthehealthsystem.Asthetheatermatures,itisimportantforthemedicalleadertoprogressivelyadoptUShealthcarequalitystandardstothedegreetowhichitispracticableinthemoreaustereenvironment.ItisnotuntilmuchlaterinthematurationcontinuumthatthehealthcarefacilitieswouldevenconsiderJointCommission*accreditation.Leadersshould,however,instillqualitymanagementstandards,patientsafety,andperformanceimprovementsystemsthatembraceUSqualitystandardsasthatiswhatSoldiers,commanders,andtheSoldierslovedonesexpectanddeserve.Overtime,moremedia,electedofficials,coalitionnationleaders,claimsattorneysandexternalagenciestakeinterest,notjustinsurvivalratesandcasualtyfiguresinthedeployedhealthcareorganization,buttheyalsodemandinformationtodocumentthequalityofcaredelivered,particularlyinhighvisibilitycasesorafteruntowardoutcomes.AdoptionofasmanyJointCommissionstandardsandprinciplesaspracticalsafeguardsboththepatientsandthemedicalforcesinterests.Thoughithappens,inthematuretheateritisneverproperformembersofthehealthcareteamtosaythisiscombat;wedontdothatqualityimprovementBShere.Themedicaltaskforceheadquartersinthematuretheaterestablishesaninspectionprogramwhichshouldincluderegularassessmentsofthehospitalsandmedicalcompaniesadherencetostandardsrangingfromtheprovisionofcare,todocumentationandcommunication,totheenvironmentofcare.Thehighrateofturnoverinthematuretheaternecessitatesahighfrequencyofqualityandsafety-orientedstaffassistancevisits.LeadersandqualitymanagementstaffmembersinthematuremedicaltreatmentfacilitiesandmedicaltaskforceheadquartersusethesamepatientandsystemtracermethodologycommonlyusedinUShealthcarefacilitiesinordertoassessandimproveclinicalandsupportsystemquality.Manning:Asthetheaterofoperationsmatures,themedicalforceaddstheappropriatestaffcommensuratewithincreasedcarespecialization,technologyofequipment,andsophisticationofthephysicalplant.Medicalleadersshouldconsideremployingfulltimecontractfacilitymaintenance,utilities,andhousekeepingstaffoncethehospitalorclinicisinapermanentlocation.Severallowerdensityorfrequentlydeployedspecialtiesbecomeover-usedordepletedduringlongertermoperationsinthematuretheater.ItiswisetoconsiderpermittingUSgovernmentcivilianemployeesorcontractorstoperformselectfunctionsinthemorepermanenthealthcarefacilities.Itisimportanttoworkallofthedetailsofbothcivilianpersonnelmanagement,includingmanagement-employeerelations,andcontractingofficerandcontractingofficerrepresentativerolesandrequirementswellinadvanceofbringingciviliansorcontractorsintothehealthcarefacilities.Additionally,asthebusinessaccountabilityandfinancerequirementsinthemedicaltreatmentfacilitiesandthemedicalC2headquartersincrease,leadersshouldconsiderwhichofthesefunctionsmustbedoneintheaterandwhichcouldbeperformedremotelybyacontractororotheragencyinthecontinentalUnitedStates(CONUS)indirectsupportofthedeployedmedicaltaskforce.EquipmentandStandardization:StandardmedicalequipmentsetsfortheCSHsandthemedicalcompaniesarerarelyadequatefortheexpeditionarymedicalforcebecausetheytendtolackseveralitemsofdiagnosticandsurgicalequipmentwhichprovidersrelyuponintheirpractice.Mostexpeditionarymedicalunitsdeploywithaugmentationequipmenttheyhavespeciallyprocuredinordertomeettheirprovidersbasicrequirements.Thelongerthemedicalforcestaysinthetheater,andthemorebroadlythehealthcarefacilitiesscopeofcareexpandsinordertoaccommodatespecialtycareprovidersneeds,thegreaterthedemandfortraditionalmedicalequipmentfoundincommunityhospitalsandmedicalcentersin *JointCommissiononAccreditationofHealthcareOrganizations,OneRenaissanceBlvd,OakbrookTerrace,Illinois60181HealthcareSystemPlanningAlongtheCombatTheaterMaturityContinuum:HowanExpeditionaryMedicalForceTransitionstoanIntegratedHealthcareSystem

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OctoberDecember200817THEARMYMEDICALDEPARTMENTJOURNALCONUS.Ashospitalsmoveintomorepermanentfacilities,theyreplacetheirdeployablehospitalbedswithcommercialbeds.Theyalsoaddmoresophisticatedrefrigeratorswithalarmsystems,c-arms,variousscopes,monitors,andcommercialsterilizersinordertomeettheclinicalqualityanddurabilityrequirementsofthestaff.Ratherthanpermituncheckedacquisitionofawidevarietyofequipmentfromaplethoraofmanufacturersforthevariousfacilitiesacrossatheater,themedicaltaskforceinthematuretheaterestablishesamedicalequipmentstandardizationboardtoconsiderandprocurethecommonlyacceptedadvancedequipmentwhichcanbesharedbetweenfacilities,andmaintainedwithacommonsetofrepairandcalibrationequipment.ThesemultidisciplinaryequipmentstandardizationboardsfunctionsimilarlytoacapitalequipmentprogramandbudgetadvisorycouncilinCONUSmilitarytreatmentfacilities(MTFs).Reducingthevarietyofmodelswithinacommontypeofmedicalequipmentallowstheclinicalengineeringstafftomaintainacommonsetofrepairskills,manuals,parts,andsparemedicaldevicestoprovidetofacilitieswhentheirequipmentisoutforrepair.Giventhattheintermediatematurityhealthsystemsdonothaveadedicatedcapitalequipmentbudget,theMTFsequipmentisfundedonarequirementsbasisusingaletterofjustificationandanoperationalneedsstatementwhichpassesthroughservicecomponentcommandchannelsforapprovalatthemilitaryservicesecretarysoffice.TheArmysOfficeofTheSurgeonGeneralandtheUSCentralCommandrecentlyestablishedaJointMedicalTechnologyAssessmentReviewTeamtoserveasanobjectiveofficetoguideandvalidatetheacquisitionofhighcostandadvancedtechnologymedicalequipmentrequirementsforthematuringtheatersofIraqandAfghanistan.CommunicationandDocumentationofCare:Althoughdocumentationofhealthcareisbeneficialinmanagingthehealthofapatient,andforcommunicationbetweenmembersofthehealthcareteam,itisnotcommonlyamongthehighestofprioritiesintheexpeditionarymedicalforce.Asthetheatermaturesandthehealthcareorganizationsassumeamorepredictablepatternofoperations,themedicalrecordbecomesmoreimportanttothehealthcareteam.Themorematurehealthcaresystemsestablishstandardsrequiringproviderstodocumenttheircareusingtheelectronicmedicalrecord(EMR).Thehardenedfacilitiesandmorereliableutilitiesprovideamorestableenvironmentimprovingthereliabilityofinformationsystemsandtheelectronicmedicalrecord.TheEMRfollowsthepatientasheisevacuatedthroughthehealthcaresystemoutoftheatertomilitaryorVeteransAffairshealthcarefacilitiesinCONUS,andprovidesalongitudinalrecordforreferencethroughouthislife.TheMTFsinthemorematuretheateralsousetheelectronicmedicalrecordtoperformmedicalrecordreviewstoassistwithqualitymanagementfunctions.Theyalsotypicallyhavearobustsetofsecureandnonsecuretelephonesanddedicatedbandwidthonthematurebasesnetworks,andtheyuseenhancedVSAT(verysmallapertureterminal)satellitesystems.AsisthecaseinCONUS,healthcareprovidersaregenerallydissatisfiedwiththeslowspeedoftheEMRsystem,butinmanycasesthematurehealthcarefacilitiesacquirevoicerecognitionsoftwaretomitigatetheirfrustrationbyassistingwiththedictationofclinicalnotes.BusinessandAccountingFunctions:TheatermedicalrulesofeligibilityoftenrequiretheUShealthcarefacilitiesinthetheaterofoperationstoprovidecaretoallcategoriesofpatientswhopresentattheirfacilitiesinordertopreservelife,limb,oreyesight.DeployedMTFsdonothaveanyorganiccapabilitytoperformanymedicalrecordcoding,thirdpartyinsurancebillingorcollecting,oraccountingforcontractorornoncoalitionforcehealthcare.Additionally,thedeployedmedicalfacilitiesandheadquarters,eveninthesemimaturetheaterssuchasIraqin2008,5yearsaftertheinvasion,lacktheresourcemanagementstaffs,manpower,andworkloadaccountingstaffstoperformbasicworkloadaccountingandanalysisfunctions.Atsomepointfartheralongthetheatermaturitycontinuum,thesebusinessandaccountingfunctionsshouldbeadded.Asstatedearlier,manyofthesefunctionsmaybeperformedremotelyfromCONUSinsupportofthedeployedMTFs.ThefundingofdeployedMTFsisnormallyrequirements-basedandthusnotsubjecttothetypicalconstraintsofafixedorworkload-adjustedbudgetingsystem.Asthetheatermaturesevenfurtherandbudgetingsystemsevolve,thedeployedmedicaltaskforceshouldconsiderestablishingresourcemanagementorbusinessoffices.CONCLUSIONThematurationoftheIraqtheaterofoperationsoverthefirst5yearsdemonstratesthatleadersdeliberately

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18www.cs.amedd.army.mil/references_publications.aspxandsuccessfullyimprovedquality,integration,andaccessibilityofthehealthcaresystem.Astheadagegoes,Soldiersdowellthosethingstheircommanderchecks.Thishasproventrueinassessingtheremarkableimprovementsinthecontentofcareaswellasthemedicalsupportsystems.Whenplanningandexecutingfuturecampaigns,itisimperativethatwedeliberatelydesignandimplementmechanismstocatalyzethematurationandensurequalityperformanceoftheimportanthealthcareandsupportfunctionsbasedontheconditionsintheoperationalenvironment.Asthemedicalforceenjoysthebenefitofmoretime,leadersmustestablishandmonitordecisionpoints,analyzetheenvironment,developplans,andthenprofessionallymanagethismaturationinordertostrategicallyimprovehealthcare.Itistooeasytostandstill,analyzingandobserving,waitingfortherateofchangetoslowbeforeacting.LeadersmustnotviewthedeployedUShealthcaresystemasaseriesofone-yeardeployments,butinsteadpurposefullyguidedevelopment,strivingtoachieveUSqualitystandards,constantlyimprovinghealthsystemintegration,anddevelopingfacilitieswithtechnologicallyappropriateequipment,allwhileleadingawell-trained,adaptive,andcompetentstaff.Inconclusion,whenconsideringthelengthoftimeittakesforatheatertomature,itishelpfultolookatoneArmyhospitalinSeoul,Korea,whichpassedamajormilestone58yearsafteritsupportedexpeditionaryoperationsintheKoreanWar.Ithasbenefittedfrommanygenerationsofimprovements,butithascontinuouslywrappeditsservicesaroundtheoperationalneedsofthesupportedunitsandmettheneedsofitsindividualpatients.Theformer121stEvacuationHospitalmadeoneofitsfinaladvancesalongthematuritycontinuumasitwasgiventhepermanentnameastheBrianAllgoodArmyCommunityHospitalinJune2008,inhonorofthisoutstandingofficerwhosacrificedhislifewhileleadingthematurationofthehealthcaresystemsinIraqonJanuary20,2007.REFERENCES 1.FieldManual3-0:Operations.Washington,DC:USDeptoftheArmy;February2008:chap1,p1-16.2.MedicalCorpsProfessionalDevelopmentGuide.FortSamHouston,TX:USArmyMedicalDepartmentCenterandSchool;March2002:27.AUTHOR Atthetimethisarticlewaswritten,COLBudingerwastheDeputyCommandingOfficer,TaskForce62Med-icalBrigade,Baghdad,Iraq.HealthcareSystemPlanningAlongtheCombatTheaterMaturityContinuum:HowanExpeditionaryMedicalForceTransitionstoanIntegratedHealthcareSystem COLSCOTTJOINSTHEAMEDDJOURNALEDITORIALREVIEWBOARDTheAMEDDJournalwelcomesCOLDanaP.Scott,VC,USAasamemberoftheEditorialReviewBoard.COLScottistheDeputyChief,USArmyVeterinaryCorps,AMEDDCenter&School,FortSamHouston,Texas.COLScottjoinstheboardreplacingCOLMarcE.Mattix,VC,USA.COLMattixhasbeenamemberoftheBoardsinceOctober2007.WethankCOLMattixforhisdedicationtothehighstandardsandprofessionalqualityofthispublication,andhissupporttoourmission.WewishhimwellinhisreturntothebigskiesandwideprairiesofMontana.TheEditors

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OctoberDecember200819Positionsbuiltonsystemsofactivitiesarefarmoresustainablethanthosebuiltonindividualactivities.MichaelPorter1INTRODUCTIONThemedicaltaskforcessystemoforganizationalstrategyandchangemanagementlieswithinthecombathealthcaresupportsystem(CHSS).TheCHSSisacustomizedoffshootfromtraditionalbalancedscorecards2inthatthetaskforcedoesnotstatetheoperationalobjectivesonthestrategymap,butsimplyshowsthestrategicmacro-objectives.Therearesub-systemsandselectinitiativeswhichsupporttheaccomplishmentoftheseobjectives.TheCHSSmodifiedstrategymapshowstheinterdependenciesandsynergyofvarioussubsystemsinsupportofTaskForce62MedicalBrigadesstrategicobjectives(listedonpage20).ThemedicaltaskforceforOperationIraqiFreedomcompleted5yearsofsupporttoMulti-NationalForces-Iraqcombatoperationsinearly2008.Thetaskforceheadquartershasengagedineveryaspectofcommandandcontrol(C2)foreachofthemedicalfunctionsinIraqwithdistinctrequirementsfrompredeploymentplanning,planningforfuturerequirementstoreception,staging,onward-movementandintegrationtomissionexecution,sustainment,andredeployment.ThemedicaltaskforceinIraqhasC2responsibilityfor46medicalunits.Theseunitsconsistof4hospitals,4headquarterselements,and38companiesanddetachmentsthatprovidehealthcaretoUSandCoalitionforces,selectcontractors,anddetaineepopulationsthroughouttheIraqiareaofresponsibility.Althoughtherehavebeennumerousrotationsandafreshlookatthedeliveryofhealthcareeachyear,therewereveryfewsignsofhealthsystemsintegrationbeyondtraumamanagement.ThecommanderandseniorleadersoftheTaskForce62MedicalBrigade(TF62MED)identifiedarequirementforintegrationandstandardizationofprocessesandsystems,andanincreasedemphasisontaskforce-wideperformanceimprovement.Thevehicletoimplementastrategywasmodeledafterthebalancedscorecard.2Thismethodenablesthecommanderandseniorleaderstoillustrateacustomizedstrategymapdemonstratingtaskforcestrategiesandtheabilitytocommunicatethemacrosstheorganization,aswellastoidentifykeyinternalprocessesthatdrivestrategichealthservicesupportsuccesses.Ultimately,themedicaltaskforcecommanderisresponsibleforimplementingDepartmentofDefense(DoD)healthcarepolicy.Examplesofthisarethedocumentationofcareintheelectronicmedicalrecord,treatmentofmildtraumaticbraininjuryandposttraumaticstressdisorder,andtheimplementationofrecommendationsaftertheMentalHealthAssessmentTeam(MHAT)V*study.3TheTF62MEDCHSSstrategymap,presentedasFigure1onpage6,providesagraphicaldepictionoffunctionsandrelationshipsbetweenallmedicalunits,aswellasdifferentmedicalwarfightingfunctions.AllthemedicalwarfightingfunctionsaresynthesizedintoanintegratedhealthcaredeliverysysteminordertoASystematicApproachtoCombatHealthcareImprovement:TaskForce62MedicalBrigadeCombatHealthcareSupportSystemModelMAJAlanUeoka,MS,USA *MHATVisthefifthofaseriesofmentalhealthadvisoryteamssentbytheArmySurgeonGeneraltothetheatersofoperations(IraqandAfghanistan)toassessthementalandbehavioralhealthofdeployedSoldiers;thequalityofmentalandbehavioralhealthcare;accesstothiscare;andtomakerecommendationsforchangestoimprovethementalhealthandmentalhealthservicestoourmenandwomenwhoaredeployedintocombatenvironments.

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20www.cs.amedd.army.mil/references_publications.aspx *Chain-teachisamethodofunittraininginwhichdesignatedunitmembersfirstreceivethetraining,afterwhichitistheirresponsibilitytotrainanotherlevelofpersonnel,whointurnwillcontinuetrainingothers.Thetrainingcontinuesinapyramidfashionuntilallpersonnelrequiringsuchtraininghavereceivedit.provideeffectivebattlefieldhealthcare.Themodelisonlyablueprintforhowwebuilditisnotthebuilding.Thecombathealthcaredeliverysystemusesastrategymap,adoptedfromKaplanandNortonsongoingstudiesonstrategicmanagement.4Themedicaltaskforcefurtherdividedourmissioninto3achievableends:1.ProvideWorld-ClassWarriorHealthcaretoUSandCoalitionForces.TheintentistooptimizeWarriorreturn-to-dutyandconservecombatpower.Thisfocusesonmedicaltreatmentofbothbattleinjuryanddiseaseandnonbattleinjury(DNBI),andcarefortheinjuredandill.Thededicationtohumanlifehasledtoanalmost98%return-to-dutyrateforeveryservicememberarrivingatourtreatmentfacilities.2.ProtecttheHealthofUSandCoalitionForces.Theintentistomaximizepresent-for-dutyandreduceDNBI.Thisfocusesonproactive,systematicsurveillanceandpreventionofthreatstoservicememberhealth.Currently,thereisaDNBIrateofonly2.5%,whichisthelowestinthehistoryofwarfare.3.EnhanceGovernmentofIraqCredibilitybySup-portingSelf-ReliantIraqiPublicHealthSystems.TheintentisthepromotionofmedicaldiplomacyandtheenhancementoftheGovernmentofIraqs(GoI)credibility.FocusesoneffortsandsystemstosupporttheGoIsabilitytoeffectivelydefenditself,andensurebasicservicesfortheIraqipeople.Theseendsdrivethetaskforceseffortstowardachievingunilateralimprovementinfocusedareasthroughweeklyreviewandmanagementofmeasurabletasks.Theseendsarelistedatthetopofthestrategymap.Asanintegratedhealthcaredeliverysystem,themedicalbrigadetaskforceheadquartershasbeenabsolutelycriticaltotheestablishmentofdocumentedprocessandimprovedhealthcaresystemsandsubsystems.Inrapidlychangingandfluidenvironmentslikecounterinsurgencyoperations,unitsfindtheirsustainablesolutionsthroughinjectingtheirunitswiththecultureofprocessimprovementandcontinuallearningandgrowth.Thevehicletoimplementastrategywasmodeledafterthebalancedscorecard2andstrategymap.Thismethodenabledthetaskforcecommanderandseniorleaderstoshowthetaskforcehowtocreateacustomizedstrategymapthatallowsthetaskforceto:Clarifytaskforcestrategiesandcommunicatethemacrosstheorganization.IdentifythekeyinternalprocessesthatdrivestrategichealthservicesupportsuccessintheIraqtheaterofoperations.AligntheDoDsinvestmentinpeople,technology,andorganizationalcapitalforthegreatestimpactincombatcasualtycare.Exposegapsinthemilitaryhealthsystemstrategiesandtakeearlycorrectiveaction.IMPLEMENTINGTHECOMBATHEALTHCARESUPPORTSYSTEMSTRATEGYMAPTF62MEDsystematicallyimplementedandrigorouslyexecutedastrategymapknownastheTF62MEDCHSSthroughoutthetaskforcetothelowestunitlevels.Thetaskforcebegantheimplementationofthestrategymapthroughachain-teaching*program,directedthroughafragmentaryorderandrequiringallunitstocomplywiththetop-downdrivenvisionofthesystem.Performanceimprovementandpatientsafetyarethetaskforcesmaineffortensuringthatdesiredoutcomesarerealizedandsystematicfixesareestablished.LeadersensureeverymemberoftheirsectionorunitareabletodescribehowtheyfitintotheCHSSmodelandsupportthe3majorpurposesofthemedicaltaskforce.Allmembersofthetaskforcearealsochargedtodescribeaspecificsystematicperformanceimprovementinitiativeonwhichtheyareworking.DESCRIPTIONOFTHESTRATEGYMAPTheTF62MEDcombathealthcaresupportsystemormodifiedstrategymapportraysthekeyelementsthatmakeuptheorganizationandhowtheyfittogetherintheoverallstrategy.Themodifiedstrategymapconsidersperspectivesofthestakeholders(militaryASystematicApproachtoCombatHealthcareImprovement:TaskForce62MedicalBrigadeCombatHealthcareSupportSystemModel

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OctoberDecember200821THEARMYMEDICALDEPARTMENTJOURNALhealthsystem)andcustomers(patientsandcasualties).Thedepthofthemodelisbaseduponobjectivesandresources.ObjectivesAllCHSSobjectivesandmeasuresofeffectivenessaredevelopedundertheacronymSMARTERspecific,measurable,accountable,results,timebound,en-compassing,andreviewed.SMARTERobjectivesaredefinedas:Specific:Statesspecificendpointsdesired.Measurable:Measuresresultsusuallybyanumberorpercentage.Accountable:Identifiesandholdsindividual,team,department,sectionorunitaccountableforactionandoutcomes.Results:Identifiestheoutcomesdesired,nottheprocesstogetresults.Time-bound:Specifieswhenresultsaretobeachieved.Encompassing:Alignswithandsupportsallotherobjectives(ie,inclusiveandlinkedornestedwithhigherheadquarters).Reviewed:Evaluatedtocheckrelevanceandpro-gresstowardsresults.Theseprincipleshelpedthebrigadestaffshapethemeasurableobjectivesfortheirindividualstaffsections.Theseobjectivesmustfitintothetaskforcecommandersvision,framedbyEnds,Ways,andMeans.EndsAsdiscussedonpreviouspages,thetaskforceused3achievableEndstofocusthecollectiveeffortsanddefineleftandrightlimits.Thereare3majorendstotheTF62MEDstrategymap:1.OptimizeReturn-to-DutyandConserveCombatPower.TheintentistooptimizeWarriorreturn-to-dutyandconservecombatpower.ThisfocusesonmedicaltreatmentofbothbattleinjuryandDNBI,andcarefortheinjuredandill.2.MaximizeWellPresent-For-DutyandReduceDNBI.Theintentistomaximizepresent-for-dutyandreduceDNBI.Thisfocusesonproactive,systematicsurveillanceandpreventionofthreatstoservicememberhealth.3.ImprovedHealthStatus,PublicConfidence,IncreasedCapabilityandCapacity.TheintentisthepromotionofmedicaldiplomacyandtheenhancementoftheGoIscredibility.FocusesoneffortsandsystemstosupporttheGoIsabilitytoeffectivelydefenditself,andensurebasicservicesfortheIraqipeople.WaysTheWaysdeliverthehowtotheorganizationalgoalsatthetopofthestrategymap.OurinternalprocessandsystemsprovidethoseWaysinwhichweconductourdailyoperations.Theinternalprocessandsystemsaresubdividedintothefollowing3components:WarriorHealthcareSystemsconsistofhospitali-zation,surgery,diagnosticandspecialtycare;theprimaryanddentalcaresystem;traumaandchroniccareclinicalpracticeguidelines;medicalregulation;andclinicalintegration.Thewarriorhealthcaresystemfocusesonprovidingemergency,acute,andchroniccare,hospitalization,andsurgerytoUSandcoalitionforcesandotherbeneficiaries.Italsoensuresthat,whenapplicable,providersuseclinicalpracticeguidelinestocapitalizeonbestpracticesandthemanagementcareofpatientsrelyingontheintegratedhealthsystemmedicalunits.ForceHealthProtectionSystemsconsistofpreven-tivemedicinesystems,veterinarycaresystems,mentalhealthcare,andbuildingresiliency.Thefocusofthiscomponentistoproactivelyidentifyenvironmentalandhealthriskstotheforce,developsystemstomonitorandmitigaterisks,maximizing(well)present-for-dutystrength.Additionally,theresourcesofthesespecialtyareassystematicallydevelopandimplementinterventionstoenhancethefuturehealthandresilienceoftheservicemember.MedicalCivil-MilitaryOperationsSystemsconsistofprofessionalmeetings,engagements,publiceducation,andmedicaltraining(Pro-MEET).CooperativemedicalengagementsfacilitateimprovedaccesstoIraqhealthservices,timelyIraqipatienttransfers/dischargesfromUStoIraqifacilities,includingthedetaineehealthcaresystem.Themedicaltaskforcecancapitalizeonanincreasedlevelofsecuritytodevelopthehostnationsmedicalcompetency,prestige,salary,

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22www.cs.amedd.army.mil/references_publications.aspxandemploymentconditions.ThetrainingthetaskforceprovidesIraqiphysiciansandmedicalstaffareeventsthatcanbeleveragedforpositivelocalmediaeffortstobothpromoteIraqipublicconfidenceandlegitimizetheMinistryofHealthinparticular,andtheGoIingeneral,bysynchronizinginformation,publicaffairs,andpsychologicaloperationsenablers.Thefirstelementofmedicalcivil-militaryoperationsishealthsectorlegitimacyandefficiency.LegitimacyandefficiencyoflocalhealthcareservicessupporteffortswhichbuildtheIraqipeoplesconfidenceintheirhealthservices,andencouragewiseuseofresources.Thesecondelementisprofessionalmedicalengagement,educationandtraining(Pro-MEET)whichprovidesprofessionaltraining,education,andcounseltoimprovetheeffectivenessoftheGoIpatientcareandhealthsystemmanagement.ThethirdelementisUS/IraqifocusedandstrategicpartnershipwhichselectivelyjoinsresourcesofCoalitionandIraqigovernmentandprivatesectorentitiestoenhanceIraqiself-sufficiency.MeansLearningandgrowthencompasstheMeansbywhichweconductourdailyoperations.Thefollowingareapplications,enablers,andprogramsthatprovidetheMeansbywhichtheTF62MEDexecutesthepreviouslydelineated3componentsoftheinternalprocessesandsystemswhichdefinetheWays:ClinicalQualityManagement:Ensurehealthcaredeliveredwithinacceptedstandards.ComprehensiveRiskManagement:Retrospectivereviewsamplingnormalcases(morbidityandmortality,sentinelevents,etc).ElectronicClinicalDocumentation:Integratedinformationsystemstodocumentcareandcommunicationwithinandacrossthecontinuumofcare.LogisticsandMaintenanceManagement:Proactiveandresponsivesystemstoprovideandmaintainthesuppliesandequipment.HealthFacilitiesPlanningandManagement:Establishandmaintainphysicalplantsandenvironmentofcare.ContinuingEducationandTraining:Providing,improving,andrefreshingindividualandcollectiveskills.AgileJoint/MultinationCommandandControlStructureandMethods:Agileorganizationandleadershipbasedonforces,function,andgeography.OrganizationalAssessment:Physicalandvirtualassessmentsandreviews.Efficiency,Effectiveness,Outcome,Measure-mentandAccountabilitySystems:Meanstoensureweareachievingdesiredoutcomeseffectivelyandwisely.MoralCompass,EthicalSystemFramework:Dotherightthingrespectingothers.DevelopAdaptiveLeaders:Leaderswhoarevalues-groundedandwholeadinaccordancewiththestandardsofArmyCommandPolicy.5ResourcesTheresourcesblockisintegraltothefoundationofthemodel,uponwhichsittheEnds,Ways,andMeans.People,fiscalmanagement,andinformationsystemstructuresmustbepresentandfollowasolidprocesstoprovideaninimitableandinvaluableproduct.ThefollowingresourcessupporttheoverallstrategyoftheTF62MEDCHSS:ForceandHumanResourcesManagement:Com-petent,cared-forpersonnelwiththeintentskillsattherightsites.FiscalStewardship:Adequateoperatingfundsmanagedwithtaxpayersinterestsinmind.MedicalInformationManagement/InformationTechnology,MilitaryHealthSystemAcquisition,Research/Development,andInfrastructure:Ro-bustinformationtechnology,acquisition,andresearchsystemsandinfrastructure.FOUNDATIONOFTHETF62MEDICALBRIGADECHSSAllsuccessfulstrategiesmusthaveafoundation.TheTF62MEDstrategicfoundationisnestedintheacronymF.L.A.G.family,leadership,ambas-sadorship,andgrowth.ThetenetsofthephilosophyofF.L.A.G.arepresentedonthefacingpage.ImplementationStrategyWithoutquantifying,astrategicobjectiveissimplyapassivestatementofintent.4(p365)ASystematicApproachtoCombatHealthcareImprovement:TaskForce62MedicalBrigadeCombatHealthcareSupportSystemModel

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OctoberDecember200823THEARMYMEDICALDEPARTMENTJOURNALThemedicaltaskforcedevelopedmetricsinconcertwiththecommandersvisionofprovidingUShealthcarethroughasystematicprocessimprovementculture.Eachsectiondevelopedthesemetricsbasedontheirrespectivecontributiontotheframeworkofthesystem,oroneachoftheirbuttonsonthestrategymap.Inordertobuildconsistentlydevelopedmeasurements,thestaffusedthefollowing3-pointframeworkforeachobjective:1.Objective:Definesthepurposeofthemetricinquantifiedandachievableterms.2.Benchmark:Definescomparablestandards;firstinArmystandards,thenJointCommission*standards,andfinallybrigadestandards.Eachsucceedingstandardisusedonlyifthehigherleveloneisnonexistent.3.Assessment:Defineshowthebrigadeismeetingtheobjectiveintemporalobjectivesandtaskaccomplishment.Itmustbestatedherethatnotallobjectivesarequantifiable.Wherethiswasthesituation,thetaskforceusedaqualitativedemonstrationofhowwetargetedtheproblemorissue.Thestaffsectionusedeitherastoryboardorprojectmaptoshowtheprogressofanactionorprojecttoupdatethecommander.Thestaffhadtoincorporateanunder-standingofthequantificationprocessintothetaskforceorganizationalstrategyandvision.Thestaffconsid-ered3ingredientsofthedynamicsofstrategyandaddedthemtoourstrategymapprocesses.Theseingredientsalsokeptthestafffocusedonachievableandfeasibletasksandobjectivesthatwereallrelatedtotheendsandcenteredonourstakeholders.Quantify:Establishtargetsandvalidatethecause-and-effectrelationshipsinthestrategymap.DefinetheTimeline:Determinehowstrategicthemeswillcreatevalueinshort-,medium-,andlong-termhorizonstocreatebalancedandsustainedvaluecreation.SelectInitiatives:Choosethestrategicinvestmentsandactionprogramsthatwillenabletheorganizationtoachieveitstargetedperformanceinthestatedtimeframes.ThetaskforceimplementedthecombathealthcaresupportsystemmodelwiththepublicationofFragmentaryOrder#291toTF62MEDOperationsOrder07-09,adirectivewhichprovidedatop-downcommunicationofstrategyandimplementation.Thisensuredcommonunderstandingofthetaskforcemission,vision,andvalues,andenabledcommunicationoforganizationalgoalsandobjectivesthroughanimplementationbriefing.Thisstrategywasimplementedbysubordinatestaffsectionsandcommandswithin30daysofitscreation.Thiswasaccomplishedbyusingachain-teachingpresentationprovidedinthepublisheddirective.Thedirect *JointCommissiononAccreditationofHealthcareOrganizations,OneRenaissanceBlvd,OakbrookTerrace,Illinois60181Internalmilitarydocumentnotreadilyaccessiblebythegeneralpublic. Reproductionofthein-theaterposterdisplayingthetenetsoftheF.L.A.G.institutionalphilosophydevelopedbytheTF62MedicalBrigadeasthefoundationforthecombathealthcaresupportsystem. IwillneverleaveafallencomradeWenotonlyfightfortheConstitutionandourDemocracy,Wefightforeachother.Familiestakecareofeachotherandtreatoneanotherwithdignityandrespect.YouenlistSoldiers,Sailors,Airmen,andMarines,butreenlistFamilies.IwillneveracceptdefeatNooneismoreprofessionalthanI.Leadfromthefrontwithpersonalandorganizationalintegrity.LeadershipisaTEAMsport-counsel,coach,andmentor.IwillalwaysplacethemissionfirstDuty,Honor,Country!Yourcharactermusthonorournation,yourservice,unitandFamily.Ethicalconductandmedicaldiplomacyareforcemultipliers.IwillneverquitKnowyourjob,doyourbest,anddevelopyourabilitiestotheutmost.Alwaysseektoimproveyourphysicalandspiritualfitness.Wearealearningorganizationandmustmaintainaperpetualquestforknowledge.SOHELPMEGOD! Family,Leadership,Ambassadorship,andGrowth Yourlifeisnotimportantexceptfor theimpactithasonanotherlifeJackieRobinson

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24www.cs.amedd.army.mil/references_publications.aspxreportingunitsweretaskedtonotifytheTF62MEDdeputycommandingofficeronceallofficersandseniornoncommissionedofficershavebeenbriefedonthemodifiedstrategymap.Theheadquartersstaffwasresponsibleforfurtherdevelopmentofthestrategyandmetricstomeasureperformanceandprogressbyasking2simplequestions:Arewealignedwiththestrategy?Arewemakingprogress?Theclinicaloperationssectiongainedownershipofthewarriorhealthcaresystemandforcehealthprotectionsystems.TheCivil-MilitaryOperationsOfficergainedownershipofthemedicalcivil-militaryoperationssystem.Therestofthestaffsectionsgainedownershipoftheelementswithinthewaysandmeans.Additionally,theTF62MEDcommanderisprovidedamonthlystrategyassessmentusinganinteractivemodelofthestrategymap,inwhicheachbuttonislinkedtotheobjectivesandmeasurementsinaPowerPointdashboard.Thisoperatesjustlikeawebpage,whicheventuallyisoneoftheend-productsofthisproject.Thecommanderandstaffsarealsoprovidedwithabinder(updatedmonthly)withdocumentationofmetricsinasnapshot.SUMMARYAnorganizationsmission,vision,andvaluesarejustwordsintangibleconcepts,unactionabledirectives,andinconsequentialthoughts.Withouttheemphasis,energy,andadefinedprocessandframework,thewordshavelittlemeaningtotheorganization.TaskForce62createdthisorganizationalvisionandcommunicationsstrategythroughatestedmodelbasedonKaplanandNortons4continuingstudiesonorganizationalstrategy.Thetaskforceaccomplisheditsstrategyonlybyovercomingthemostdifficulthurdleinchangingorganizationalcultureacceptingchange.Overtime,thestaffevolvedfromcompliancetocommitmenttothecultureofprocessimprovementandorganizationalintrospection.Wecoulddothisbecausetheclimateduringourweeklyreviewswasnotpunitiveordefensive,butcollaborativeandchallenging.Wealsosawthevalueaddedtoourunitandtaskforcegrowthanddevelopmentand,intheprocess,learninganddevelopmentasindividuals.Futuremedicaltaskforceswillhavetheabilitytogaingroundanddevelopthismodelforconclusion.AstheArmyMedicalDepartment(AMEDD)continuestodevelopandrefinelessonslearned,theCHSSmodelpresentedherecanbethefoundationfortheAMEDDandDoDsvisioninthecreationandmodificationofschoolhouseprogramsofinstructionsanddoctrinetoberelevanttothematuringcombattheaterofoperations.REFERENCES 1.PorterME.CompetitiveStrategy:TechniquesforAnalyzingIndustriesandCompetitors.NewYork,NY:TheFreePress;1980.2.BalancedScoreboardInstitute.Whatisthebalancedscoreboard?.Availableat:http://www.balancedscorecard.org/BSCResources/AbouttheBalancedScorecard/tabid/55/Default.aspx.AccessedOctober6,2008.3.MentalHealthAdvisoryTeam(MHAT)V:OperationIraqiFreedom06-08,Iraq;OperationEnduringFreedom8,Afghanistan.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;Feb-ruary14,2008:26.Availableat:http://www.armymedicine.army.mil/reports/mhat/mhat_v/MHAT_V_OIFandOEF-Redacted.pdf.4.KaplanRS,NortonDP.StrategyMaps,ConvertingIntangibleAssetsintoTangibleOutcomes.Boston,MA:HavardBusinessPress;2004.5.ArmyRegulation600-20:ArmyCommandPolicy.Washington,DC:USDeptoftheArmy;March18,2008.AUTHOR Whenthisarticlewaswritten,MAJUeokawastheChiefofOperationsfortheOperationIraqiFreedomMedicalTaskForce(62ndMedicalBrigade)inBaghdad,Iraq.ASystematicApproachtoCombatHealthcareImprovement:TaskForce62MedicalBrigadeCombatHealthcareSupportSystemModel

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OctoberDecember200825Thepeoplewereneitherfriendly,norunfriendly,theywereseekingonlysurvival.RobertWilensky1COIN[counterinsurgencyoperations]canbecharacterizedasarmedsocialwork.ThismakesCMO[civil-militaryoperations]acentralCOINactivity,notanafterthought.CMOisoneofthemeansofrestructuringtheenvironmenttodisplacetheenemyfromit.2Whataremedicalcivil-militaryoperations(CMO)?AsthedeployedTaskForce62MedicalBrigade(TF62MED)Civil-MilitaryOperationsSection(S9)workingintheIraqtheaterofoperationsoverthepast14months,wehaveencounterednumerouschallengeswhileexpanding,contracting,deconflicting,andintegratingtheroleofcivilaffairsintothemedicalmission.Thereisnodoubtthathealthservicescanhaveasignificantpositiveimpactincounterinsurgencyoperationsandstabilityoperationswhenitisproperlyplannedandexecuted.TheonlycurrentdoctrinethatspecificallyaddressesmedicalCMOisJointPublication4.02;HealthServiceSupport,3whichdefinesmedicalcivil-militaryoperationsashealth-relatedactivitiesinsupportofajointforcescommandthatestablish,enhance,maintain,orinfluencerelationsbetweenthejointorcoalitionforceandhostnation,multinationalgovernmental,andnongovernmentalcivilianorganizationsandauthorities,andthecivilianpopulace,inordertofacilitatemilitaryoperations,achieveUSoperationalobjectives,andpositivelyimpactthehealthsector.3(pIV-7)Thereareasignificantnumberofentitiesorstakeholdersinvolvedinmedicalcivil-militaryactivities,includinghostnationgovernmentagenciessuchastheministryofhealth(MoH)andministryofdefense(MoD),internationalorganizations,nongovernmentalorganizations,interagencydepart-ments,theUSDepartmentofState,andCoalitionforces,eachwithuniquecapabilitiesandobjectives.ThisarticlefocusesonhowtheMedicalBrigadeanditsdirectreportingunitsarespanningthehealthcarespectrumworkingwithcivilianandmilitaryhostnationmedicalandveterinaryorganizationstoenhancethehostnationscredibilitybysupportingself-reliantIraqipublichealthsystems.WhendeterminingthemedicalCMOmission,itisimperativetounderstandthatmedicalCMO,althoughimportant,issecondarytothemedicalbrigadesprimarymissionofprovidingworld-classWarriorhealthcaretoUSandCoalitionforces.TheorganicmedicalbrigadehasnumerousstrengthsandisuniquelyqualifiedtoprovidetrainingtopersonnelatMedicalCivil-MilitaryOperations:TheDeployedMedicalBrigadesRoleinCounterinsurgencyOperationsLTCJeffreyBryan,USACPTDanelleMiyamoto,MS,USALTCVincentHolman,MS,USA ABSTRACTMedicalcivil-militaryoperationsareacriticalcombatmultiplierdirectlysupportingthecounterinsurgencyfight.ArmyMedicalDepartmentSoldierssupportmedicalcivilaffairsactivitiesatalllevelsfromplatoontotheUnitedStatesMission-Iraq(DepartmentofState)initiativesenhancingthelegitimacyofmedicalservicesintheIraqMinistryofHealth,MinistryofDefense,MinistryoftheInterior,andMinistryofJustice.Thecivil-militaryoperationsmissionofthedeployedTaskForce62MedicalBrigadehasalsoevolvedintoabroadmissionencompassingover120contractorsincludingIraqi-American,BilingualBiculturalAdvisorsSubjectMatterExpertsservingascasemanagementliaisonofficersandmedicaltrainers,aswellasIraqiAdvisorTaskForcemembersprovidingmedicalatmospherics,assessments,training,andtheoverallmanagementofIraqilinguistssupportingalllevelIIImedicalfacilities.

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26www.cs.amedd.army.mil/references_publications.aspxalllevelsinthehealthcareindustry,anddirecthealthcaretoeligibleIraqis.ItalsohasnumerousconstraintsandlimitationsthatothermedicalsupportCoalitionforceunitsdonothave.Wehaveworkedtomitigatethoselimitations.Forexample,thebrigadeisnotequipped,staffed,nortrainedtoconducttacticalmissionsoutsideofasecureareawithoutsupportfrommaneuverelementsorspecializedcontractors.TF62MEDdoesnotownbattlespace,limitingengagementstospecificMoHandMoDrepresentativesthathaveaccesstoCoalitionforcefacilities.Understandingthestrengths,limitations,constraints,andmitigatingfactorsofthedeployedmedicalbrigadeiscriticalwhenplanningmedicalcivil-militaryactivities(MCMA).WhilerefiningMCMA,theS9sectionshouldbeplannedfromthefocusofthe5factorsfromArmyFieldManual8-42,4whichlaysoutspecificplanningconsiderationsforforeigninternaldefensemissionsthatapplyequallytocurrentCOINoperations.AllbrigadeMCMAinitiativesmustaddressthese5factorsfromFieldManual8-42priortoapprovalofmissionexecution:Planisdevelopedwiththehostnationsassistance.Planenhancesratherthanreplacesthehostnationsexistingprograms.HostnationhastheresourcestocontinuetheprogramsiftheUSmilitaryeffortissharplycurtailedordiscontinued.HostnationreceivesthecreditfortheprogramratherthantheUSmilitary.Thisisaccomplishedbyensuringthatallcombathealthserviceoperationsincluderepresentativesofthehostnationoritsmilitary.HealthServiceSupportgoalsandobjectivesareconsideredforeachregionorprovince.Asaresultofmissionanalysis,themissionofmedicalcivil-militaryoperationshasevolvedandbeenrefinedtoimprovethehealthstatus,publicconfidence,andincreasingcapabilityandcapacity.Tosuccessfullyaccomplishthismission,theCMOsectionisfurtherdividedtoaddress3distinctobjectives:Professionalmeetings,engagements,education,andtraining(Pro-MEET)andcooperativemedicalengagementsFacilitateimprovedaccesstohostnationhealthservicesFacilitatetimelyhostnationpatienttransfers/dischargesfromUStohostnationfacilitiesPROFESSIONALMEETINGS,EDUCATION,ENGAGEMENTSANDTRAINING,COOPERATIVEMEDICALENGAGEMENTSTheMedicalBrigadeconductsasignificantamountofprofessionalmedicaltraining.WhenplanningmedicaltrainingprogramsintheCOINenvironment,wehavefoundthattheguidanceinArmyFieldManual3-24iscritical:Keepprogramssmall.Thismakesthemcheap,sustainable,low-key,and(importantly)recoverableiftheyfail.2(pA-8)TheMedicalBrigadesupports2long-termtrainingprograms:a10-weekMoDsponsoredtraumatrainingcourseintheinternationalzone,andthe8-weekIraqicorrectionalmediccoursesonCampsCropperandBucca.TheremainingcoursesthattheMedicalBrigadehasestablishedacrossthetheateraresmallerscale,short-term,noncertificate-producingtrainthetrainercoursesdesignedtoincreasetheprofessionalismandbuildthecivilcapacityoftheIraqihealthcaresystem.Overa12-monthperiod,theMedicalBrigadeconducted82eventsprovidingfullspectrumhealthservicestrainingto824students.TheMedicalBrigadeheldcoursesindentistry,veterinarianservices,medicallogistics,oxygengeneration,basictoadvancedlifesaving,burncare,trauma,andgroundambulancetraining,tonameafew.TheMedicalBrigadeplannedandconducted15cooperativemedicalengagements(CMEs)andassistedwithnumerousothersthroughoutIraq.TheCMEsaredesignedtogainIraqisupportandfacilitatetheestablishmentandrestorationofbasichealthservices(seeFigure1).OurcontractedIraqi-Americandoctors,alongwithlocalphysicians,dentists,andhealthcareworkersprovidethepatientcare,ensuringtheengagementshaveanIraqiface.WealsoprecoordinatewithlocalleadershipandMoHfacilitiesforpossiblereferrals.Duringthese15engagements,wehavehad6,447patientencounters.TheuseoflocalIraqidoctorsandlocallyprocuredmedicationensuresthepatientsseetheirgovernmentprovidingessentialservices.Justoverthepastfewmonths,theseCMEshaveevolvedfromprimarilyprovidingmedicalcareandreferralstotheteachingofpreventivemeasures.Thefocusofthistrainingistoteachthewomenandchildrenwaystheycanimprovethequalityoftheirhealth,whilekeepingitsimpleenoughtoallowthemtosharetheknowledgewiththeirfamilymembers.EducatingtheIraqisandbuildingawarenessisjustoneofthewaysthatCMEsarehelpingtoenforcethelegitimacyoftheIraqimedicalsystem.MedicalCivil-MilitaryOperations:TheDeployedMedicalBrigadesRoleinCounterinsurgencyOperations

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OctoberDecember200827THEARMYMEDICALDEPARTMENTJOURNALFACILITATEIMPROVEDACCESSTOIRAQIHEALTHSERVICESTheIraqiAdvisorTaskForce(IQATF)team,detailedinFigure2,hasvisitedandassessed255newmedicalandhealthcarefacilitiesandupdatedover500previouslyassessedfacilities.ThisimprovedvisibilityonIraqifacilityscapacityandcapabilitiesexpandsourabilitytoreferIraqipatientstothecorrectfacilitiesfortreatment.TheS9sectionproducesanaverageof50reportspermonth,includingexecutivesummariesandIraqi-specificrequestsformedicalinformationacrosstheIraqtheaterofoperations,whichareusedtogeneratenumerousintelligencesummaries.WehavealsoplacedanIQATFliaisonofficerintovariouspositions,includingtheMulti-NationalForce-Iraqsurgeoncell,toprovideastrategiclinkbetweenthemandtheMinistryofHealth.FACILITATETIMELYIRAQIPATIENTTRANSFERS/DISCHARGESFROMUSTOIRAQIFACILITIESTheMedicalBrigades17casemanagementliaisonofficers(CMLOs)areresponsibleformanagingthetransitionofIraqipatientsbackintotheIraqihealthcaresystemforfurthercareaftertheyarestabilizedatoneofourfacilities.Theothertaskistoassistthemintheirreturnhomeoncetreatmentiscomplete.Inthelast10months,theCMLOshaveassisted5,746Iraqipatients,including966directtransferstohostnationfacilities.TheMedicalBrigadeiscommittedtoplanningandconductinginitiativesthatsupporttheIraqiSecurityForcesandbuildcivilcapacity.AsdescribedinFieldManual3-24:5-3.COINoperationscombineoffensive,defensive,andstabilityoperationstoachievethestableandsecureenvironmentneededforeffectivegovernance,essentialservices,andeconomicdevelopment.ThefocusofCOINoperationsgenerallyprogressesthrough3indistinctstagesthatcanbeenvisionedusingamedicalanalogy:Stopthebleeding.Inpatientcarerecovery.Outpatientcaremovementtoself-sufficiency.Understandingthisevolutionandrecognizingtherelativematurityoftheoperationalenvironmentareimportanttotheconduct(planning,preparation, CooperativeMedicalEngagementsThe3characteristicsaimedtoincreasethecapacityandlegitimacyoftheprovincialandnationalgovernmentsofIraq:MedicaltreatmentandengagementsmustbeprovidedbyIraqpersonnelwithCoalitionforcesintheadvisoryandsupportrole.KEY:ShowtheMinistryofHealthandMinistryofDefensetobeinthelead.Capabilitiesprovidedatthecooperativemedicalengagement(CME)mustbesustainablegiventhecurrentcapabilitiesoftheMinistryofHealth.CMEswillaffordthesametreatmenttothepopulaceregardlessofreligiousorpoliticalaffiliation.CMEsarenotfreeclinics.ThisisnotsustainableandunderminesthelegitimacyoftheGovernmentofIraqCMEsmustcomplementthestrategicgoalsandobject-tivesoftheMinistryofHealthtoshiftfromacentrallycontrolledcurativecaremodelofhealthservicetoamoredecentralizedprimarycaremodelwithemphasisonpreventionmeasuresandmaternalandchildhealth.Figure1.CharacteristicsofcooperativemedicalengagementsasappliedintheIraqtheaterofoperationsinthecurrentcounterinsurgencyenvironment. IraqiAdvisorTaskForce(IQATF)TheIQATFisacontractforcemultiplierwhichprovidesthemeanstogatheratmosphericsonlocalnationalmedicalfacilitiesandcapabilities.Italsoprovidesadvisoryandassistanceservicestoassistmilitarycommandersandstafftounderstandatmosphericinformationintheareasofsocial,religious,economic,political,publicperceptions,andtribalissuesthroughtrendandeventanalysis.IQATFPositionsSpecialAdvisor.AphysicianwhoisthelinktohighestlevelsoftheMinistryofHealth.MilitaryAnalyst.SpecialForces/SpecialOpera-tions,preferablyamedic,toprovidecontinuityforoperations.IraqiAdvisor.NativeIraqiabletorecruitanddirectlocalnationadvisorteams.LocalNationalAdvisors.Liveandworkinlocalcommunities;gatherlocalmedicalatmospherics.Figure2.TheIraqiAdvisorTaskForceasorganizedin theIraqtheaterofoperationsinthecurrentcounter-insurgencyenvironment.

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28www.cs.amedd.army.mil/references_publications.aspxexecution,andassessment)ofCOINoperations.Thisknowledgeallowscommanderstoensurethattheiractivitiesareappropriatetothecurrentsituation.2(p5-2)Asthesecuritysituationallowsandwebegintotransitionfrominpatientcaretooutpatientcare,theMedicalBrigadewillcontinuetoexpanditsmedicalcivil-militaryoperationsroleinengagingallentitiesinvolvedinhealthcaretofosterhostnationlegitimacy.TheMedicalBrigadeshouldconcentrateonprogramsthathaveproveneffectivenesssimilartothelocalnonresidentcontinuingeducationprogramscurrentlybeingconductedbyforwardsurgicalteams.Trainingshouldbeespeciallyfocusedontheneedsofthatparticularhospitalorregion,andbasedonthelogisticalcapabilitiesofthathospital.ThiswillreinforceexistingIraqimedicaleducationfacilitiesformedicalprofessionalsandexpandnationalprograms,includingeducationalopportunitiesinprehospitalcaretoachievetheultimategoaloflegitimacyandself-reliance.Currently,thereisaninitiativeforUScombatsupporthospitalstoprovideaplatformforIraqistolearneffectivehealthcareteamtrainingbywatchingandinteractingwithUShealthcareprofessionals.Thehealthprofessionaltrainingcourseconceptincludesmentorshiponinterdisciplinarycare,team-orientedpatientsafetyculture,environmentofopencommunication,andenvironmentofcaremanagementandinfectioncontrol.Althoughtheprogramiscentrallydesignedandmanaged,courseswillbeexecutedlocallyinaccordancewiththefacilitysabilitytohost.Alloftheprogramsaredesignedtobekeptat4weeksorlessinresidence,andtominimizedependencyoncoalitionforcemedicalfacilities.SUMMARYMedicalcivil-militaryoperationsareacriticalcombatmultiplierdirectlysupportingtheCOINfight.AMEDDSoldierssupportmedicalcivilaffairsactivitiesatalllevels,fromplatoontoUnitedStatesMission-IraqinitiativesenhancingthelegitimacyofmedicalservicesintheMinistryofHealth,MinistryofDefense,MinistryoftheInterior,andMinistryofJustice.TheCMOmissionofthedeployedmedicalbrigadehasalsoevolvedintoabroadmissionemployingnumerouscontractorsincludingIraqiAmerican,Bi-LingualBi-CulturalAdvisorsSubjectMatterExpertsservingascasemanagementliaisonofficers,andmedicaltrainers,IraqiAdvisorTaskForcemembersprovidingmedicalatmospherics,assessmentsandtrainingandtheoverallmanagementofIraqilinguistssupportingalllevelIIImedicalfacilities.ThisuniquemissiondemonstratestheneedforadeployedmedicalbrigadeS9staffofatleast3CivilAffairstrainedpersonnelpreferably2officersinthegradeoflieutenantcolonelthroughcaptain,andaseniornoncommissionedofficerinthegradeofsergeantfirstclassormastersergeantinordertolead,plan,andexecutetheseelaborateCMOfunctions.Inviewoftheevolvedmission,itisrecommendedthatthedeployedmedicalbrigadesmodifiedtableoforganizationandequipmentbeexpandedtoreflecttherequirement,andmedicalserviceofficersandnoncommissionedofficersbeidentifiedtofilltheseslotsandattendtheresidentcivilaffairscourse.REFERENCES 1.Wilensky,RJ.MilitaryMedicinetoWinHeartsandMinds:AidtoCiviliansintheVietnamWar.Lubbock,TX:TexasTechUniversityPress;2004.2.FieldManual3-24:Counterinsurgency.Washington,DC:USDeptoftheArmy;15December,2006.3.JointPublication4-02:HealthServiceSupport.Washington,DC:JointStaff,USDeptofDefense;31March2006.4.FieldManual8-42:HealthServiceSupportinStabilityandSupportOperations.Washington,DC:USDeptoftheArmy;27October1997:chap3.AUTHORS Whenthisarticlewaswritten,thecoauthorswereassignedasfollows:LTCBryanwastheCivil-MilitaryOperationsOfficer,TaskForce62MedicalBrigade,Baghdad,Iraq.CPTMiyamotowastheDeputyCivil-MilitaryOperationsOfficer,TaskForce62MedicalBrigade,Baghdad,Iraq.LTCHolmanwastheOperationsOfficer,TaskForce62MedicalBrigade,Baghdad,Iraq.MedicalCivil-MilitaryOperations:TheDeployedMedicalBrigadesRoleinCounterinsurgencyOperations

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OctoberDecember200829Itissaidthatnoonetrulyknowsanationuntilonehasbeeninsidethejails.Anationshouldnotbejudgedbyhowittreatsitshighestcitizens,butitslowestones.NelsonMandela1INTRODUCTIONCoalitionforcesintheIraqtheaterofoperationswillprogressivelytransfertheaterdetentionoperationstotheGovernmentofIraq(GoI)inthenearfuture.ThiswilloccurbytrainingIraqipersonnelandtransferringfacilitiestotheGoIinaccordancewithinternationalstandards,completingthetransitioninphases,promotingIraqisovereigntywhileprotectingthepublicandtherightsofthedetainees.Healthcareisanintegralpartofthistransition.Toensureanappro-priatetransitionofthedetaineehealthcare,theUSmustfacilitateidentificationandparticipationofnongovernmentalandothergovernmentagencysub-jectmatterexpertisetoassistintheinteragencyplanning,developingandexecutingdetaineehealth-caretransitionfromamilitary-centrictoacivilian-centriccorrectionalmodel.ThepurposeofthisarticleistohighlighttheframeworkoftheUScorrectionalmodelandidentifyaplausiblestrategyfortran-sitioningdetaineehealthcaretotheGoIandprovidearecommendedwayaheadforthemilitaryhealthsystemsunderstandinganddevelopmentofacorrec-tionalhealthcaremodelforcombatoperations.BACKGROUNDUnitedNationsSecurityCouncilResolution(UNSCR)15112authorizescoalitionforcestodetainanypersontheydeemanimperativesecuritythreat.DetaineeoperationswithintheIraqtheaterofoperationsareinstrumentaltosustainedpeace.Whathappenstotheprograms,andthedetainees,willdependonwhatthegovernmentofIraqmakesofthemwhenittakesthereinsaftertheexpirationofUNSCR1511.AmericancontroloverdetentionexpiresafterDecember2008,thoughabilateralagreementbetweentheUSandIraqisindevelopmenttoextendthatdeadline.Meanwhile,theMulti-NationalForce-Iraq(MNF-I)commandresponsiblefordetentionoperations,TaskForce134istrainingmoreIraqicorrectionalofficerstoensureanappropriatelevelofhostnationcapabilityandcapacity.Detaineesarenottechnicallyprisonersorenemyprisonersofwar.TheDepartmentofDefense(DoD)definesadetaineeasanypersoncaptured,detained,held,orotherwiseunderthecontrolofDoDpersonnel(military,civilian,orcontractoremployees).Itdoesnotincludepersonsbeingheldprimarilyforlawenforcementpurposes,exceptwheretheUnitedStatesistheoccupyingpower.Similarly,differentwordsareusedforvariousgroupsofpeoplewhoaredetained.Thoseawaitingtrialmaybeknownaspre-trial,under-trial,orremand,andareoftenreferredtoasdetainees.Inthisarticle,thewordprisonisusedforallplacesofdetentionandthewordprisonerisusedtodescribeallwhoareheldinsuchplaces.ESTABLISHINGACORRECTIONAL/PRISONFRAMEWORKDetaineeoperations,likecorrectionalorprisonmanagement,isaverycomplexundertakingrequiringawiderangeofskillsfromthosewhosetaskitistoTransitionoftheDetaineeHealthcareSystemtoaCorrectionalModel:AnInteragencyApproachLTCVincentHolman,MS,USA ABSTRACTTheArmyMedicalDepartment(AMEDD)willplayakeyroleinthetransitionofdetaineehealthcareoperationsfromUScontroltoadesignatedauthority,whetheritisIraqorathirdparty.AlthoughtheAMEDDhasgarneredsignificantexperienceintheprovisionofdetaineehealthcareoverthepast5years,itwouldbeprudenttoimplementaninteragencyapproachtotransitioningdetaineehealthcare.ThattransitionmuststartwithleveragingofthesubjectmatterexpertiseoftheUSBureauofPrisonsandNationalCommissiononCorrectionalHealthcare.CurriculumdevelopmentofdetaineehealthcareintheprogramofinstructionattheAMEDDCenterandSchooliscritical.

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30www.cs.amedd.army.mil/references_publications.aspxdirectprisons.Thereisacommonsetoffactorswhich,whentakentogether,constituteamodelforgoodprisonmanagementwhichcanserveasamodelfortheGovernmentofIraq.Inanydemocraticsociety,workinprisonisapublicservice.Prisonsareplaces,likeschoolsandhospitals,whichshouldberunbythecivilpowerwiththeobjectiveofcontributingtothepublicgood.Prisonauthoritiesshouldhavesomeaccountabilitytoanelectedparliament,andthepublicshouldberegularlyinformedaboutthestateandaspirationsoftheprisons.Governmentministersandsenioradministratorsshouldmakeitclearthattheyholdprisonstaffinhighregardfortheworktheydo,andthepublicshouldbefrequentlyremindedthatprisonworkisanimportantpublicservice.Virtuallyallprisonerswillonedayreturntolifeincivilsociety.Iftheyaretolivewithinthelawitwillbeimportantthattheyhavesomewheretolive,thattheyhavetheopportunityofemployment,andthattheyhaveapropersocialsupportstructure.Itisveryimportant,therefore,thattheprisonadministrationhavecloselinkswithotherpublicserviceagencies,suchasthesocialwelfareandhealthauthorities.Thisismorelikelytohappeniftheprisonadministrationitselfisacivilorganization,notamilitaryone.Whenpeoplethinkofprisonstheytendtoconsiderthephysicalaspects:walls,fences,abuildingwithlockeddoorsandwindowswithbars.Inrealitythemostimportantaspectofaprisonisthehumandimension,sinceprisonsareprimarilyconcernedwithpeople.The2mostimportantgroupsofpeopleinaprisonaretheprisonersandthestaffwholookafterthem.Thekeytoawellmanagedprisonisthenatureoftherelationshipbetweenthesetwogroups.Theroleoftheprisonstaffis:totreatprisonersinamannerwhichisdecent,humaneandjust;toensurethatallprisonersaresafe;tomakesurethatdangerousprisonersdonotescape;tomakesurethatthereisgoodorderandcontrolinprisons;andtoprovideprisonerswiththeopportunitytousetheirtimeinprisonpositivelysothattheywillbeabletoresettleintosocietywhentheyarereleased.3BUREAUOFPRISONSAccordingtotheUSFederalBureauofPrisonswebsite:TheFederalBureauofPrisons(BOP)wasestablishedin1930toprovidemoreprogressiveandhumanecareforfederalinmates,toprofessionalizetheprisonservice,andtoensureconsistentandcentralizedadministrationofthe11federalprisonsinoperationatthetime.TheBureauprotectspublicsafetybyensuringfederaloffendersservetheirsentenceofimprisonmentininstitutionsthataresafe,humane,cost-efficient,andappropriatelysecure.4TheBOPisheavilyinvolvedintheefforttoreducefuturecriminalactivitybyprovidinginmateswitharangeofprogramsthathavebeenproventohelpthemadoptacrime-freelifestyleupontheirreturntothecommunity.TheBureausmostimportantresourceisitsstaff.Themorethan35,000employeesoftheBureauofPrisonsensurethesecurityofFederalPrisons;provideinmateswithneededprogramsandservices,andserveasmodelsformainstreamvalues.TheBureausemployeesarethemeansbywhichtheagencymeetsitsobligationtoprotectpublicsafetyandprovidesecurityandsafetytothestaffandinmatesinitsfacilities.ThephilosophyoftheBureauisthatreleasepreparationbeginsonthefirstdayofimprisonment.Accordingly,theBureauprovidesmanyself-improvementprograms,includingworkinprisonindustriesandotherinstitutionjobs,vocationaltraining,education,substanceabusetreatment,parenting,angermanagement,counseling,religiousobservanceopportunities,andotherprogramsthatteachessentialskills.Researchshowsthatindustrialworkprograms,vocationaltraining,education,anddrugtreatmentinprisonplayamajorroleinimprovingpublicsafety.Theseprogramsreducerecidivismandmisconductinprison.Drugtreatmentprogramsalsodecreaseoffendersrelapsetodruguseafterrelease.Manycorrectionalsystems,includingtheBureau,havedocumentedthesuccessoftheseprograms.TransitionoftheDetaineeHealthcareSystemtoaCorrectionalModelAnInteragencyApproach

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OctoberDecember200831THEARMYMEDICALDEPARTMENTJOURNALInmateprograminvolvementisultimatelygearedtowardhelpinginmatespreparefortheireventualrelease.TheBureaucomplementsitsarrayofprogramswithaspecificReleasePreparationProgram,ResidentialRe-EntryCenters(halfwayhouses)andanInmateTransitionBranchwhichprovidespost-releaseemploymentassistancetoinmates.TheHealthServicesDivisionoftheBureauisresponsibleforthementalhealth(psychiatric)servicesprovidedtofederalinmatesinBureaufacilities,includingdelivery,infectiousdiseasemanagement,andmedicaldesignations.TheDivisionalsocoordinatesasafetyprogram(occupationalsafety,environmentalhealth,andlifesafetyandfiresafety)thatensuresasafe,healthyenvironmentforstaffandinmates.TheBOPhasover3,000healthcarepositions,includingapproximately750PublicHealthCommissionedOfficersdetailedfromtheDepartmentofHealthandHumanServices.TheseprovidershavebeensupportingthemedicalmissionoftheBOPsince1930.TRANSITIONTHEPROPOSEDSOLUTIONTheNationalCommissiononCorrectionalHealthCare(NCCHC)isaprivateorganizationcommittedtoimprovingthequalityofcareinournationsjails,prisons,andjuveniledetentionandconfinementfacilities.5TheNCCHCissupportedbynationalorganizationsrepresentingthefieldsofhealth,law,andcorrectionalcustody.TheNCCHChasunparalleledexpertiseinthecreation,implementation,andmonitoringofnationalcorrectionalhealthcarestandardsthatarebasedonwidelyacceptedprinciplesofcare.Ithasproposeda3-phase,multiyearprojecttoassistMNF-IandDepartmentofJustice(DoJ)intransitioningcoalitioncontrolofthecorrectionalhealthcareofitssecuritydetaineestotheGoI.Additionally,thiseffortisdesignedtoachieveanefficientandeffectivetransferofmilitarystandardsintoaninternationallyrecognizedcivilianmodelofcorrectionalhealthcareserviceswhichisacceptedbyIraqisandtheirgovernment.ThefirstandsecondphasesoftheprojectaredesignedtoprepareandassisttheMNF-IandtheGoIintheestablishmentofculturallyrelevanthealthcarestandardsforuseintheIraqcriminaljusticesystem.Thethirdphaseinvolvestheplanning,application,andmonitoringoftheIraqicorrectionalhealthstandards.TheNCCHCrecognizestheuniquechallengestothegoaloftransitioningthecurrenthealthcareoperationsfrommilitarycontroltoprovisionofservicesunderacivilianmodel,aswellasthechallengestotheIraqipeopleinestablishingarespectedcriminaljusticecorrectionalhealthsystem.AnimportantobjectiveisfortheinternationalcommunitytorespectandhaveconfidenceinanIraqicriminaljusticesystem.Consequently,theremustbeadherencetointernationallyrecognizedstandards.Toachievethisgoalandobjective,theNCCHCproposes:AnintroductorymeetingofkeyrepresentativesfromvariousmilitaryandIraqiorganizations,andtrainingof50MNF-IandIraqipersonneltoimprovetheirskillsinsettingandmonitoringstandards.DevelopmentofculturallyrelevanthealthcarestandardsfortheIraqicriminaljusticesystem.AssistancetotheMNF-IandIraqigovernmentinthedevelopmentofanimplementationplantoensuretheefficientandeffectiveapplicationofstandards,policies,andproceduresintheIraqicriminaljusticesystem.AssistanceintheapplicationofcorrectionalhealthcarestandardstoIraqicorrectionalfacilities.AssistanceinthedevelopmentandimplementationofamonitoringsystemtoassuretheinternationalcommunitythatthecorrectionalhealthcareforIraqiprisonersishumaneandmeetsrecognizedstandards.Inphaseone,theNCCHCproposes2meetings:Thefirstisaone-dayintroductorymeetingintheUnitedStateswithkeyofficialrepresentativesoftheDoD,MNF-I,DepartmentofJustice,IraqiMinistryofJustice/MinistryofHealth,theNCCHC,andothersdeemednecessaryinachievingthegoalsandobjectivesofthisproposal.Thepurposeofthismeetingistodiscussthecommonissuesandexpectationsfortheproject;determinetheparticipantsfortraining(phaseone),standardsdevelopment(phasetwo),andsystemimplementationandmonitoring(phasethree);andthecreationofacommitmentforthelong-termeffortwithkeyIraqidecision-makers.Asaresultofthismeeting,individualswillbeidentified

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32www.cs.amedd.army.mil/references_publications.aspxandselectedtoparticipateinthespecifiedphasesofthisplan.Thesecondmeeting,a5-daytrainingsession,willbeheldtoorientMNF-IstaffandselectedIraqipersonnelinthedevelopmentandmaintenanceofacorrectionalhealthcaresystem.AsuggestedcriteriaforselectionofparticipantswillbethosewhoarenecessarytoadviseonanappropriatecorrectionalhealthcaresystemforIraq,andwhocanreasonablybeexpectedtobeamongthoseeventuallyoverseeingoractuallyimplementingthestandards.TheobjectivesforthismeetingaretoprovideafoundationforMNF-IstaffandIraqiparticipantstounderstandwhatisinvolvedinastandardsettingprocess,togainanoverallunderstandingoftheNCCHCstandardsandapproach,andtoraiseissuesintegraltotheeventualadvise/consentprocessforIraqicorrectionalhealthcarestandards.Theindividualsinvolvedintheintroductorymeetingwillbeselectexecutivesandgovernmentofficialswhocancreateanenvironmentfortheoverallsuccessofthetransition.Inphasetwo,theNCCHCproposestoassistinthedevelopmentofIraqicorrectionalhealthcarestandards.Phasetwobuildsontheactivitiesofphaseone,butcouldbetakenasastandaloneproject.OutcomesforphasetwoincludeamanualofIraqistandardsforcorrectionalhealthcareservicesandanevaluationreportoftheactivitiesprovidedtoMNF-I.Inphasethree,theNCCHCproposestoassisttheMNF-IindevelopingadetailedplantoimplementandmonitortheIraqicorrectionalhealthcarestandardswithintheIraqicriminaljusticesystem.ThisincludestheestablishmentofdetailedplanstoimplementIraqistandards,creationofaqualityassurancemonitoringsystem,andatrain-the-trainerprogram.TheimplementationofIraqicorrectionalhealthcarestandardswillbeginwithapilotproject.Whatislearnedfromthatprojectwillresultinapplicationsdevelopedandimplementedthroughoutthesystem.Goodhealthisimportanttoeveryone.Itaffectshowpeoplebehaveandtheirabilitytofunctionasmembersofthecommunity.Ithasaparticularsignificanceintheclosedcommunityofaprison.Byitsnature,theconditionofimprisonmentcanhaveadamagingeffectonboththephysicalandmentalwell-beingofprisoners.Prisonadministrationshavearesponsibility,therefore,notsimplytoprovidemedicalcare,butalsotoestablishconditionswhichpromotethewell-beingofbothprisonersandprisonstaff.Prisonersshouldnotleaveprisoninaworseconditionthanwhentheyentered.Thisappliestoallaspectsofprisonlife,butespeciallytohealthcare.Aprisoneroftenarrivesinprisonwithpreexistinghealthproblemswhichmayhavebeencausedbyneglect,abuse,orbytheprisonerspreviouslifestyle.Prisonersoftencomefromthepoorestsectionsofsocietyandtheirhealthproblemsreflectthis.Theywillbringwiththemuntreatedconditions,addictions,andmentalhealthproblems.Theseprisonerswillneedparticularsupport,aswillthosemanyotherswhosementalhealthmaybesignificantlyandadverselyaffectedbytherealityofimprisonment.ETHICALFRAMEWORKItisalsoimportantthattheIraqipublicandmediaareawareofthevalueswithinwhichIraqiprisonswouldoperate.Iftheroleoftheprisoninacivilsocietyisproperlyunderstood,itismorelikelythatthepublicwillappreciateeffortsmadebytheprisonauthoritiestoimplementgoodpractice.Tothatend,thebasicsofthenecessaryethicalframeworkforthemedicalhealthcareprovidedwithinanIraqiprisonsystemisclearlydefinedintheOathofAthens6(below),anethicalcodeadoptedbytheInternationalCouncilofPrisonMedicalServicesin1979.TransitionoftheDetaineeHealthcareSystemtoaCorrectionalModelAnInteragencyApproach OathofAthensInkeepingwiththespiritoftheOathofHippocrates,thatweshallendeavortoprovidethebestpossiblehealthcareforthosewhoareincarceratedinprisonsforwhateverreasons,withoutprejudiceandwithinourrespectiveprofessionalethics.Werecognizetherightoftheincarceratedindividualstoreceivethebestpossiblehealthcare.Weundertake1.Toabstainfromauthorizingorapprovinganyphysi-calpunishment.2.Toabstainfromparticipatinginanyformoftorture.3.Nottoengageinanyformofhumanexperimen-tationamongstincarceratedindividualswithouttheirinformedconsent.4.Torespecttheconfidentialityofanyinformationobtainedinthecourseofourprofessionalrelation-shipswithincarceratedpersons.5.Thatourmedicaljudgmentsbebasedontheneedsofourpatientsandtakepriorityoveranynonmed-icalmatters.

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OctoberDecember200833THEARMYMEDICALDEPARTMENTJOURNALRECOMMENDEDENDSTATEThedetaineehealthcareoperationswillbesuccessfullytransferredtotheGoIcorrectionalhealthcareoperationswhenthefollowingconditionsaremet:GoIcorrectionalhealthcarestandardsarecodifiedincorporatingregional,internationallyacceptedstandardsandtheOathofAthens.Correctionalmedicalfacilitiesareoperational(staffed,trained,equipped).Essentialmedialservicesareavailableandprovided:EmergencymedicalservicesSickcallAcutecareDentalcareDiagnosticservicesWAYAHEADTheAMEDDwillplayalinchpinroleinthetransitionofdetaineehealthcareoperationsfromUScontroltoadesignatedauthority,whetheritisthehostnationorathirdparty.AlthoughtheAMEDDhasgarneredsignificantexperienceintheprovisionofdetaineehealthcareoverthepast5years,itwouldbeprudenttoimplementaninteragencyapproachtothetransitionofdetaineehealthcare.ThisapproachmuststartwithleveragingthesubjectmatterexpertiseoftheBureauofPrisonsandNationalCommissiononCorrectionalHealthcare.DetaineehealthcarecurriculumdevelopmentintheprogramofinstructionattheAMEDDCenterandSchool(AMEDDC&S)iscritical.ArepresentativefromtheBureauofPrisonsHealthServiceDivision,operatedbythePublicHealthService,wouldbeanappropriateadditiontotheAMEDDC&Sfaculty.Suchexpertisewouldassistthedevelopmentofacomprehensiveapproachtotheedu-cationoftheDoDmedicalcommunityindetaineeandcorrectionalhealthcare,withthecreationofaDetaineeHealthcareCenterofExcellenceastheAMEDDC&StransitionsintotheMedicalEducationandTrainingCampus(METC).TheArmyTrainingWithIndustry(TWI)program7isanexcellentfrontseatapproachtoprovidingAMEDDpersonnelwiththeknowledgeandexperienceofthebestbusinesspracticeofacivilianorganizationoragency.ToensurethebestbusinesspracticesofcorrectionalhealthcarearegatheredandcodifiedintotheArmyandmilitaryhealthsystemdoctrine,DoDmilitarypersonnelshouldbeprovidedanopportunitytoexperienceaone-yearTWIwiththeBureauofPrisonsHealthServicesDivision,followedimmediatelybyaone-yearutilizationtourattheMETCtocodifydoctrine,policy,andtactics,techniquesandprocedures.ThisTWIopportunityshouldincludeasimultaneousfellowshipofMedicalCorps,ArmyNurseCorps,DentalCorps,ArmyMedicalSpecialistCorps,MedicalServiceCorps,andAMEDDenlistedparticipants.IdentificationofAMEDDpersonnelwhohaveservedinpositionsdirectlyinvolvedindeliveryoradministrationofhealthcaretodetaineesshouldbecapturedbyanadditionalskillidentifier(ASI)entitledDetainee/CorrectionalHealthcareStaff,toreadilyidentifypersonnelandleveragetheircapabilitiesatboththefutureMETCandtheJointForceMedicalReadinessTrainingCenterasconsultants.Toensurecontinuousgrowthincapacityoftheknowledgebase,supportshouldbegainedfromtheNCCHCandinstitutetheirCertifiedCorrectionalHealthProfessional(CCHP)certificationandcontinuingeducationprogram.ThiswouldbeanotherpathtowardsachievingthedetaineehealthcareASI.Medicalpersonnelworkingindetaineesettingsfaceuniquechallenges:workingwithinstrictsecurityregulations,dealingwithcrowdedfacilities,under-standingthecomplexlegalandpublichealthconsiderationsofprovidingcaretoincarceratedpopulations,andmore.EstablishingacadreofcertifiedcorrectionalhealthprofessionalsisthesurestwayfortheArmyandthemilitaryhealthsystemtosustainpersonnel,aknowledgebase,andtoolstomeetthesechallenges.TheCCHPdesignationidentifiesanindividualasonewhohasdemonstratedmasteryofnationalstandardsandtheknowledgeexpectedofleadersworkinginthefieldofcorrectionalhealthcare.TheNCCHCoffersacompleteselectionofapplicablepublications*whichcouldbeinstitutionalizedbytheAMEDDandDoDastheauthorizedMedicalEquipmentBookSetDetaineeHealthcareOpera-tions.AlongwiththeappropriateDoDregulationsandmanuals,thiswouldgreatlyincreasetheknow-ledgebaseofthemedicalstafftaskedtoprovidehealthcareinadetaineesetting. *http://www.ncchc.org/pubs/catalog.html

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34www.cs.amedd.army.mil/references_publications.aspxBybringingtobearthefulltechnicalexpertiseofournation,wewillensureoursustainedexcellenceindetaineehealthcareoperationsfortheyears,genera-tions,andconflictstocome.REFERENCES 1.MandelaN.LongWalktoFreedom.London:LittleBrown;1994.2.UnitedNationsSecurityCouncil.UNSecurityResolution1511.NewYork,NY:UnitedNations;16October2003.Availableat:http://daccessdds.un.org/doc/UNDOC/GEN/N03/563/91/PDF/N0356391.pdf?OpenElement.3.CoyleA.AHumanRightsApproachtoPrisonmanagement:HandbookforPrisonStaff.London:InternationalCenterforPrisonStudies;2002:14.4.AbouttheBureauofPrisons.FederalBureauofPrisonswebsite.Availableat:http://www.bop.gov/about/index.jsp.5.AboutNCCHC.NationalCommissionforCorrectionalHealthCarewebsite.Availableat:http://www.ncchc.org/about/index.html.6.MedicalEthicsinthePrisoncontext.PrisonHealthCarePractitionerswebsite.Availableat:http://www.prisonhealthcarepractitioners.com/Medical_ethics.shtml#International_Council_of_Prison_Medical_Services.7.AACTrainingWithIndustry.USArmyAcquisitionSupportCenterwebsite.Availableat:http://asc.army.mil/career/programs/twi/default.cfm.AUTHOR Atthetimethisarticlewaswritten,LTCHolmanwastheOperationsOfficer,TaskForce62MedicalBrigade,Baghdad,Iraq. AUSArmycombatsupporthospitalinIraqduringtheearlyphasesofOperationIraqiFreedomTransitionoftheDetaineeHealthcareSystemtoaCorrectionalModelAnInteragencyApproach

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OctoberDecember200835Thisisagameofwitsandwill.Youvegottobelearningandadaptingconstantlytosurvive.GeneralPeterJ.Schoomaker,USA1BACKGROUNDInearly2003,USforcescrossedtheborderofKuwaitintoIraqinwhathasbecomeknownastheroadtoBaghdad.Acompletemedicaltaskforceunderthe30thMedicalBrigadewereapartofthoseforces.AllthemedicalfunctionalareaswererepresentedintheTaskForce30thMedicalBrigade.The212thMobileArmySurgicalHospitaldeployedfarforwardtoprovideresuscitativesurgeryforourwoundedSoldierstostabilizethemforswiftevacuationtoKuwait,furthertoGermany,andontohospitalsinthecontinentalUnitedStates(CONUS).Combatsupporthospitals(CSH)wereestablishedalongtheaxisofadvanceatmajorlogisticsbases,suchasthe28thCSHatTallil.MedicalevacuationhelicoptersfilledtheairfieldsinKuwait,Tallil,Baghdad,andultimatelywereposturedtoprovidewoundedSoldiersdedicatedsupportalwayslessthan90minutesafteremergencysurgicalintervention.TheUSmilitaryquicklydeclaredvictoryovertheIraqiforcesandsettledinforwhathasbecomeanoccupationofIraqthathaslasted5years,andcontinues.ThecompetencyandefficiencyofUSmedicalprofessionals,coupledwiththetremendousstrategicevacuationcapabilitiesoftheUSmilitaryhaveprovidedourwoundedWarriorswithalifelinethathasliterallysavedthousandsoflivessincethebeginningofOperationIraqiFreedom.Inlate2003,thecomplexityofthesecuritysituationinIraqbegantochange.Forexample,convoyswerebeingambushedandsniperswereindiscriminatelytargetingnotonlytheUSforces,butalsothelocalpopulation.TheUSwasengagedinacounterinsurgencyfightinIraq.Whatwasoncethoughttobeanopen-armswelcomeasliberatorsofIraqfromtheharshdictatorSaddamHusseinwasnowafightforsurvivalonthestreetsofBaghdad,Fallujah,andMosul.ViolencehaderuptedthroughoutIraqastheShia,Sunni,andKurdishmilitantsallviedforpowerinpost-SaddamIraq.USforcesweretargetedandcasualtiesgrew.ImprovisedexplosivedevicesinallformsemergedasthegreatestindiscriminatethreatEmploymentofaJointMedicalTaskForceinaCounterinsurgencyOperationalEnvironmentCOLScottAvery,MS,USALTCVincentHolman,MS,USA ABSTRACTTounderstandthecomplexityofthemedicaltaskforcemissioninsupportofOperationIraqiFreedom,wemustfirstunderstandtheoperationalenvironmentanditsimpactonthemilitaryhealthcaresystemandthemedicaltaskforcechargedwithitsexecutionintheater.Historically,themedicaltaskforcehasfocusedalmostexclusivelyondeliveringarobustandaccessiblesetoflevelIIandIIIcareandforcehealthprotectionsupportsinceoperationsbeganinIraq.Consequently,after5yearsofstablepositioning,security,andinfrastructurewithinourbases,therewerenodiscernablestandardizationofhealthcaresup-port,clinicalquality,ormedicalequipmentbeyondwhattheunitshadchosentoadopt.TaskForce62MedicalBrigadehastakenadvantageofthisuniquetimeinhistorytoplaceaconcertedfocusoninstitutionalizingourcombathealthcaresystemandmeetingthechallengesofthecounterinsurgencyoperationalenvironment.Whereasourpredecessorsrightlyfocusedondeliveringcombathealthsupportduringtheirtenure,wefocusedonthefuture,layingthefoundationfortheeventualtransitiontoanenvironmentsimilartothatintheRepublicofKoreaasthesecuritysituationimproves.ThefoundationlaidduringOperationIraqiFreedom07-09canbethefoundationfortheArmyandthemilitaryhealthcaresystemsvisionincreatingandmodifyingthedeliveryofUSstandardhealthcareinacombattheater.

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36www.cs.amedd.army.mil/references_publications.aspxonthebattlefields.Casualties,bothUSandIraqicivilian,mountedandsupportforthewarinIraqbeganitsquickdecline.ThemedicalforcethathadsupportedtheroadtoBaghdadandtheinitialoccupationofIraqwasgreatlytested.Overthenext5yearstheUScasualtytollinIraqwouldsurpass4,000deadand30,000wounded.ThemedicaltaskforceswouldrotatethroughBalad,theInternationalZoneinBaghdad,andultimatelysettleatCampVictory,nearBaghdad.The30thMedicalBrigade(MEDBDE)wouldbereplacedbythe2ndMEDBDE,andthenthe44thMedicalCommand(MEDCOM),the30thMEDBDEagain,the3rdMEDCOM,andnowthe62ndMEDBDE,whichwillbereplacedbythe44thMEDCOMinthefallof2008.Eachcommandwouldestablishitsprocedurestoprovideworld-classhealthcaretooursupportedforces.Eachwouldreshapethemedicalenvironment,andeachwouldmaintaina97%to98%survivalrateforanyonethatarrivedatalevelIIIhospitalalive.ThephenomenalsuccessofourmedicalforcesinsupportingUS,Coalition,IraqiSecurityForces(ISF),aswellasintheprovisionoflife-savingmedicalcaretocivilianswithinthemedicalrulesofeligibility,isaltogethertheresultofsuperiormedicalleadershipandtheadaptabilityofourmedicalforcesinsupportingthecounterinsurgency(COIN)fightinIraq.THEENVIRONMENTTounderstandthecomplexityofthemedicaltaskforcemissioninsupportofOperationIraqiFreedomCOINoperations,wemustfirstunderstandtheoperationalenvironmentanditsimpactonthemilitaryhealthsystemandthemedicaltaskforcechargedwithitsexecutionintheater.COINoperationscombineoffensive,defensive,andstabilityoperationstoachievethestableandsecureenvironmentneededforeffectivegovernance,essentialservices,andeconomicdevelopment.SuccessfulconductofCOINoperationsdependsonthoroughlyunderstandingthesocietyandculturewithinwhichtheyarebeingconducted.Forcesmustunderstand:OrganizationofkeygroupsinthesocietyRelationshipsandtensionsamonggroupsIdeologiesandnarrativesthatresonatewithgroupsValuesofgroups(includingtribes),interests,andmotivationsMeansbywhichgroups(includingtribes)communicateThesocietysleadershipsystem.STRATEGICGOALSThefirstprincipleofforcehealthprotectionisconformity.Assuch,themedicaltaskforcehasadopted3strategicgoalstonestwiththeMulti-NationalCoalition-IraqandMulti-NationalForce-Iraqcommandersgoals.ThesegoalsarecompletelyconsistentwiththeUSnationalgoalsaswellasthoseofthemilitarycommandersontheground.Provideworld-classWarriorhealthcaretoUSandcoalitionforcesProtectthehealthofUSandcoalitionforcesEnhancetheGovernmentofIraq(GoI)credibilitybysupportingaself-reliantIraqipublichealthsystemThesegoalsultimatelyaimtowardlimitingthelossoflifeinIraq,preservingthehealthoftheforceontheground,andsupportingtheGoIintheirdevelopmentofaself-relianthealthcaresystem.MULTI-NATIONALFORCE-IRAQCOMMANDERSCOUNTERINSURGENCYGUIDANCETheCoalitionperformedawiderangeofmissionstoprovidesecurityandimprovedqualityoflifeforpopulationofIraq.Onmissionsrangingfromfullspectrumcombatoperationsagainstterroristandcriminalelements,toconvoyescort,toexplosiveordnancedisposal,civilmilitaryaffairs,reconstruction,medicalsupport,andmilitaryandpolicetraining,membersofMulti-NationalForce-Iraqhaveacquittedthemselveswithskillandprofessionalism.GeneralDavidPetraeus,CommandingGeneralMulti-NationalForcesIraq2OnJune21,2008,GeneralPetraeuspublishedaCommandingGeneralsMessage*highlightinghis25pointsofguidanceconcerningtheCOINfightfortheIraqtheaterofoperations.Thefollowingparagraphsdescribethe62ndMEDBDE(TaskForce62)imperativeswhichweredevelopedandadoptedtosupportoperationsintheCOINenvironmentinconcertwiththeapplicablepointsofGENPetraeusEmploymentofaJointMedicalTaskForceinaCounterinsurgencyOperationalEnvironment *Internalmilitarydocumentnotreadilyaccessiblebythegeneralpublic

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OctoberDecember200837THEARMYMEDICALDEPARTMENTJOURNALCommandingGeneralsMessage(indicatedinparenthesesasCOINguidance):Followthebattle.InaCOINenvironment,thenextmasscasualtyeventisonlyoneimprovisedexplosivedevicedetonationaway.Battletrackingisimperativeinorderforthemedicaltaskforcetomonitorthebattlefieldsituationtoprovideresponsivesupport,aswellastoanticipatecombathealthcaresupportrequirements.Accessibilitytoforwardsurgicalinterventionisakeycomponentofasolidplantoincreasekineticorlethaloperations.(COINguidance#12:Fightforintelligence.)Ensurethegapiscovered.CoalitionmaneuverunitsimplementCOINguidanceandmoveoffoftheforwardoperatingbasetowalkamongthepopulationtheysecureandserve.Itallowsfortheextensionofoperationalreachviacommandoutposts/jointsecuritystation/patrolbaseexpansion.However,thisactivityimpactsthehealthservicesupportfootprintasthelevelI/IIcapabilityisdisplacedfromtheforwardoperatingbase,creatingagapofcoveragefortheremainingpopulationatrisk.Themedicaltaskforce,incoordinationwiththetheatersurgeonandmaneuverunitcommandsurgeons,forecastthesegapstoensurecontinuityofcareofthepopulationatriskwhichremainswithoutlevelI/IIservices.Assecuritygainsarerealizedfromtheongoingsurgeoperationsandthesurgebrigadecombatteamsarenotbackfilled,thegapiswidened.Additionally,theintroductionofnonstandardmaneuverbrigadesdeployedwithoutorganicorhabituallevelI/IIcreatesanothergapinlevelI/IImedicalcapacity.MedicalforcesduringOperationsDesertShield/DesertStorm(1991)were14%oftotalforces,3%inOperationEnduringFreedom(Afghanistantheater),and4%inOperationIraqiFreedomduring2004.Thesmallmedicalfootprintdemandsthatwenotonlyprovideefficaciousandefficienthealthservicesupport,butalsothatwesynchronizeourmedicalforcesinacollaborativeefforttoresolveissues.Throughthecollectiveeffortsofthemilitaryhealthsystemforwardanduseofstate-of-the-arttechnology,conditionsaresetforacontinualincreaseinhostilesurvivability,asseenintheimprovementfrom78.3%in1991to90%in2007.(COINguidance#2:Liveamongthepeople.COINGuidance#3:Holdareasthathavebeensecured.)Nestcombathealthcaresupportoperations.TheobjectivesoftheUSDepartmentsofStateandDefensearenestedwhenemployingtheinstrumentsofnationalpower.IntheIraqtheaterofoperations,theinstrumentsavailabletothetheatercommandermustbenestedandemployedtomeetthetactical,operational,strategic,andnationalobjectives.Themedicaltaskforceprovidesastrategicbridgetoaccomplishingtheseobjectivesthroughtheexecutionofmedicaldiplomacyandmedicalcivil-militaryoperations.(COINguidance#6:Generateunityofeffort.COINguidance#15:Buildrelationships.)Perfectcombathealthcareonepatientatatime.ThemedicalteamtreatsonepatientatatimeensuringUSstandardofqualitycare.Themedicaltaskforcescovenantwiththepatientistoensurethatappropriatecareisprovidedbytheappropriatemedicalteam,attheappropriatelocation,withtheappropriatesuppliesandequipment.(COINguidance#21:Empowersubordinates.Resourcetoenabledecentralizedaction.)Honorthehostnationslegitimacy.Themedicalrulesofeligibilityhavegreatsignificancewhenitcomestohealthcareonthebattlefield.Legitimacyistheperceptionthatagovernmentisfairandisworkingintheinterestsofanationasawhole.Thegovernmentdoesnothavetobeefficientbutmustbeeffective.Governmentsmaybelegitimate(ornot),butitiscivilsocietythatconferslegitimacy(ornot).Governmentscanruleinawaythatseemseffective,butitiscivilsocietysreactiontothatrulethatactuallydetermineswhetherornotitiseffective.(COINguidance#9:FosterIraqilegitimacy.)Tellthemedicaltaskforcestory.Independentlocal,national,andinternationalmediacoverageofourmilitaryoperationsandourenemiesactivitiesiscriticaltooursuccessintheglobalinformationenvironment.Thisisparticularlytrueintodays24-hournewsenvironment.Unfortunately,ourenemiesinIraqhavewonasignificantvictorybyforcingmostWesternmediatoreportonlyfromsecurecompounds,touseembedswithcoalitionforces,ortoretellsecond-handinformationgainedfromlocalIraqistringers,someofwhomhavequestionableagendasandloyalties.Toaddressthissituation,wemustdevelopsolutionsforimprovingmediaaccesstothebattlefieldandouractivitieswithoutcompromisingthemediasindependenceorouroperationalsecurity.Thiscouldincluderelativelysimpleactionssuchasmakingiteasierforjournaliststogetaccreditedand

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38www.cs.amedd.army.mil/references_publications.aspxtransportedtothecombatzone,andofferingincreasedlogisticalsupporttohelpdefrayescalatingcosts.Itisimportant,too,despitewhatwemaysometimesperceiveasunfairtreatmentfromthemedia,thatweunderstandandsupportthecrucialroletheyplayinreportingtherealitiesofourcombatoperationstotheworld.(COINguidance#19:Befirstwiththetruth.COINguidance#20:Fighttheinformationwarrelentlessly.)THEWARFIGHTINGMEDICALTASKFORCECombatHealthcareSupportCombathealthcaresupportfallsunder2separateyetmutuallysupportingwarfightingfunctions,sustainmentandforceprotection.Thesustainmentwarfightingfunctionistherelatedtasksandsystemsthatprovidesupportandservicestoensurefreedomofaction,extendoperationalreach,andprolongendurance.TheenduranceofArmyforcesisprimarilyafunctionoftheirsustainment.SustainmentdeterminesthedepthanddurationofArmyoperations,itisessentialtoretainingandexploitingtheinitiative.Sustainmentistheprovisionofthelogistics,personnelservices,andcombathealthcaresupportnecessarytomaintainoperationsuntilmissionaccomplishment.Internment,resettlement,anddetaineeoperationsfallunderthesustainmentwarfightingfunctionandincludeelementsofall3majorsubfunctions.Combathealthcaresupportconsistsofallsupportandservicesperformed,provided,andarrangedbytheArmyhealthsystem.Itpromotes,improves,conserves,orrestoresthementalandphysicalwell-beingofSoldiersand,asdirected,otherpersonnel.Thisincludescasualtycare,whichinvolvesallArmyandmilitaryhealthsystemfunctionsanddetaineehealthcare.Theprotectionwarfightingfunctionincludesforcehealthprotection.Forcehealthprotectionincludesallmeasurestopromote,improve,orconservethementalandphysicalwell-beingofSoldiers.Thesemeasuresenableahealthyandfitforce,preventinjuryandillness,andprotecttheforcefromhealthhazards.ThemeasuresincludethepreventionaspectsofanumberofArmyhealthsystemfunctions.SecurityEnvironmentManagingthethreatsoftheenvironmentwillgreatlyimpacttheabilityofthemedicalforcetoinfluencetheoutcomeduringCOINoperations.Inapermissivesecurityenvironment,medicalforceshavethefreedomofmaneuvertooperatethroughoutthecountrysideandpartnerwithgovernmentalhealthcareprofessionalstoprovidethepopulacewiththeappropriatehealthsupport.InIraq,however,thesecuritysituationdoesnotlenditselftoavarietyofdecentralizedmedicaloperationstoassistthelocalpopulation.CompetinginterestsbetweenShia,Sunni,Kurdish,andChristianpopulationslimittheavailabilityandcapabilityofbothUSandindigenoushealthcareworkers.REVOLUTIONIZINGCOMBATHEALTHCARESUPPORT:SYSTEMATICAPPROACHTOCOUNTERINSURGENCYHistorically,sinceoperationsbeganinIraq5yearsago,themedicaltaskforcehasfocusedalmostexclusivelyonthedeliveryofarobustandaccessiblesetoflevelIIandIIIcareandforcehealthprotectionsupportcapabilities.Immediatelyuponassumingthemission,the62ndMEDBDEnotedthatthetaskforceischargedtodeliver3essentialdimensionsofcombathealthsupport:Provideworld-classWarriorhealthcaretoUSandcoalitionforces,ProtectthehealthoftheUSandcoalitionforces,andSupportself-reliantIraqiSecurityForcesandgovernmentofIraqhealthcareandpublichealthsystems.Althoughtherehavebeennumerousrotationsandafreshlookatthedeliveryofhealthcareeachyear,therewereveryfewsignsofhealthsystemintegrationbeyondtraumamanagement.Thehighrateofturnoverofunitsledtogapsorseamsinourservices.Eachnewlyarrivedunitessentiallyreinventedtheirapproachtoexecutingthemissionthattheirpredecessorshadrefinedduringtheirtours.Thisresultedinanunacceptablyhighdegreeofvarianceinthequalityandaccessibilityofservicesacrossthebattlespace.Anintegrationandstandardizationofsystemsinuseandincreasedemphasisontaskforce-wideperformanceimprovementwasidentifiedasrequiredbythecommanderandseniorleadersofthetaskforce.Thevehicletoimplementastrategywasmodeledafterthebalancedscorecard.3AgraphicalrepresentationoftheTaskForce62CombatHealthcareSupportSystemispresentedasFigure1onEmploymentofaJointMedicalTaskForceinaCounterinsurgencyOperationalEnvironment

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OctoberDecember200839THEARMYMEDICALDEPARTMENTJOURNAL *AreaofConcentration70H:HealthServicesPlans,Operations,Intelligence,Security,andTrainingMedicalOperationsOfficerMilitaryOccupationalSpecialty38B:CivilAffairsSpecialistMilitaryAreaofConcentration70A:HealthcareAdministrationOfficerMilitaryOccupationalSpecialty42A:HumanResourcesSpecialistpage6.Itprovidestheoverallstructurethemapforimplementationofthesystem.Thismethodwouldenablethetaskforcecommanderandseniorleaderstoshowthetaskforcehowtocreateacustomizedstrategymapthatallowsthetaskforceto:Clarifytaskforcestrategiesandcommunicatethemacrosstheorganization.IdentifythekeyinternalprocessesthatdrivestrategichealthservicesupportsuccessintheIraqtheaterofoperations.AligntheDoDsinvestmentinpeople,technology,andorganizationalcapitalforthegreatestimpactincombatcasualtycare.ExposegapsintheMilitaryHealthSystemstrategiesandtakeearlycorrectiveaction.Thismodelisthewayinwhichtocommunicatethemedicaltaskforcestrategyandmonitorandmeasuretheprogressofouradvancementsinthe3majorEnds:Provisionofworld-classWarriorhealthcareHealthprotectionofUSandCoalitionforcesSupportforself-reliantISFandGoIhealthcareThesemajorEndsareonlypossiblethroughclosecoordinationwiththeMNF-ISurgeontovalidateouralignmentwiththemedicalstrategicplan;andthesynchronizationacrossallmultinationdivisions/forcetoprovideaseamlessandintegratedhealthsystemfortheWarrior.COUNTERINSURGENCYDOCTRINEIMPACTONHEALTHSERVICESUPPORTCommandandControlTheCOINoperationalenvironmentrequiresanechelon-above-divisioncommandandcontrolstructurethatcoversthebreadthofmedicalfunctionalresponsibilitiesrepresentedinthetheater.Medicalcommandandcontrolforatheaterofoperationsrequireskeypersonnelenablers.Thesesubjectmatterexpertsprovideauniquecontributiontothefightwiththeirknowledge,skills,andabilities.Thismanningshouldincludethefollowingadditionalpersonnel:publicaffairsnoncommissionedofficer,medicaloperationsofficer(Captain,AOC70H*),medicalplansofficer(Captain,AOC70H),civilaffairsnoncommissionedofficer(MasterSergeant,MOS38B5L).Additionally,thefollowingpositionsarecriticalandkeyenablersforthecommanderandmedicaltaskforce:deputycommandingofficer(Colonel,AOC70A),inspectorgeneral(LieutenantColonel),andequalopportunitynoncommissionedofficer(SergeantFirstClass,MOS42A40).Theadditionofthesespecialtyareasbringstherightenablersforeffectivecommandandcontrolbyanechelon-above-divisionmedicalbrigade.HospitalizationAworkhorseintheCOINenvironmentisthecombatsupporthospital(CSH).TheCSHbringsaplethoraoflifesavingandlifesustainingcapabilitythatcanprovidesplit-basedoperations.Additionally,theCSHbringsamedicaldiplomacyaspecttothestrategicobjectiveswithinthetheater.Asatheatermatures,theCSHsenduringoperationisdegraded,andsplit-basedoperationspresentuniquechallengesthataredifficulttoresolvewiththemanpowerthatremainsafteraCSHisdividedinto2elements.CurrentmissionrequirementsinIraqhavecreatedademandformultipleservicesthatarenotpartofthestandardcombat-focusedmission.ACSHpersonnelandequipmentauthorizationdocumentisnotdesignedforenduringsplit-basedoperationsinalethalCOINenvironment.Thepopulationatriskissignificantlydifferent,presentingrequirementssuchasOB-GYN,pediatrics,chronicdiseases,andgeriatricsderivedfromthelocalpopulationandcontractors.Thereisarequirementforspecialtyclinicalstaffintheareasofpediatrics,fellowshiptrainedtraumasurgeons,additionalemergencymedicinephysicians,gastroenterology,cardiothoracicsurgeon,infectiousdiseasespecialist,vascularsurgeon,OB-GYN,pulmonologist,urologist,andaburnsurgeon.ThesituationoftheIbnSinaCSHpresentsanotherproblemwithresourceallocation.Althoughtheyarenotauthorizedatrainedpublicaffairsofficeroraprotocolofficer,theIbnSinaCSHhostsmultiple

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40www.cs.amedd.army.mil/references_publications.aspxmilitaryandciviliandignitaries,aswellasUS,Arab,andinternationalmediaagenciesduetoitslocationinBaghdad.Lastly,personneldepthdoesnotallowenoughresourcestoconductsafeorefficient24/7operations.Tosustainsplit-basedoperations,additionalauthorizationsarerequiredinthefollowingspecialties:emergencymedicinephysician(AOC62A),diagnosticradiologist(AOC61R),operatingroomnurse(AOC66E),criticalcarenurse(AOC66H8A),emergencymedicinenurse(AOC66HM5),operatingroomspecialist(MOS68D),andpharmacist(AOC67E).CriticalMedicalTeamSourcingTheimplementationofCOINdoctrineformaneuverunitshas,asanunanticipatedconsequence,resultedinadegradationofcriticalmedicalteams(treatment,trauma,behavioralhealth,andcriticalcare)capabilityandcapacityintheIraqtheaterofoperations.ThedoctrinehasdecreasedavailablelevelI/IIonforwardoperatingbases(FOBs).AsmaneuverunitsaremovingoffFOBs,theoperationalreachisextendedviacommandoutpost/jointsecuritystation/patrolbase(COP/JSS/PB)expansiontomaintaincontrolofbattlespace.ThisCOP/JSS/PBexpansionplanimpactsthetheatershealthcaresupportsystemfootprintastheorganicorhabituallevelI/IIcapabilityisdisplacedfromtheFOB.Additionally,thedeploymentofnonstandardmaneuverbrigadesintothetheaterhascreatedagapinlevelI/IImedicalcapacity.AnadditionalcriticalconcernisthatmedicalunitsaredeployedataP-2*unitstatusreportingpersonnelratingwithoutregardtothemanningofcriticalmedicalteamsandkeyindividuals,whichinturncreatesashortageofmedicalteamcapacity.Minimalmanningofthecriticalmedicalteamsisnotacceptablewithoutthekeyindividualsandplacesanincreasedrelianceonechelon-above-divisionmedicalassetsfornondoctrinalmissions.AcorporatechangetoArmyRegulation220-14iswarrantedtotrackcriticalmedicalteamsasreportableinaccordancewithTable7-5Squad/crew/team/systemmanningandqualificationcriteria.Also,thiswillenablevalidationoftrainingofmedicalunitsandmaneuverunitswithmedicalelementsonlyifthemedicalteamisfullymannedwiththedesignatedkeyindividual,minimalmanningisnotanoption.SUMMARYThefoundationlaidduringOIF07-09canbethefoundationfortheArmyandMilitaryHealthSystemsvisionincreatingandmodifyingthedeliveryofUSstandardhealthcareinacombattheater.TheCOINenvironmentpresentsuniquechallengesformedicalforcesprovidingsupporttoourWarfightersinIraqandAfghanistan.Medicalinfrastructureinsecondandthirdworldcountriespresentschallengesforournationalandmilitaryleadershipthatmustbeaddressedtobesuccessfulinthelongtermcampaignplanningassociatedwithcounterinsurgencyoperations.Dependingonthesecuritysituation,governmentalandnongovernmentalhealthcareorganizationsmaynotbeabletoprovidethenexusforlong-termrecoveryintheseregions.Althoughallmedicaloperationsmustbelinkedtoalong-termrecoveryoftheindigenoushealthsystem,themedicaltaskforcepossessesuniquecapabilitiesandcapacityintheirlexiconthatmustbeleveraged.Medicalleadershipmustbecreative,adaptive,anddisciplinedtoprovideresourcesfortheeventualsuccessofCOINoperations.REFERENCES 1.FieldManual3-24:Counterinsurgency.Washington,DC:USDeptoftheArmy;15December2006:ix.2.Headquarters,Multi-NationalForce-Iraq.TheCo-alitionOperations2007YearinReview.Multi-Na-tionalForce-Iraqwebsite.February7,2008:page4.Availableat:http://www.mnf-iraq.com/images/stories/Press_briefings/2008/april/2007_year_in_review_final_2.pdf.3.BalancedScorecardInstitute.Whatisthebalancedscorecard?.Availableat:http://www.balancedscorecard.org/BSCResources/AbouttheBalancedScorecard/tabid/55/Default.aspx.AccessedOctober6,2008.4.ArmyRegulation220-1:UnitStatusReporting.Washington,DC:USDeptoftheArmy;December19,2006.AUTHORS Atthetimethisarticlewaswritten,COLAverywastheChiefofStaff,TaskForce62MedicalBrigade,Baghdad,Iraq.Atthetimethisarticlewaswritten,LTCHolmanwastheOperationsOfficer,TaskForce62MedicalBrigade,Baghdad,Iraq. *Personnelmanningofqualifiedpersonnelandseniorleadershipbetween75%and84%ofauthorizedpersonnelstrength.4(p35)EmploymentofaJointMedicalTaskForceinaCounterinsurgencyOperationalEnvironment

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OctoberDecember200841InlateAugust2007,approximately2weeksafterTaskForce62MedicalBrigade(TF62MED)assumedthemedicalcommandandcontrolmissioninIraq,thetheatermedicalregulatingofficer(MRO)receivedanemailwitharedexclamationpointfromtheTF62MEDcommanderrequestinganexplanationastowhy2IraqipatientswereregulatedfromMedicalCityinBaghdadtotheAirForceTheaterHospital(AFTH)inJointBaseBalad.TheMROrespondedthatthetheaterMROdoesnotregulatepatientsfromMedicalCitytoJointBaseBaladbecause,withoutproperauthority,thatwouldbeaclearviolationofthemedicalrulesofeligibility.TheMROstatedthattherewouldbeaninquiryabouthowthepatientsarrived,focusedontheemailfromthecommanderoftheJointBaseBaladhospitalwhichclearlyimpliedthatthetheaterMROhadinfactregulatedtheseIraqipatientsfromMedicalCitytohishospital.EarlierinthedaytheAFTHatJointBaseBaladhadinfactreceived2Iraqipatientswhohadobviouslyreceivedmedicaltreatmentpriortoarrivingatthatfacility,anditwasclearthatthemedicaltreatmenthadbeenongoingfordays.Onepatientinparticularwasparalyzedwithgunshotwoundstohisuppertorso.Theotherpatienthadvariousseriouswoundswhichhadbeeninflictedduringcombatoperations.Bothpatientswereinneedofcontinuedurgentmedicalcare.Duringthehours-longinvestigationastohowthesepatientscametoarriveattheJointBaseBaladhospital,allpartiesinvolvedinthepatienttransferwerecontacted.Thisincludedthemedicalevacuation(MEDEVAC)companythatflewthemission,thebattalioncommandpostthatcalledintheMEDEVACrequest,thetroopmedicalclinictowhichthepatientswereinitiallybroughtbytheunitpatrollingthearea,andthecommandsergeantmajor(CSM)ofthebattalioninvolved.Basically,atthetimeoftheincident,theregionfromwhichthesepatientscamewasexperiencingmostoftheeffectiveenemyattacksagainstCoalitionForcesintheentireIraqtheaterofoperations(ITO).TheCSMdetailedthemissionthatprecededthepatienttransferandindicatedthatahighlevelinsurgentwasnowincustodybecauseoftheoperation.Duringthefollowupmissionswithlocalleaders,therewasarequestfromoneofthoseleaderstohaveaUSmilitaryphysicianlookatthesepatientstodetermineifCoalitionForces(CF)couldhelpthem.Thepatientsweretransportedtoasmalltroopmedicalclinicwithonehealthcareproviderwhodeterminedthatthesepatientswoulddieiftheydidnotreceivecompetentmedicalattention.Anevacuationrequestwasmade,aMEDEVACunitrespondedandtookthepatientstotheclosestlevelIIIfacility,whichwastheJointBaseBaladhospital.AfterinformingtheCSMofthesecondandthirdordereffectsofsuchatransferandreiteratingthemedicalrulesofeligibility(MROE),theCSMstatedthat,becauseofthistransfer,thenextstreettheypatrolinthistownwillnotbelitteredwithimprovisedexplosivedevices.Thatisadifficultpositiontochallenge.ThetheaterMROsresponsibilityistoreceiveandrespondtocountlessinquiresofthistypetodeterminehowpatientsthatappearedtoviolatetheMROEcouldberegulatedtoCFhospitals.TounderstandthelinkbetweenmedicalregulatingoperationsandtheMROE,thisarticleaddressesTheComplexityofMovingPatientsinTodaysMaturingCounterinsurgencyEnvironment:Whom,When,andHowLTCMichaelC.Richardson,MS,USA ABSTRACTMedicalregulatingoperationsandthetheatermedicalrulesofeligibilityareinextricablylinkedinthedeliveryofcombathealthservicesupportintheIraqtheaterofoperations.Thelinkbetweenmedicalregulatingoperationsandthemedicalrulesofeligibilityismorethanthemedicalregulatingoperationsofficer(MRO).InanoperationalenvironmentasvastasIraqinvolvinghostnationcivilians,Iraqimilitarypersonnel,Iraqidignitaries,andahostofotherpotentialpatients,thecomplexmissionofexecutingmedicalregulatingoperationswhileadheringtomedicalrulesofeligibilityisanextremelydynamicundertaking.ThetheaterMROisalwaysexpectingbutneverknowswhattoexpectinthatnextcallorthatnextemail.

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42www.cs.amedd.army.mil/references_publications.aspxTheComplexityofMovingPatientsinTodaysMaturingCounterinsurgencyEnvironment:Whom,When,andHowmedicalregulatingoperations,thentheMROE,howtheyeachplayaroleinthematurationofthedeliveryofcombathealthservicesupport,andhowtheyeachcanbeusedtoassistinthesuccessfulcounter-insurgencyoperationsexpectedinIraqforyearstocome.MEDICALREGULATINGOPERATIONSDoctrinally,theMROatthemedicalbrigade(medicaltaskforce)regulateshospitaltransfersbetweenUSandCoalitionForceslevelIIIfacilitiesandcoordinatesforthestrategicaeromedicalevacuation(AE)flightsleavingtheater.ThetheaterMROintheITOoperatesfarfromthedoctrinalblueprint.Medicalregulatingoperationsatthemedicaltaskforcelevelspansthetactical,operational,andstrategicinfluencesthroughouttheentireITO.Medicalregulatinggetstherightpatienttotherightplace,attherighttime,bytherightmeans.TheMROcoordinatesandsynchronizesavastarrayofresourcestoensurelivesaresavedandtheresourcesareusedasefficientlyandeffectivelyaspossible.Duringtheinitialstagesofconflict,effectiveismorecriticalthanefficient.However,asthetheatermaturesandfootprintsshrink,asinlevelIIIfacilitiesbecomingLevelII,orareductioninthenumberofMEDEVAChelicoptersavailableintheater,orperhapsthedecreaseinthenumberofaeromedicalevacuationflightsleavingtheITO,efficiencyplaysanincreasinglyimportantrole.TheresourcesincludeeverylevelofUSmedicalcarein-theater,fromthesmallestofclinicstothelargestofhospitals,whicharenotallequalincapabilityorcapacity,aswellasthemilitaryhospitalinGermanyandthemostadvancedmedicalfacilitiesintheUnitedStates.InadditiontoUSmilitarymedicalcare,NATO*andnon-NATOmedicalunitsfromBritain,Poland,Korea,andArmeniaaremedicalresourcesin-theaterwhicharepartofthemedicalregulatingpuzzlethatisassembledinvariouswayseverydaytoensuresuccessincaringforthetheaterspatients.MedicalregulatingresourcesalsoincludethehelicoptersdispersedthroughouttheITO,whichincludesUSArmy,Navy,MarineCorps,CoalitionForce,andIraqiAirForce,aswellasairplanesfromthosesourcesandtheUSAirForceandcivilianairambulances.PATIENTREGULATINGRESOURCESMedicalTreatmentFacilitiesThemedicaltaskforcedoesnotexercisecommandandcontroloverallmedicalassetsintheater,onlythosethatareechelons-above-division(EAD).However,thereareEADmedicalresources,suchastheAirForcetheaterhospitalortheAirForceexpeditionarymedicalsquadron,thatmayormaynothaveacommandrelationshipwiththemedicaltaskforce.ThislackofcommandandcontrolcreateschallengesformedicalregulatinginthatpatientsflowfromnumerousclinicstohospitalswithouttheknowledgeoftheMRO.OnlythoseEADmedicaltreatmentfacilitiesthatfallunderthepurviewofthemedicaltaskforcearerequiredbyordertoreportpatienttransferstothetheaterMROforappropriateregulation.Assuch,patientsoftenarriveatahospitalthatdoesnothavethecapabilitytocareforthepatient.Asdiscussedpreviously,notallhospitalsareequalincapabilityorcapacity.Theyallhaveinpatientcapability,CTscanners,operatingrooms,laboratory,etc.However,inmostcasespatientsrequiringmovementafterinitialresuscitationneedaspecificspecialtysuchasneurosurgery,ophthalmologyorgastrointestinalinterventiontoaddresstheirmedicalconditions.ItisthelackofaspecificmedicalspecialtyatthefacilitywherethepatientfirstarrivesthataccountsformostoftheerrorsinpatientmovementamongclinicsoutsideofthecontrolofthetheaterMRO.Regardless,itisimperativethattheMROknowthecurrentcapabilitiesandcapacityofeverylevelIIIandlevelII+medicalfacilityintheITO,aswellasinKuwaitandQatar,toensuretheappropriateregulationofpatients.KuwaitandQatarhavetheirownmedicaltreatmentfacilitieswhichthetheaterMROusesasnecessarytoappropriatelyregulatepatients.TheExpeditionaryMedicalFacility-Kuwait(EMFK),aLevelIIIhospitaloperatedbyUSNavy,hasincreasedcapabilityduetotheavailabilityofcivilianassetsinKuwaitCity.Specifically,KuwaitCityhasanMRIscannerthatisavailablefordiagnosticpurposes.Inaddition,bothKuwaitandQatarhavetheabilitytoallowCoalitionForcesandsomecivilianstoreceivetreatmentand/orrecuperateattheirlocationsforupto30days.TheWarriorReturnUnitislocatedinKuwaitandtheTheaterTransientHoldingDetachment(TTHD)islocatedinQatar.This30-dayrecoveryperiodallowsinjuredWarriorstoremainintheUSCentral *NorthAtlanticTreatyOrganizationComputedtomographyMagneticresonanceimaging

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OctoberDecember200843THEARMYMEDICALDEPARTMENTJOURNALCommandareaofresponsibility,conservingfightingstrength,increasingthereturntodutyrate,andoptimizingthehealthoftheforce.IfitwerenotfortheWarriorReturnUnitortheTTHD,theWarriorswhorequireanextendedperiodofrecoverywouldhavetoberegulatedtoGermany,or,inmanycases,totheUnitedStates.ThecombinedreturntodutyrateforboththeWarriorReturnUnitandtheTTHDisapproximately94%,whereasthereturntodutyrateforLandstuhlRegionalMedicalCenterinGermanyisapproximately24%.Figure1showstheincreaseinpatientsbeingregulatedfromtheITOtotheWarriorReturnUnitandTTHDsinceOctober2007.ThrougheducationandincreasedemphasisonregulatingsouthtoKuwaitandQatarversusnorthtoGermany,theuseofthesefacilitiesfromtheITOisontherise.RegulatingsouthversusnorthisnotonlyfortheWarriorReturnUnitandtheTTHD,butisalsodrivenbygeographyandcapability.TheUShospitalinBucca,Iraq,primarilytreatsdetainees.Therearealso2clinicswithsurgicalcapabilityandaBritishhospitallocatedinthesouthernportionofIraq.Eachofthesefacilitiesoftenreceivespatientsbeyondtheircapabilityand,afterinitialresuscitation,thepatientsmustbefurtherregulatedtoahigherlevelofcare.RegulatingsouthtoKuwaitfromthisareaofIraqforthosepatientsthatareeligibleisalwaysthefirstchoice.ThetheaterMROinstitutedthisregulatingtechniqueinSeptember2007.Priortothat,mostpatientsfromthesefacilitieswereregulatednorthtoBaghdadorJointBaseBaladwhichexhaustedthelimitedMEDEVACassetsinthesouthernportionofIraq.Ittakesapproximately4to5hoursandnumerousMEDEVACaircrafttomoveonepatientfromBuccatoBalad,whereasittakes25minutesandonly2aircrafttomoveapatientfromBuccatoKuwait.ThegreaterefficiencyaffectedtheMEDEVACresource,whichistheprimarytransporterofpatientsbetweenfacilitieswithintheITO,andtoandfromKuwait.PatientMovementbyHelicopterThevastmajority(99%)ofalltheintratheaterpatientmovementsregulatedthroughouttheITOaremovedviaMEDEVAChelicopters.However,notallpatientsmovedviaMEDEVAChelicoptersintheITOareregulatedthroughthetheaterMRO.Mostofthepointofinjury(POI)missions,suchasanattackedconvoy,arecalleddirectlytotheclosestMEDEVACcompanyfromtheforcesatthescene.ThesePOIs,aswellasthosemissionsfromnon-EADmedicalfacilities,arenottypicallyregulatedbythetheaterMRO.ThetheaterMROdoeshavevisibilityofthesemissionsthroughtheuseofMicrosoftInternetRelayChat 9281463372109172363205122757711212478820119215652201420631357112968312228134412018113151348108201571212102168020406080100120140160180 BAGHDAD MOSUL BALAD ALASAD TIKRIT OTHERFACILITIES TOTAL OCT07 NOV07 DEC07 JAN08 FEB08 MAR08 APR08 MAY08 JUN08 JUL08 Baghdad Mosul Balad Alasad Tikrit OtherFacilities Total Figure1.Numberofpatients,byfacility,transferredtotheWarriorReturnUnitinKuwait,ortheTheaterTransientHoldingDetachmentinQatar,fromOctober2007throughJuly2008(dataasof4August2008).

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44www.cs.amedd.army.mil/references_publications.aspx(mIRC),whichisthesinglebestinnovationinmedicalregulatingandsituationalawarenesssincethehighfrequencyradio,intermsofcommunicationcapability.Forpatientmovementandsituationalawareness,mIRCallowsreal-timechatamongallinvolvedparties.AllMEDEVACrequestsarepostedinmIRCsothetheaterhasvisibilityonwhatishappening,andwhen.Itisnotperfect,butitcomesveryclosetoreal-timeawareness.ThemIRCcapabilityallowsoneofthemostsignificantdeviationsfromdoctrineintheMROsavailabletools.ItallowsthetheaterMROtoregulatepatientsfromPOItothemostappropriatefacility,especiallyduringamasscasualtyproducingevent.Acaseinpoint:asaresultofasuicidebomberinamarket,36hostnationpatients,consistingofIraqiciviliansandIraqiSecurityForce(ISF)personnelwithhorrendousinjuries,werebroughtintoasmallforwardoperatingbasewhichhadonly2healthcareproviders.ThecliniccalledanurgentMEDEVACrequest.TheMEDEVACoperationsdispatcherpostedtherequestintomIRCtoprovidetheater-widevisibilityofthismasscasualtysituation.ThroughmIRCchat,thetheaterMROdirectedthefirstlifttotakeitspatientstotheclosestfacility,whiledirectingthenext2lifts,oneofwhichwasfromacompletelydifferentMEDEVACcompany,toevacuatethepatientsto2otherfacilities,therebydistributingthepatientsamong3hospitals.ThisisanexampleofhowregulatingfromPOIiscrucialtoensurethatbestcareisprovidedtothoseinneed,whileefficientlyandeffectivelyemployingthetheaterhealthcareandMEDEVACassets.TheMEDEVACcapabilityintheITOconsistsofUSArmy,CoalitionForce,andIraqiAirForceassets.TheMEDEVACresourcesarearrayedthroughouttheITOtosupporttheprimarymissionofPOIurgentandpriorityrequests.However,inreality,mostofthemissionsexecutedbyMEDEVACaretransfersfromonehospitaltothenextasregulatedthroughthetheaterMRO.ThetheaterMROregulatesmuchmorethanpatients.Blood,supplies,medicalpersonnel,medicalequipment,escorts,etc.areallregulatedandtrackedinthesamemanneraspatients.Figure2presentstheweeklyworkloadofmissionspassedtotheUSMEDEVACcommunitybythetheaterMROfromSeptember2007throughAugust 13411412614216115312112513614799107991161461081069611714910315412410310713312314219611611211915213210511982875510496918899112858810012390 050100150200250 URGENT PRIORITY ROUTINE TOTALPATIENTSMOVED TREND(TOTALPATIENTSMOVED)Figure2.ThenumberofmissionstaskedtoUSMEDEVAChelicoptersbytheatermedicalregulatingoperationsweeklyfromSeptember2007throughAugust2008. TheComplexityofMovingPatientsinTodaysMaturingCounterinsurgencyEnvironment:Whom,When,andHow

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OctoberDecember200845THEARMYMEDICALDEPARTMENTJOURNAL2008.Figure3showsthemovementsbypriorityandtypefromAugust2007throughJuly2008.TheweeklyaverageremainedrelativelyconstantthroughthepeakinMarch2008duringISFledoperations,andthenbeganadeclinethroughtheAugust2008numbers.PatientMovementbyAirplaneHelicoptersaccountformorethan99%ofallintratheatermovement,whileairplanesperformmorethan99%ofallintertheaterpatienttransportation.Thereareinstanceswherepatientsareregulatedintra-theaterviaairplane,suchaswhenweatherrestrictshelicopterflight,butdoesnothinderairplaneoper-ations.Also,sometimestheIraqiAirForceisinvolvedinthemovementortransferofanIraqipatient,oracivilianairambulanceisusedtomoveacontractororotherpatientsapprovedtobemovedoutsideofIraq.Regulatingairplane-transportedpatientsrequiressignificantlyincreasedlevelsofcoordinationtosyn-chronizepatientmovement.Thissynchronizationin-volvestheclinicsandhospitals,thetheaterMRO,theJointPatientMovementRequirementsCenter(aUSCentralCommandassetlocatedinQatar),theUSAirForce,contractors,civilianairambulancecompanies,andothercountriesaroundtheMiddleEast.Patientmovementbyairplaneistheprimeexampleofspan-ningthetactical,operational,andstrategiclinesoftheoperation.TheemphasisbythemostseniorleadersintheDepartmentofDefense(DoD)onintertheaterpatientmovementisremarkable.Theprocessisfluidandresponsive.TherearecountlessexamplesoftheexpeditiousmovementofUSurgentpatientsfromIraqtoGermany,andeventotheUnitedStates,inaslittleas16hours.Figure4depictstheweeklyaverageofpatientsmovedviaUSAirForceairplanesoutoftheITO,July2008throughAugust2008.Thereisaslightdownwardtrendinthenumbersoverthecourseofthelastyear,excludingthelastweekoftheperiod. Figure3.USMEDEVAChelicoptermissionsbypriorityandtypeduringJuly2008,incomparisontoJune2008. Asof4Aug08 35,5%25,4%11,2%112,16%222,32%164,24%77,11%45,6% UrgentLitter PriorityLitter PriorityAmbulatory RoutineLitter RoutineAmbulatory Attendants Blood MedicalSupplies JULYMONTHLYTOTALSUrgentLitter35(2)PriorityLitter25(6)PriorityAmbulatory11(1)RoutineLitter112(12)RoutineAmbulatory222(48)Attendants164(18)Blood(boxes)77(6)MedicalSupplies45(8)TotalMovedonEvac691(93) JulyBloodMovement Urgent:1Missions(4)Priority:0Missions(5)Routine:44Missions(15)Units:1618Units(410) StartinginAprilBloodwastrackedbynumberofmissionsandnumberofunits. Indicatesanincreaseordecrease()identifiestheamountchangedfromthepreviousmonth MonthlyAverageSinceTOAUrgentLitter44PriorityLitter39PriorityAmbulatory13RoutineLitter158RoutineAmbulatory268Attendants173Blood123MedicalSupplies46AverageMovedonEvac864 MonthlyAverageSinceAugust7,2007* July2008MonthlyTotals indicatesincreaseindicatesdecreaseNumberin()isthenumericchangefromthepreviousmonth.

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46www.cs.amedd.army.mil/references_publications.aspxIraqiAirForceTransportofIraqiPatientsAsthetheatermatures,increasedemphasisisplacedontheGovernmentofIraqhealthcare/militarysystemtocareforitscitizens.Theemphasisonpatientmovementisnoexception.Thereisevidenceofprogresstowardsself-relianceintheIraqiAirForceinthemovementofIraqipatientsthroughoutIraq.AllIraqimilitaryairplanesandhelicoptersbelongtotheIraqiAirForce.Theyhave3C-130transportairplanesandafleetofUH-1andMI-17helicoptersintheirinventoryformanyuses,including,ofcourse,patienttransportation.ThroughcoordinationandsynchronizationwiththetheaterMRO,thehospitals,andtheCoalitionAirForceTransitionTeam,theIraqiAirForcehascom-pleted8patientmovementsbyairplane,totaling18patients,inthelastyear.Eachofthe18patientswastransferredfromaUSmilitaryhospitaltoanIraqimedicalfacility.EachIraqiAirForceairplanemissionmarksasuccessfulstepinthedirectionofself-reliance.Whilethose8missionswerecoordinatedthroughthetheaterMRO,duringtheISFledoperationinBasrahinMarch2008,theIraqiAirForceexecutedmorethan250ISFpatientmovesfromBasrahtotheBaghdadarea,andfurtherground-evacuatedthepatientsintoIraqimedicalfacilities.TheIraqiAirForcemovedal-most600unitsofbloodfromtheBaghdadareatoBas-rahtosupportcombatoperations.AllofthesemissionswereexecutedusingtheIraqiAirForceC-130s.Self-relianceforpatientmovementisnotlimitedtoairplanes.InMarch2008,2IraqiAirForcemedicsgraduatedfromthefirstclassoftheIraqiAirForceFlightMedicsCourse.InMayandJune2008,theIraqiAirForcecompleted2helicopterpatientmovementsusingboththeUH-1andtheMI-17helicopters,withatleastoneoftheflightmedicsonboardeachmission.The2missionsmovedpatientsfromtheUShospitalinJointBaseBaladtotheUSmilitaryhospitalinBaghdad,wherebothpatientswerefurtherregulatedtoMedicalCityinBaghdad.Withguidance,theIraqiAirForcewillcontinuetomovepatients,withthegoalofIraqismovingIraqistoIraqihealthcarefacilities.Thiswillassistwiththeself-relianceoftheGovernmentofIraq,lesseningtherelianceontheUSmilitaryhealthcaresystem,andallowinggreateradherencetothemedicalrulesofeligibility.Figure4.TheweeklyaveragenumberofpatientstransportedfromtheIraqtheaterofoperationsonUSAirForceairplanes(STRATEVAC),July2008throughAugust2008. 157224156131190200229183199172213142173164190180110145200218163198185171118157181159169154144167145146158163170156140140173179184151125149178168193164221 0100200300 STRATEVAC AVERAGE TRENDLINE TheComplexityofMovingPatientsinTodaysMaturingCounterinsurgencyEnvironment:Whom,When,andHow

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OctoberDecember200847THEARMYMEDICALDEPARTMENTJOURNALMEDICALRULESOFELIGIBILITYMedicalRulesofEligibilityguidetheDoDmedicalelementswithregardtowhomtheycantreat,whentheycantreat,andwhytheycantreat.TheMROEhavenotchangedsignificantlysincetheearly1990s,andassuchremainsomewhatvague.ARANDCorporationreport,SecuringHealth:LessonsfromNation-BuildingMissions,1looksatthehealthaspectsofnationbuildingduringtheoccupationsofGermanyandJapan,aswellasoperationsinSomalia,Haiti,Kosovo,Afghanistan,andIraq.ThefollowingcitationfromthatreportonthemissioninKosovocapturestheessenceofDoD/USpolicywithregardtotheprovisionofhealthcaretohostnationciviliansduringoperations:USpolicytendedtofavoranarrowerdefinitionofthemedicalmission,onethatfocusedonprovidingmedicalsupporttotheforceandprovidedcaretociviliansonlyinemergencies.AccordingtoUSpolicy,militarymedicalunitswerenottogetinvolvedinrefugeecareorintherebuildingofhealthcareinfrastructure.TheMROEforIraqisbasicallythesame.Militarymedicalunitsareauthorizedtotreatanyonetopreventlossoflife,limb,oreyesight.OtherthanCoalitionForces,detainees,andselectUScivilianpersonnel,thereisambiguityastowhoisentitledtowhatcare,andwhen.Thiscreateschallengestoeveryoneinvolvedinpatienttreatmentandmovement.ThetheaterMROisthesubjectmatterexpertonMROE.Questionsconcerningeligibilitynumberthehundreds,answeringthemischallengingatbest.Forexample:IfwedonttakethisISFoutofthisIraqifacilityhewilldie.Doesthatmakeitlife,limb,oreyesight?ThisUgandancontractorhasaterminaldiseasebutwecantdoanythingforhim.CanweadmithimandsendhimtotheUS?AnIraqigeneralssingledaughterispregnantwithcomplicationsandwillbekilledifthelocalsfindout.WehavetogethertoBaghdadEveryoneofthesequestionshasthesameanswerperhaps.Somearemuchmoreexecutablethanothers,buteachoneisreal,eachoneisnow,eachoneisimportant,and,onanygivenday,manyofthemareoccurringatthesametime.ThisistheambiguityoftheMROE:Didwecauseit?Dowecareforit?Canwecareforit?Whatstheprocess?Thereinexiststheinextricablelinkbetweenmedicalregulatingandmedicalrulesofeligibility.Thereisalwaystheprocessalludedtoabove.Thatprocessinvolvesrequestingexceptionstopolicy.Thisprocesscanbechallenging,but,giventhecurrentpolicyofrestrictingcareversuscompleteaccesstocare,especiallyforhostnationcivilians,itismeanttobechallenging.ItischallengingtoprotectUSmilitaryhealthcareresourcesandsupportthelegitimacyoftheGovernmentofIraqthroughallowingtheMinistryofHealthtocareforIraqssonsanddaughters.MEDICALDIPLOMACY:MEDICALREGULATINGANDMEDICALRULESOFELIGIBILITYNagletal2speaktosecuringthecivilian,battleforciviliansupport,andfocusingontheneutralorpassivemajority.Medicaldiplomacycanhelpinprovidingsecurityforthecivilianpopulace,whilebattlingforciviliansupport.MedicaldiplomacyfocusesonthepassivemajorityinprovidingcareasanadjuncttotheIraqihealthcaresystem,notastheIraqihealthcaresystem.Aplayerinthecounterinsurgencyfightcouldbe,andshouldbe,medicaldiplomacybyusingthemilitarymedicalcapacitytotreatIraqiciviliansandwintheheartsandmindsofthelocalpopulace.AkeycomponentinmedicalregulatingandstrictMROEislimitedmedicalcapacityandcapability.IftheUShad10,000inpatientbedsspreadacross500hospitalswitheveryconceivablespecialtyateachfacility,therewouldbenoneedtomedicallyregulatepatientsoradheretothecurrentMROE.TherealityisthatDoDmedicalfacilitiesareextremelylimitedinthenumberofbedsandspecialtiesintheater,wheretheyarelocated,experienceconstantturnoverofpersonnel,areunderpressuretodownsizethemedicalfootprint,andfunctionunderapolicyofnotreadilyprovidingcaretootherthanthoseclearlyeligible.Therefore,thereisarequirementforaggressivemedicalregu-latingandstrictadherencetothepublishedMROE.Aggressivemedicalregulatingbeginswiththestabilizetotransportmindset.ThismindsetisthemedicalregulatingmantratoensuretheDoDhospitalstransportIraqiciviliansfromUSfacilitiesandintotheIraqihealthcaresystemattheearliestopportunity,asdirectedbycompetentmedicalauthority.Byregulatingpatientsearlierratherthanlater,thetheaterisbetterabletomanagebedcapacity,hospital

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48www.cs.amedd.army.mil/references_publications.aspxspecialty,andmovementresources.TheIraqipatienttransportisfacilitatedbytheCivil-MilitaryLiaisonOfficers(CMLO)andtheBilingualBiculturalAdvisor-SubjectMatterExperts(BBA-SME),whicharepartofcivil-militaryoperationsunderthemedicaltaskforce.TheseCMLOsandBBA-SMEsensurethatIraqipatientsareappropriatelyregulatedtoacceptingIraqifacilities.ThetheaterMROandthecivil-militaryoperationsofficersynchronizethecoordinationandexecutiontoaggressivelyregulateIraqipatientsintotheIraqihealthcaresystem.ThelimitingfactorforboththeUSmilitaryandtheIraqihealthcaresystemsiscapacity.USMILITARYMEDICALCAPACITYThelimitedUSmilitaryinpatientbedsspreadacrosstheITOareunderutilizedasevidencedbythebedfilloccupancynumbers.SinceJanuary2007,theaveragedailybedfillacrossallinpatienthospitalsis41%.Figure5detailstheaveragebedfillthroughJuly2008.Further,asshowninFigure6,thesignificantmajorityofpatientsinthoseoccupiedbedsareIraqi,afactthathasexistedforthe20-monthperiodcoveredbythedata(December2006throughJuly2008).Therewere1,346admissionsinJanuary2007,andover1,600inMayandJune2007.Since,wehaveseenasteadydeclineinadmissionswithalowof972inMay2008.JuneandJuly2008reflectonlyaslightincreaseat984and1,055respectively.ThedemographicsofthoseadmittedtoUSmilitaryfacilitiesarechanging.PriortoJune2008,USmilitaryadmissionsaccountedformorethan40%,whereasIraqisaccountedforalmost38%.InJuly2008,USmilitaryadmissionsaccountedfora15-monthhighof51%,andIraqis(hostnationciviliansandIraqiSecurityForces)combinedaccountedfora15-monthlowof17%.Finally,themakeupofadmissionsischangingaswell.SinceJanuary2008,therateofadmissionsforbattleinjurydeclinedfromover400inJanuarythroughMarch2008,tojustmorethan180forJuneandJuly2008.Figure7presentsthedata.FromMaytoJuly2008,anaverageofonly32%ofthebedswereoccupied,indicatingexcesscapacity.Thereisalsoexcesscapacityinouroutpatientclinicsaswell.Thisexcesscapacityallowsimplementationandexpansionofmedicaldiplomacyinthecounterinsurgencyfight.MEDICALDIPLOMACYNagletalquoteformerArmyViceChiefofStaff,GeneralJackKeane2(pxiv):AftertheVietnamWar,wepurgedourselvesofeverythingthathadtodowithirregularwarfareorinsurgency,becauseithadtodowithhowwelostthatwar.Inhindsight,thatwasabaddecision.PerhapswecouldlearnfromthemedicaldiplomacyofVietnamasdetailedbyWilensky3:Almost40millionencountersbetweenAmericanmilitaryphysiciansandVietnameseciviliansoccurredfrom1963to1971intheMedicalCivicActionProgram(MEDCAP)aloneduringtheVietnamconflict.Asidefromthehumanitarianreasonsforthevariouscivilianmedicalaidprograms,SpurgeonNeelthoughtthatmedicalserviceswereproperlyusedforpoliticalgain.MEDCAPwasatacticalemploymentofmedicalcapabilitytotryandinfluencethepeopleweweretheretryingtohelp.NeelalsofeltthatanotherreasonfortheprogramswasthattheyimprovedtheimageoftheUnitedStates.MedicalCivicActionProgramevents(MEDCAPs)arebeingconductedsporadicallythroughoutIraqbysmallunitengagements,but,outsideoftheErbilregion,thereisnoapparentconcertedefforttouseMEDCAPsincounterinsurgencyoperationstowintheheartsandmindsoftheIraqipopulace.TheZaytunDivisionoftheRepublicofKoreaArmyintheErbilregionisaprimeexampleofmedicaldiplomacy.TheKoreanhospital,incooperationwithKoreancivilaffairs,treatsapproximately120Iraqi(Kurdish)patients4daysperweek.Thisaccountsformorethan90%oftheiroutpatientworkload.ThecivilaffairsunitscreensthelocalIraqisneedingcare,providesthematicketwhichentitlesthemtoacuteandchroniccareintheKoreanhospital.TheKoreansprovideamonthly,fair-likeeventwhich,inadditiontoTaeKwonDoandmagicshowdemonstrations,includeshealthscreeningandeducation.Theeventshavehadnosecurityissues.ThehospitalleadershipattributesthemedicalcareprovidedtothelocalpopulaceasakeyelementinthesecuritysuccessesenjoyedinthenorthernpartofIraq.Itisimpossibletosatisfyeveryone.However,usingmedicaldiplomacyasatoolinthecounterinsurgencyfightisanalternativetosignificantlyrestrictingaccessTheComplexityofMovingPatientsinTodaysMaturingCounterinsurgencyEnvironment:Whom,When,andHow

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OctoberDecember200849THEARMYMEDICALDEPARTMENTJOURNAL 11811812713212512412610912310511110310410211090938752%45%44%43%43%46%48%46%46%46%40%45%38%40%37%38%37%40%33%34%32% 0204060801001201400%10%20%30%40%50%60%70%80%90%100%Nov-06Dec-06Jan-07Feb-07Mar-07Apr-07May-07Jun-07Jul-07Aug-07Sep-07Oct-07Nov-07Dec-07Jan-08Feb-08Mar-08Apr-08May-08Jun-08Jul-08 NumberofBeds MonthlyBedfill AverageBedfill TrendLine Figure5.PercentageaveragedailyinpatientbedfillatUSmilitaryfacilitiesintheIraqtheaterofoperations,November2006throughJuly2008,basedontotalof274operationalavailablebeds.*Dataasof4August2008.Note:InpatientsconsistofUS,Iraqimilitary,andotherseligibleunderthemedicalrulesofeligibility.*Availableoperationalbedsdecreasedto254on17July2008 Figure6.ComparisonofUSandIraqipatients(actualnumbersandpercentages)occupyinginpatientbedsatUSmilitaryfacilitiesintheIraqtheaterofoperationsfromDecember2006andJuly2008.Dataasof4August2008. 1824252928282425262524222220212828898592909285907688717471718159535025%29%25%15%20%20%22%22%23%19%23%21%24%22%21%21%18%24%30%33%66%65%67%75%72%72%68%74%69%71%70%72%68%67%69%68%74%65%58%57%0204060801001201400%10%20%30%40%50%60%70%80%90%100%Dec-06Jan-07Feb-07Mar-07Apr-07May-07Jun-07Jul-07Aug-07Sep-07Oct-07Nov-07Dec-07Jan-08Feb-08Mar-08Apr-08May-08Jun-08Jul-08 NumberofIraqipts. NumberofUSpts. US IRAQI IraqiPatients USPatients USAverage IraqiAverage

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50www.cs.amedd.army.mil/references_publications.aspxtocare.AbalancemustbestruckbetweentheacceptableCFmedicalfootprinttheability,throughsecurity,toprovidecaretothelocalpopulacewhileensuringexcesscapacityismaintainedforthatexpectedsurgeinCFcasualtieswiththeabilitytoensuretheGovernmentofIraqiscaringforitscitizens.ThisparadigmshiftinthemedicaldiplomacylineofoperationinsupportofthecounterinsurgencyfightwouldcertainlyinvolvemedicalregulatingoperationsandavarianceofhistoricalDoD/USpolicyonmedicalrulesofeligibility.Perhapsthenthenextstreetthecommandsergeantmajorandhisunitpatrolswillnotbelitteredwithimprovisedexplosivedevices.CONCLUSIONTheinextricablelinkbetweenmedicalregulatingoperationsandthemedicalrulesofeligibilityismorethanthemedicalregulatingoperationsofficer.InanoperationalenvironmentasvastasIraqinvolvinghostnationcivilians,Iraqimilitarypersonnel,Iraqidignitaries,andahostofotherpotentialpatients,thecomplexmissionofexecutingmedicalregulatingoperationswhileadheringtoMROEisanextremelydynamicundertaking.ThetheaterMROalwaysexpectsbutneverknowswhatwillbecontainedinthatnextcallorthatnextemail:ThereareconjoinedtwinsinanIraqihospitalthattheKingofSaudiArabiahasaccepted.IftheSaudiscannotgetthemmoved,canwemovethemintoourfacilityandthenarrangefortransportationtoSaudiArabia?REFERENCES 1.JonesSG,HilborneLH,AnthonyCR,etal.SecuringHealthLessonsfromNation-BuildingMissions.SantaMonica,CA:RANDCorporation;2006.2.NaglJA,PetraeusDH,AmosJF.TheUSArmy-MarineCorpsCounterinsurgencyFieldManual.Chicago,IL:UniversityofChicagoPress;2007.3.WilenskyRJ.MilitaryMedicinetoWinHeartsandMinds:AidtoCivilianintheVietnamWar.Lubbock,TX:TexasTechUniversityPress;2004.AUTHOR Atthetimethisarticlewaswritten,LTCRichardsonwastheIraqTheaterofOperationsMedicalRegulatingOfficer,TaskForce62MedicalBrigade,Baghdad,Iraq. Figure7.AdmissionstoUSmilitarymedicalfacilitiesJanuarythroughJuly2008,brokendownbycauseforadmission.Thetrendforbattleinjuriesisclearlydown,whiletheadmissionratefornonbattleinjurieshasremainedrelativelyconstant. 41142241237729518518720626517916518716620366170252753349063366501002003004005006007008001234567 Jan2008 Feb2008 Mar2008 Apr2008 May2008 Jun2008 Jul2008 MonthlyAverageBattleInjury327NonbattleInjury196Disease602 BattleInjury NonbattleInjury Disease TheComplexityofMovingPatientsinTodaysMaturingCounterinsurgencyEnvironment:Whom,When,andHow

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OctoberDecember200851Planningguidancetostaff:Strivetosynchronizeasustainablehealthcaresystemdefinedbymeasurableoutcomes,innovation,andperformanceexcellenceinpursuitofperfectingcombatmedicine.COLPatrickSargent,Commander,TaskForce62MedicalBrigadeWhentheTaskForce62MedicalBrigade(TF62MED)assumedcontrolofthetheatermedicalcommandmissionin2007,itwasclearfromthe98%patientsurvivabilityratethatpreviousmedicaltaskforceshadbeensuccessfulatprovidingmedicalcare.Understandably,inthesupportofextensivecombatoperations,therehadbeenlittlesystematicplanningformorethanoneyearatatime.Also,asystemizedhealthcaredeliverynetworkthatusedevidence-basedstandardsandknowledgemanagementtoqualifyandimprovepatientoutcomeshadnotyetbeendeveloped.Consideredthetipofthespearforhealthcaredelivery,TF62MEDlaunchedacampaignplantobuildasustainablehealthcaresystem.Thissystemhad,asitsfoundation,standards-basedhealthcaredeliveryinfusedwitharelentlessfocusonevidence-basedcombathealthcareandperformanceexcellence,twoofthecommanderstop10priorities.Thesuccessofthiscampaignwouldbethetemplateforfuturedeployablemedicalsystems,andwouldensureacodifiedstand-ards-basedcontinuumofcaredeliverysystem.HEALTHCARESYSTEMASSESSMENTAmajorlong-terminvestmentassociatedwithhealthcareexcellenceisgainedbycreatingandsustaininganassessmentsystemfocusedonhealthcareoutcomes.Aneffectivehealthcaresystemdependsonthemeasurementandanalysisofperformance.Wedevelopedthehealthcaresystematicassessmentmodel(Figure1)toassessandmanageclinicalsynchro-nizationatthetactical,operational,andstrategiclevelstokeepourcombathealthcaresystemontracktowardsthe2supportingconditionsrelativetoournear-termobjectives:aggressiveforcehealthprotectionandconservationofcombatpower.The3corecompetenciesdelineatedinFigure1thatsupportedourhealthcaresystemwere:processmanagement,workforce,andworksystems.ProcessmanagementallowedustoassessandbenchmarkprocessesinourWarriorhealthcaredeliverysystemusingqualityoutcomemetricssuchasthosewiththeventilatorassociatedcarebundle*toevaluatepatientoutcomes.Ongoingassessmentofsurveillancemetricssuchasdiseaseandnonbattleinjuryratesandreportablemedicaleventsreportsprovidedcriticaldatapointsthatallowedadjustmentsinforcehealthprotectionstrategies.Weanalyzedtheworkforcebyexaminingworkforcecapacity,definedasourabilitytoensuresufficientstafftoaccomplishourworkprocessesandsuccessfullydeliverpatientcare.Workforcecapabilitywasdefinedasourabilitytoaccomplishourworkprocessesthroughtheknow-ledge,skills,andcompetenciesofourstaff.Weassessedworkforcecapacity,forexample,byusingworkloadmetricssuchasthenumberofsurgicalcases,surgicalhours,bedoccupancyrates,andnursingcarehours.Webuiltametricsworkbookforeachfacilitythatallowedustoanalyzeeachfacilitysprogress,aswellascompareandcontrastdataamongfacilities.Thesemetrics,whencomparedtoworkforcemetricssuchasnumbersandskillmixofstaff,allowedustooptimizeworkloadtoworkforceratios.Oneofthewaysweassessedworkforcecapabilitywastotrackstaffcompetencymetrics,suchascredentialing,privileging,andlicensure.Wecontinuouslyassessedworksystemdesignusingkeyworkprocessmetricstoevaluatestrategiesforredesignofsystemsandprocessestomakethemsaferforourpatients.Weusedriskmanagementmetrics,suchasincidentreporting,trendingandanalysis,tosystematicallyassessourkeyworkprocesses.Decisionsaboutthe3corecompe-tencies(processmanagement,workforce,worksystems)guidedbrigadestrategies.Thedecisionsinvolveddefining,protecting,andcapitalizingonourClinicalQualityManagementinaMatureCombatEnvironmentCOLSuszClark,AN,USAMSG(P)RichardBrewer,USA *MandatedbytheOfficeofTheSurgeonGeneral/USArmyMedicalCommandPolicyMemo07-011,datedApril26,2007.

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52www.cs.amedd.army.mil/references_publications.aspxClinicalQualityManagementinaMatureCombatEnvironmentcriticalhealthservicesupportcapabilitiesandsystemsinordertobeasustainablehealthcaresystem.PATIENTSAFETY:THEFIRSTSTEPAninitial,earlyassessmentofunitsintheateratthetimerevealedthattherewasnostandardizedapproachtopatientsafetyandclinicalriskmitigation.Subsequently,thetaskforcedevelopedandimplementedataskforce-widepatientsafetyprogramtodecreasevariationofpatientsafetypractices,improvemeasurementreliability,andpromotepatientsafetybestpracticeswithinthesystem.Incidentreportingwhichsummarizedbotherroroccurrenceaswellasnear-missreporting(wheretheerrorisidentifiedpriortoimpactingthepatient)wastrackedatthedirectreportingunitlevelforsummaryandanalysisacrossthetaskforceonamonthly,quarterly,andannualbasis.Directreportingunitsremainedresponsibleforcorrectiveactionanderrorpreventiontrainingbasedontheincidentreportfindingsateachunit,whiletaskforce-widetrendsidentifiedgener-alizedtrainingneeds.Incidentreportinganalysesleadtothedevelopmentandimplementationofstandard-izedbloodadministration,moderatesedationdeliveryandinpatientmedicationadministrationguidelines,andasharpssafetytrainingpackageforusethroughoutthetaskforce.IMPLEMENTINGQUALITYINDEPLOYEDHEALTHCARETodaysArmyhealthcaresystemcontinuestoexemplifythehighestqualityofpatientcare,bothintheUnitedStates(CONUS)andforwarddeployed.Althoughprovidingthesameconsistencyofhealthcareinanausteredeployedenvironmenthasitschallenges,theexpectationtoprovideastandard-basedhealthcaresystemremainedourgoal.Sincetheinceptionofmobilecombathospitalstotreatthesickandwounded,theconcepthasremainedthesame:provideastandard Figure1.ThehealthcaresystematicassessmentmodeldevelopedbyTF62MEDtoassessandmanageclinicalsynchronizationatthetactical,operational,andstrategiclevels.

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OctoberDecember200853THEARMYMEDICALDEPARTMENTJOURNALofcarebasedontheexperienceandtrainingoftheclinicalstaffdeployedfromCONUS-basedmedicalfacilities.Thisdoctrinalconcepthasshownresilience,butitlackedaprocesstovalidateandcodifybestpracticeswithinthemobilecombathospitals.Historically,deployablehospitalsarenotrequiredtowithstandtherigorsofaJointCommission*inspection.Higherheadquartershavehistoricallyprovidedvariousdegreesofoversightandinstitutedclinicalpolicestomaintainstandardsofcare.Toensureastandards-basedhealthcaresystem,weleveragedprovenclinicalpracticeguidelinesandmostoftheJointCommissionsnationallyestablishedstandardsofcaretovalidatemedicalunitsrotatingintotheater.Priorunitinspectionsfocusedonavailabilityofclinicalpoliciesandstandardoperatingprocedures.Inordertoadequatelyassessthecomponentsofthehealthcaresystematicassessmentmodel,wehadtogobeyondpaperpoliciestolookattheprocessesandsystemsdrivinghealthcaredeliveryatthefrontlineofcaredeliverytheunit.Todoso,wefocusedonthepatientanddevisedtheconceptofthequalityhealthcareassistancevisit(QHAV)thatusedpatientandsystemtracermethodologytoevaluateclinicalprocesses.Intheearlystagesofdevelopment,thestaffcreatedagraphicmodel(Figure2)tovisuallyportraythediversepatientsystemsthatcompelledthevalidationprocessanddrovestandards-basedcaredelivery.Themodeldepictsthepatientasthecenter-of-gravityforallhealthcaredeliveryprocesses,frompoint-of-injurythroughlevelIIIhospitalcareandtheaterevacuation,withanemphasisonquantifyingandqualifyingpatientoutcomes.UsingtheJointCommissionfunctionstodefinepatientcareandsupportprocesses,wedevelopeda120-itemQHAVchecklist(Figure3)tousewithtracermethodologyinordertoevaluateeachofourlevelIIIhospitals.PatientandsystemtracermethodologyallowedtheQHAVteamtofollow,observe,andevaluateapatientscarethroughoutthehealthcareprocess.ThepatienttracerprocessstartedfromthemomentapatiententeredalevelI(aidstation)thrulevelIII(hospital)activity,andcontinuedthroughouthis/herstayoruntildischargeorevacuationfromtheIraqtheaterofoperations.Thisprocessensuredallhealthcarefunctionalareasweresynchronizedtoprovidethebestoutcomeforthepatient.Furthermore,itgavetheQHAVteamtheopportunitytoassesspoliciesandproceduresandproviderecommendationsforperformanceimprovement.Weusedthisprocesstoevaluate7geographicallydispersedlevelIIIhospitalstwice,onceat30daysaftertransferofauthority(initialarrival)toensureappropriatestandardsandprocesseswerecodifiedandinuse.Theywereevaluatedasecondtime120dayspriortotheirredeploymenttoensurestandardshadbeenmaintainedforhandoffduringtheunitstransition.ThemodelandtheQHAVchecklistprovidedthedirectreportingunitcommandersandtheirstaffspriorityfocusareastoconsiderintheirrespectiveunitsorganizationalriskassessment.Theconceptallowedacontinuousimprovementprocessduringtheunitstourofdutyandidentifiednumerousbestpracticesthatweredisseminatedthroughoutthetaskforce.Inaddition,andmostimportantly,itensuredastandards-basedhealthcaresystemthatwasvalidatedandcodified.Theendstatewasacomprehensiveevaluationofsystemsthatwerepatient-centricandallowedforanoverarchingcollaborativeapproachtoresolveclinicalissuesthathadinundatedtherotationsofpreviousmedicalbrigades.Undoubtedly,theabilitytoapplyJointCommissionstandardsinanaustereenvironmentislimitedbyconditionsonthegroundandresourcesavailable.ThoughtherearenumerousdifferencesbetweentheenvironmentsofcareinCONUSandIraq,wedirectlychallengedthefalseassumptionthatweinitiallyheard,wecantdothatqualityimprovementstuffinacombatzone.However,thebeliefstillexiststhatwecanexpectandshouldholdourselvestoaUSstandardofcareonefoundedonprovenguidelines,practices,andpatientsafety.STANDARDS-BASEDHEALTHCAREDELIVERY:NURSINGAftervisitingseveralunits,wefoundearly-onthatthemedicationmanagementsystemrequiredsomereengineeringspecifictomedicationadministration.Concurrently,medicationadministrationerrorswereconsistentlyinthetop3errorsreportedviaourincidentreportingsystem.DuringtheQHAVs,weobservedthatnurses,usedtoelectronicmedication *JointCommissiononAccreditationofHealthcareOrganizations,OneRenaissanceBlvd,OakbrookTerrace,Illinois60181

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54www.cs.amedd.army.mil/references_publications.aspxdispensersinCONUS-basedmedicaltreatmentfacilities,hadproblemscompletingthe10rightsofmedicationadministrationwithouttheelectronicsystemsandacleardelineationofanalternatemethodofadministeringmedications.Inaddition,longhallwaysatseveralofthefacilitiesincreasedthedistancebetweenthepatientandthenursesstation,wherethemedicationswerestored,whichincreasedthechanceoferror.DuringaQHAV,wediscoveredabestpracticeinuseatoneofourfacilities:mobilemedicationcarts.Nursesformerlyusedmedicationcartstodelivermedications,butthesewereoutmodedbyimplementationofelectronicdeliverydevices.Themedicationcartscouldbestockedwithmedicationsatthenursesstation,andthenrolledtothepatient,therebydecreasingthestepsrequired,literallyandfiguratively,formedicationadministration.Tominimizemedicationadministrationerrorsamongthenewnurses,werevisedanoldadage,newnurseslearningoldtricks.Themedicationcarts,alongwithastandardizedmedicationadministrationpolicythatservedasanoperatorsmanualforthecarts,weredisseminatedthroughoutthetaskforcetopromotepatientsafetyanddecreasemedicationerrors.STANDARDS-BASEDHEALTHCAREDELIVERY:EQUIPMENTThepatientandsystemtracermethodologyidentifiedastaffthatwasunfamiliarwiththetypeofdatedequipmentbeingemployedintheater.Similarly,theprocedurestorequestandstandardizeequipmentwerenotwell-established,causingfurtherdelaysinobtainingmodernequipment.ThisrequiredstaffcoordinationbetweentheclinicaloperationsstaffandS4(logistics)todevelopaprocessthatallowedaseamlessandtransparentplatformbywhichunitscouldorderequipment.First,unitshadtoestablishacompetencychecklistrelevanttotheirequipment.ThisprovidedacodifiedsystembywhichstaffcouldClinicalQualityManagementinaMatureCombatEnvironment Figure2.ThegraphicmodeladoptedbyTF62MEDtovisuallyportraythediversepatientsystemsthatcompelledthevalidationprocessanddrovestandards-basedcaredelivery. O u t c o m e s

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OctoberDecember200855THEARMYMEDICALDEPARTMENTJOURNALdemonstratetheircompetencyonaparticularpieceofequipment.Next,theDeputyCommanderforClinicalServicesestablishedaMedicalEquipmentStand-ardizationandValidationBoardconsis-tingofclinicalhospitalleadersandequipmentproponents.Throughavirtualmeetingroom;clinicalstaffreviewed,approved,andstandardizedequipmentrequestedbyunits.Likewise,itallowedthemtolookforredundanciesorlikeitemsthathadbeenpreviouslyapproved.Thissystematicapproachallowedthetaskforcetopurchaseapproximately1,340items,valuedatapproximately$15.7million.Ofnote,theQHAVprogramsfocusonevidence-basedpracticeidentifiedforwardsurgicalteamequipmentmodificationsinthetypeofrefrigeratorsandbedsnecessarytosupportcurrentclinicalpracticeguide-linesandstandardsofpatientcare.STANDARDS-BASEDHEALTHCAREDELIVERY:DOCUMENTATIONDocumentationisacriticalcomponentofthedeliveryofhealthcare,notonlywithinIraqbutthroughoutthecarecontinuumtothelevelIVmedicalcentersinCONUS.TheQHAVteamrecognizedearlythat,althoughtheArmyhadanelectronicmedicalrecord(EMR),therewereenormousgapsinknowledgeaboutanduseofthesystem.Themedicalstaffwasnotfamiliarwithvariousmandatoryformfieldstobecompleted.Conversely,themedicalstaffcomplainedofalackoffieldsneededtocompletetheirdocumentation.Technicalproblemsbeleagueredthesystemtothepointthatmedicaldocumentationwaseitherlostordelayed,causingbreaksinthechronologicalorderoftreatment.TF62MEDClinicalOperationsandHealthInformationSystemshadtocollaboratetoinstitutechangesthatwererequestedbytheunits.Workingwithmedicalcommunicationsforcombatcasualtycare(MC4)systemconsultants,thisteameducatedstaffontheEMR/MC4systemsuse.Furthermore,workinginconjunctionwithphysiciansandnurses,theteamdroveanupgradetotheEMR,addingmorefieldstosupportclinicalnotes.Improvementsinconnectivity,access,andmedicalrecordauditsincreasedvisibilityanduseoftheEMR,notonlyinIraq,butalsoinourlevelIVmedicalcentersbackhome.Intheprevious2yearstherewereapproximately23,000inpatientand1,840,000pharmacy,laboratory,andradiology(PLX)EMRencounters.Atthetimethisarticlewaswritten(July2008),the62ndMedicalBrigadehadenteredapproximately17,250inpatientand2,115,00(PLX)encounterssinceitassumedauthorityforthetheatermedicalmission(August2007).Thisextraordinaryincreasewasreflectiveoftheinstitutionofstandardizeddetailedmedicalrecordsdocumentationthroughmedicalautomationsystemswithinthetheaterandacrossthecontinuumofcare.CONCLUSIONTheexpectationofourpatientsiswetrainaswefight,honingthoseclinicalskillsthatwillresultinflawlessdeliveryofhealthcare.Warfighterswithstandunit,battalion,andbrigadeinspectionswhichconstantlyevaluatetactics,andworktowardimprovingandsynchronizingoperationswiththegoalofaccomplishingthemissionandbringingtheSoldiershomesafely.Thosetactics,techniquesandprocedures(TTPs)getcodifiedandstandardized,andinturnbecomeanArmystandard.ThoseTTPsarelearnedthroughexperiencingharshrealities,fromtheFigure3.Excerptfromtheintegratedqualityhealthcareassistancevisitteamchecklist.Team#TeamMemberDateofTracerAttendingStaffMemberAdmissionDiagnosisInitialsofPatientSelected/Last4SSNUnitDate/TimeAdmitted123456789101112 Score2=fullycompliant1=partiallycompliant0=notincomplianceNA=notapplicableWhatCPGsareusedforprovidingresuscitativeservices?PC9.30Whatwouldyoudoifyoubecameawareofanethicalissueconcerningapatient?(Considerinterdisciplinarymeetingwithfamily,contactEthicsCommittee)RI1.10WhatisyourprocessforperformingIVmoderatesedation?PC13.20Whatareyourtwopatientidentifiers?NPSGIfapatientneedstoberestrainedformedicalreasons,howfrequentlydoordersneedtobewritten?(every24hours)PC12.140 INTEGRATEDSECURITYTEAMCHECKLIST1.Gotothefrontdesk,introduceteamandasktospeakwiththeheadnurseofNCOIC.2.Introduceteamtotheheadnurseandexplainthepurposeofyourvisitanintegratedpatienttracervisit.3.Askforabriefdescriptionoftheunit(typesofpatients,averagedailycensus,acuity,staffingcomplement).SequenceofCareReceivedPriorityQuestionsforPhysicianTeamMemberEnterAppropriateScoreBelow

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56www.cs.amedd.army.mil/references_publications.aspxsheddingofUSbloodandlossofourSoldierslives.Werecommenddeployablemedicalunitsadoptthesameconceptandensurethatcodified,evidence-basedstandardsthatcovertherigorsofaJointCommissioninspectionbethefoundationfordeployedhealthcaredelivery.Presentandfuturedeployablemedicalunitsshouldbuildtheircapabilitiesoncodifiedstandardsdevelopedfromorganizationsthathavetriedandtestedclinicalprocesses.Degradationofcapabilitiesisapparentasunitsbringavarietyoftheirownpoliciesandprocedurestothefight.Toomanyunitsstagnateinitially,astheygothroughthegrowingpainsoftryingtoimplementtheirstandards,onlytofindoutthatthepreviousunithadanguishedthroughthesameprocess,andultimatelyresortedbacktoanobjectivesetofstandards.Theperspectivefrequentlyencounteredinadeployedenvironmentisonethatisdistorted:USstandardsdonotorcannotapplyandmodifications,ifyouwill,areacceptable.Itisourbeliefthatthisperspectiveadverselyaffectshowwetrainandevaluateourdeployablemedicalunits.Itrequiressignificantchangeandrenewedfocusoncurrent,USstandards-basedhealthcare.Asanexam-ple,AnnexQ*describesTF62MEDpoliciesandproceduresrelevanttoallIraqtheaterofoperationshealthcarefacilitiesandunits.Ithaselementsofperformanceandperformancemeasurements,alongwithNationalPatientSafetyGoalstohelpassesstheperformanceofanorganization.Toensureacontinuousimprovementprocess,periodicsemiannualreviewsofsystemswillappraiseactionplansandmissionsuccess.Futureorganizationalinspectionprogramsandtrainingexercisesshouldfocusnotonlyonthecommandandcontrolaspects,butalsoontheclinicaldoctrinethroughanestablished,deployable,USstandards-basedinspectionsystem.Thesystemshoulddefinecommonpoliciesandproceduresspecifictodeployableorganizationalequipment,facilities,staffing,scopeofpractice,environmentofcare,andlogistics.Themindsetofcurrentexercisesfocusesontrauma-heavypatientplay,masscasualties,treatment,andevacuation.Allofthesearerelevant,however,uponfurtherreview,noneofthoseparticularareashaveanassociated,codified,standards-basedideology,nordotheyreflectthemajorityofchallengesfacedbyhealthcarefacilitiesinamatureoperationalenvironment.Whenreviewingandquestioningtheprocessesusedbyunits,thenormalresponseissubjectivethatshowwedoitbackhome.Again,relyingonthetheirclinicalexperiencelearnedwithinCONUSfacilities,physicians,nurses,medics,andadministratorsapplythoseoftennonstandardclinicalpracticesassociatedwitharobustmedicalsystem.Unfortunately,inadeployedenvironment,services,equipment,staffing,andlogisticalconstraintsdictateadifferentapproachastohowwedeliverhealthcare.However,USstandardsandprinciplesshouldbeemployedthroughspecificpoliciesandprocedurestailoredfordeployablemedicalunits.Leadersimplementingthesestandardswillencounterinitialresistance,buthealthcareprofessionalsquicklyrecognizethebenefitsofdeliveringUSqualitystandards-basedhealthcarewhereverintheworldtheirnationsendsthem.AUTHORS Atthetimethisarticlewaswritten,COLClarkwasDeputyCommander,Nursing,andChief,ClinicalOperations,TaskForce62MedicalBrigade,Baghdad,Iraq.Atthetimethisarticlewaswritten,MSG(P)BrewerwasSergeantMajor,ClinicalOperations,TaskForce62MedicalBrigade,Baghdad,Iraq.ClinicalQualityManagementinaMatureCombatEnvironment *AnnexQistheMedicalServicesAnnextotheTF62MEDOperationsOrder08-02(internalmilitarydocumentnotreadilyaccessiblebythegeneralpublic).Startingin2003,theJointCommissionannuallyreleasesanumberofNationalPatientSafetyGoals,anddirectsallaccreditedhealthcareorganizationstoimplementthosegoals.Althoughtheyaretermedasgoals,theyaremandatorypracticechangesmodeledafterbest-practicesthroughouttheworld.Thegoals,rangingfromverysimpletoverycomplex,addressavarietyofsafetyissuesthatconfronthospitalsonadailybasis.Availableat:http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/

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OctoberDecember200857Wewillnotbeeffectiveandrelevantinthe21stcenturyunlesswebecomemuchmoreagilebutwiththecapacityforalong-term,sustainedlevelofconflict.Beingrelevantmeanshavingacampaign-qualityArmywithjointexpeditionarycapability.ItmustbeanArmynottrainedforasingleeventlikeatrackathlete,buttalentedacrossabroadspectrumlikeadecathlete.1(p4-6)GeneralPeterJ.SchoomakerINTRODUCTIONAlthoughtherewerelonelyvoicesarguingthattheArmymustfocusoncounterinsurgencyinthewakeoftheColdWar,thesadfactisthattheArmywasunpreparedtofighttheinsurgencyinIraqwhenitbeganinthelatesummerof2003.ThestoryofhowtheArmyfounditselflessthanreadytofightaninsurgencygoesbacktotheArmysunwillingnesstointernalizeandbuilduponthelessonsofVietnam.2IftheArmyMedicalDepartment(AMEDD)doesnotwanttofollowsuitandrepeathistory,theAMEDDmustinternalizeandbuilduponthelessonslearnedinIraqtoupdatedoctrine,continueitstransformation,andmodularizethemedicalforcestructurebydevelopinghighlytrainedmedicalcapabilityteams.InIraq,counterinsurgencyoperationsareplayinganessentialroleinshapingthestrategic,operational,andtacticalenvironment,andsecuringpeaceinIraq.Combathealthcareisprovingtobeanimportantweaponsysteminitsownright,andacounterinsurgencycombatmultiplieracrosstheIraqtheaterofoperations.Therefore,thecomplexityofcombathealthcareinacounterinsurgencyenvironmentdemandsanagileandcampaignqualityAMEDDwithjointexpeditionarycapability;acapacityforrapidchangeandflexibilityinhowmedicalunitsaretrained,deployed,andemployedintheater;aswellaschangesincombathealthcareclinicalworksystemsandprocesses.ThepurposeofthisarticleistoproposetheAMEDDdevelopandimplementamodular,interoperable,jointexpeditionarycombathealthcaremodel,themedicalcapabilityteam(MCT),astheclinicalmicrosystemforcombathealthcaredeliverythatpromotesthebestpatientoutcomesinacounterinsurgencyenvironment.STRUCTURINGTHEBRIGADECOMBATTEAMCONCEPTFORHEALTHCAREDELIVERYAsdescribedinArmyFieldManual1,1theArmyrestructuredfromadivision-basedtoabrigade-basedMedicalCapabilityTeam:TheClinicalMicrosystemforCombatHealthcareDeliveryinCounterinsurgencyOperationsCOLSuszClark,AN,USAMAJJonK.VanSteenvort,MS,USA ABSTRACTTodaysoperationalenvironmentinthesupportofcounterinsurgencyoperationsrequiresgreatertacticalandoperationalflexibilityanddiversemedicalcapabilities.Theskillsandorganizationsrequiredforfullspectrummedicaloperationsaredifferentfromthoseofthepast.Combathealthcaredemandsagilityandthecapacityforrapidchangeinclinicalsystemsandprocessestobettersupportthecounterinsurgencyenvironment.ThisarticleproposestheArmyMedicalDepartment(AMEDD)developandimplementthemedicalcapabilityteam(MCT)forcombathealthcaredelivery.Itdiscussesusingtheconceptofthebrigadecombatteamtodevelopmedicalcapabilityteamsastheunitofeffectivenesstotransformfrontlinecare;providesatheoreticaloverviewoftheMCTasaclinicalmicrosystem;discussesMCTleadership,training,andorganizationalsupport,andthedeploymentandemploymentoftheMCTinacounterinsur-gencyenvironment.Additionally,thisarticleproposesthattheAMEDDinitiatethedevelopmentofanAMEDDCombatTrainingCenterofExcellencetotrainandvalidatetheMCTs.ThecomplexityofcombathealthcaredemandsanagileandcampaignqualityAMEDDwithjointexpeditionarycapabilityinordertopromotethebestpatientoutcomesinacounterinsurgencyenvironment.

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58www.cs.amedd.army.mil/references_publications.aspxMedicalCapabilityTeam:TheClinicalMicrosystemforCombatHealthcareDeliveryinCounterinsurgencyOperations *TableofOrganizationandEquipment:Definesthestructureandequipmentforamilitaryorganizationorunit.PredesignatesqualifiedActiveDutyhealthprofessionalsservinginTableofDistributionandAllowanceunitstofillActiveDutyandearlydeployingandforwarddeployedunitsofForcesCommand,WesternCommand,andthemedicalcommandsoutsideoftheUnitedStatesuponmobilizationorupontheexecutionofacontingencyoperation.3forcethemodularforceinordertomeetthevisionofacampaignqualityArmywithjointexpeditionarycapability.Thismodularorganizationsimplifiesprovi-dingforcepackages(eg,brigadecombatteam)thatarestrategicallyflexible,meetoperationalrequirements,andincreasetacticalindependence.Thebrigadecom-batteamenhancesintegrationwithArmy,joint,inter-agency,andmultinationalforces.ThisorganizationaltransformationhasmadetheoperationalArmymorepowerfulandresponsive,asdemonstratedinAfghan-istanandIraq,allowingtheArmytosustaindeploy-mentofbrigadecombatteamsforover5years.Havinganenlargedforcepoolofavailablemaneuverbrigade-basedforcesenablestheArmytogenerateforcesinapredictablerotationandgiveSoldiersandunitsmoretimebetweendeployments.Further,thismodularforcestabilizationallowshigherqualitytrainingandbettersupporttocombatcommanders.1(p4-7)TheAMEDDshouldinitiateamodularorganizationaltransformationtobecomecampaignquality(oper-ationallysustaining)withjointexpeditionarycapa-bilitytobemoreagile,relevant,andflexible.ThismodularconceptcreatesalargepoolofmedicalforcepackagesthatenabletheAMEDDtomeetoperationalrequirementsacrossthefull-spectrumofoperations,fromcombattostabilityoperations.ThisenlargedforcepoolwillalsogiveAMEDDpersonnelandTO&E*unitsgreaterpredictabilityandmoredwelltimebetweendeployments.ItdemandsachangeintheAMEDDProfessionalFillerSystembyassigningthosepersonneltoaspecificMCT.Moreimportantly,thismodularAMEDDforcewillallowtheopportunityforhigherqualityindividualandteamtraining,thusprovidingbettersupporttotheoperationalforcetheWarfighter.Todaysoperationalenvironmentinthesupportofcounterinsurgencyoperationsrequiresgreatertacticalandoperationalflexibilityanddiversemedicalcapabilities.Theskillsandorganizationsrequiredforfullspectrummedicaloperationsaredifferentfromthoseofthepast.Combathealthcaredemandsagilityandthecapacityforrapidchangeinclinicalsystemsandprocessestobettersupportthecounterinsurgencyenvironment.THEMCTASTHEFRONTLINECLINICALMICROSYSTEMINCOUNTERINSURGENCYOPERATIONSTheconceptofclinicalmicrosystemsisbasedonthescienceofchaostheoryandcomplexityscience.4Bothsciencespostulatethateventhemostseeminglydisorderedsystemshavehiddenorderedprocesses;thewholeofthesystemsisgreaterthanthesumofitsprocesses,andthatcomplexsystemsareself-organizingandhighlyadaptive.Chaostheoryandcomplexitysciencerejectthenotionthatsystemsarecomposedofrepairable,replaceablepartsthatcanbeseparatedandanalyzed.5Thesetheoriesdescribesystemsasdynamic,thatis,systemswhosestateevolveswithtimeandarehighlysensitivetoinitialconditions.Behaviorappearschaotic,butthesesystemsareactuallydeterministic;futuredynamicsarefullydefinedbytheirinitialconditions,withnorandomelementsinvolved.5JamesQuinnstatesthatsystemredesignmustbeginatthesmallestreplicableunitasearlyaspossibleinthedesignprocess.6Basedonthistheory,theMCTisthesmallestreplicableunit,ortheunitofeffectiveness,designedtoalignAMEDDstrategywithclinicalcapabilityandcombathealthcaredelivery.TheMCTismodeledafterthebrigadecombatteamconceptinanefforttomodularizeforcestructureintomedicalforcepackagesthatarepatient-centeredandteam-driven.AnMCTcanbedefinedasamodular,interoperable,highly-trainedmedicaloperationalunitofeffectivenessthatistask-organizedwithspecificmedicalcapabilitiesandequippedtoperformapatient-focusedmissionunderthedirectionoftheMCTleaderincombat.TheMCTisthelocusbetweentheAMEDDvisionandcombathealthcaredelivery,servingasacatalystforchangeatthefrontlinecareinterfacethatlinkstheAMEDDscoreclinicalcompetencieswiththehealthcareneedsofSoldiers,Marines,Sailors,andAirmen.TheMCTsaresmall,interdependentgroupsofprofessionalswhoregularlyworkandtraintogetherinordertodevelopintohighlyproficientspecializedmedicalteamsthatprovidecombathealthcaretoaspecificgroupofpatients.Asaclinicalmicrosystem,MCTshaveuniqueclinicalaims,linkedprocesses,sharedinformationenvironmentsandperformanceoutcomes.MCTsareembeddedinthemacrosystem,thecombatsupporthospital(CSH)where,asatypeof

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OctoberDecember200859THEARMYMEDICALDEPARTMENTJOURNALcomplexadaptivesystem,theymustdothework,meetpatientandstaffneeds,andmaintainthemselvesasaclinicalunitofeffectiveness.Emergencetheoryadvocatesenvironmentsthatencouragepeopletoorganizethemselvesaroundcommonproblemsinordertoseekcreativesolutions.5Centraltoeverymicrosystemisthepatient.MCTsareorganizedaroundthecommonproblemsetsassociatedwithcombathealthcaredeliveryforresuscitative,surgical,andcriticalcarepatients.Theteampossessestheappropriateclinicalcompetenciestoresolvecombathealthcaredeliveryproblemsetsassociatedwiththeirspecificgroupofpatients.Forexample,theresuscitativeMCTincludes,ataminimum,anemergencymedicinephysician(AOC*62A),emergencymedicinenurse(AOC66HM5),andspeciallytrainedhealthcarespecialist(MOS68W).Themicrosystemistheplacewhereclinicalqualitymanagement,efficiency,andinnovationaremade,andstaffmoraleandpatientsatisfactionbegin.Findingtimetoimprovecarecanbedifficult,buttheonlywaytoimproveandmaintainqualityandsafetyisbyblendinganalysis,measuringandredesigningintotheregularpatternsandthedailyhabitsoffront-linecliniciansandstaff.AtthefoundationoftheMCTconceptistheimportanceofsourcingcombathealthcaredeliverythewaycliniciansprovidecareasateam.Traditionally,healthprofessionalstrainingandsocializationemphasizesindividualskills,education,andachievementthatleadstodifficulty,whendeployed,withcollaborationandthedevelopmentofteamworkcompetencies.TheAMEDDssourcingofclinicalcapabilityisunit-centric(ie,CSH)andAOC/MOS-driven,andrunscounterintuitivetowhatcliniciansbringtothefightincombat:patient-centered,team-drivencare.Thereisgrowingevidencethatthefocusonindividualskilldevelopmentandindividualaccountabilityandachievementthatresultsfromexistingmodelsofhealthprofessionaltraining,andwhichiscontinuallyreinforcedbyhumanresourcemanagementpracticeswithinhealthcaresystems,isnotconsistentwiththecompetenciesrequiredforeffectiveteamwork.7Teamworkisessentialintheprovisionofhealthcare.Thedivisionoflaboramongmedical,nursing,andmedicsmeansthatnosinglestaffmembercandeliveracompleteepisodeofhealthcare.Inhealthcare,wherepatientoutcomesaredependentoneffectiveinterdisciplinaryteamwork,thereisaneedforbetterpreparationofhealthprofessionalsinteamwork.Manystudieshaveidentifiedteamworkasarequirementforhighquality,safecare.7TheMCTistheunitofeffectivenessthatprovidesaninnovativemeanstoperfectcombatmedicinebyaligningAMEDDstrategiesofhowwedelivercarewiththeAMEDDimperativesofquality,safe,world-classcarebyproducingpatternsofcriticalresults,suchaspatientandriskoutcomes.KEYSUCCESSFACTORTOTHEMCT:THEMCTLEADERTheJointCommissionsseriesofarticles,MicrosystemsinHealthCareidentifies9successcharacteristicsofhigh-performingmicrosystems.8ThesecharacteristicsparalleledthosedescribedinthestudybytheInstituteofMedicine9withthedifferencebeingleadershipemergedasakeysuccessfactoratthemicrosystemlevelandresonatedthroughouttheothereightcharacteristics.4InastudybyLeggat7whichexaminedcriticalteam-workcompetenciesforhealthservicemanagers,thenumberoneindividualcharacteristicforateamthatmostcontributedtothesuccessoftheteamandeffectiveteamworkwasleadership.Thetermleaderisawordthatarisesfromtherootwordslaithoorlaithanmeaningway,journey,ortotravel.Thus,MCTleadershipislesswhoapersonisorwhattheydoasaleader,butmoreofhowtheyinfluencetheteamsjourneyastheteamadaptstoenvironmentsofcare.10Theleaderprovidesconstancyofpurposetocreateateamenvironmentthatcentersonthepatient,promotesteamautonomyandaccountability,embracesprocessimprovement,andharnessesdataandtechnologytodevelopperformancepatternsandoutcomes.Thefollowingparagraphsdiscussthetop3MCTleader-shipimperativeswebelievearecrucialforhigh-per-forming,qualityteams.KNOWLEDGEMANAGEMENTWeickobservedthatsystemscannotbeimproveduntiltheperformanceofthefactorspreventingfailurearenoticed.11Leadersmustnoticeandmakesenseofthesefactors.Aftermakingsenseofwhatsbeennoticed,leadersmusttakeaction.MCTleadersmustbeknowledgeableonthedifferentmanagementandprocessmanagementmodelsforsuccessinchaoticand *AreaofConcentrationMilitaryOccupationalSpecialty

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60www.cs.amedd.army.mil/references_publications.aspxcomplexsystemswithinamacrosystem(eg,CSH)wherenonlinearproblemsandprocessesexist.Sincetraditionalstatisticaltoolsaregenerallyinsufficienttocapturetherichnessofinformationinhealthcaresys-temsinfusedbythecomplexitythathumansintroduceintoasystem,MCTleadersmustbeabletocreatecontextforstatisticaldataforusebytheMCT.Forex-ample,flowchartsthatuseboxestocapturethedynamicsofaprocessdonotclearlyarticulatetheim-portanceoftherelationshipsamongtheboxeswhereintracaregapscanoccur;forexample,duringpatientcarehandoffsbetweenMCTs(eg,resuscitativeMCTtoasurgicalMCT)orduringmedicalevacuation(MEDEVAC)transportsbetweendifferentechelonsofcare.LeadersshouldbeawareofnewmanagementtheoriessuchasclockwareandswarmwarewhichoffertheMCTleaderanintellectualdiagramforoutlininggeneralgoalsandboundariesforteamimprovement.5Clockwaredefinesthoseboundariesdelineatedbytactics,techniques,andprocedures(TTPs)towhichateammustadhereforstandards-basedcare.Forexample,bloodadministrationisanexampleofclockwareinthatitrequiresadherencetoregulationsandpoliciesenforcingsafepatientcaretopreventerrors.Traditionalclinicalqualitymanagementbenchmarksworkwelltomeasurethistypeofprocess.LeadersuseswarmwaretheorywhencreativityandinnovationarerequiredtoproducesolutionsoutsidetheboundariesofTTPs.Forexample,enablinganMCTtoredesigntheMEDEVACpatienttransferprocessforefficiencyandsafetytopreventpatientdelayswouldusetraditionalmetricstoevaluatetheprocess(eg,turnaroundtime),butrealizesomevariablesthatimpactpatientoutcomesduringthatprocessmightnotbesoeasilyquantified.Whenusedtogethertoproducebothtightandlooseparameters,clockwareandswarmwaretheoriesencourageagile,adaptiveteamresponsestoavarietyofscenarios.CREATINGSYNERGYLeaderscanstronglyinfluencethewayworkgetsdoneinanMCTmicrosystembyunderstandingprocessmanagementandusingspecificprocessestomakethingshappen.Complexitysciencedelineatesstrangeattractorsinnaturesuchasthephenomenaofeddiesinriversthatcausenewflowpatterns.5MCTleadersinherentlyarestrangeattractorswhocreateboundariesorrestraintsfromwhichpatternsinsystemsevolve.Inordertodoso,theMCTleaderspossesscharacteristicssuchasanabilitytofacilitateacommonteamlanguagetoavoidconfusionandpromoteteameffectiveness.Overtimetheycreateshareddefinitions.Forexample,eachteammembershouldunderstandwhatconstitutes,fortheteam,asuccessfulpatientoutcomeasdelineatedbypalliativeversusaggressivetreatmentofapatient.12Leadersleverageteamcommunicationvenuesasaninventionplatformwherethevoltageofnewideascreatesteamsynergyforprocessredesignandimprovement.Leadersareabletostructurethesharedinformationthenconnectittoplansforaction.Therefore,MCTleadersmustbeadeptatfacilitatingreciprocalrelationshipsbetweenothermicrosystemsandlinkingtheMCTtothemacrosysteminordertomitigateintracaregapsamongdifferentmicrosystems.Theymustfacilitatecollaborationandacommonvocabularywithothermicrosystemstomanageoverlappingsharedprocesses,suchaspatientadmissionsanddischarges,ormanagementofsuppliesandequipmentusedbytheteam.CENTERINGTheMCTleadermustbeavirtuosoinmindfulwatchfulness,anabilitytoconstantlyandactivelyattendtoandfocustheteamonthepatientastheteamscenter-of-gravity.Leadersmustbeabletoorchestrateateaminterdisciplinaryapproachthatprovidescaresynchronicityforgoodpatientoutcomesandmitigatesacompetingfocusondisciplinary-centeredcare(ie,physician,nursing).Leadersidentifyandhelptheteamaddressotherstrangeattractors,suchasteammembercharacteristics,technology,environment,andprocessdesignthateitheraccelerateordeceleratetheteamsabilitytoprovidepatient-focusedcare.MCTleadersuseteamstressorconflictinaforgedbyfiremethodtoachieveteamcongruenceandcatalyzechange.Theymakeindividualandteamvaluesactionableandaccountable.Finally,effectivequalityleadersrecognizethecomplexitythathumansintroduceintosystems.Leaderscreateateamculturethatpromotesflexibilityofrolesandunderstandingandrespectingeachothersroleswithrespecttoprofessionalscopesandstandardsofpractice.10Eachteammembershouldfeeltheyareamemberofaneliteteamandhaveconfidenceineachotherscompetence.Leadersmustcreatevenues,overMedicalCapabilityTeam:TheClinicalMicrosystemforCombatHealthcareDeliveryinCounterinsurgencyOperations

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OctoberDecember200861THEARMYMEDICALDEPARTMENTJOURNALtime,toallowtheteamtoreflectonwhatisworkingandwhatisnotinordertocreatechangeandpatientcareimprovements.BUILDINGANMCT:TRAINING,MANNINGANDORGANIZATIONALSUPPORTAlthoughmicrosystemsworkatthemicrointerfaceoffrontlinecare,theycanproduceresultsatthemacro-organizationallevel.Asmicrosystems,theMCTsprovidemoreagilityandresponsivenesstoadaptationandcanmorequicklyprovidelessonslearnedatthemicrolevelfrontlineofcare.Thelessonslearnedatthemicrolevel,aggregatedatthemacrosystemlevel,iden-tifyorganizationalbestpracticesandprovidecoherencethroughoutthemacrosystemasalearningorganization.TheMCTsrequireorganizationalsup-portfromamacrosystem(eg,CSH)intheformofresourcestoenhanceandlegitimizetheworkofthemicrosystem.4ParticularlyimportantistheneedforongoingteamtrainingfortheMCTs.TeamtrainingmustberesourcedappropriatelytoensuretheMCTsdevelopteamworksystemsandworkprocessesovertimeinsupportofpatient-centeredcare.Currentpredeploymenttrainingandvalidationexercises(eg,missionreadinessexercise)conductedforechelon-above-division(EAD)medicalunitsareonlyatthemacrolevelanddonotaddressthemicrosystemlevel.Therefore,theAMEDDshouldinitiatethedevelop-mentofanAMEDDCombatTrainingCenterofExcellencethatfocusesonthetrainingandvalidationoftheseMCTs.TheCenterwouldensurethattheindividualsandtheteamarehighlyproficientintheirspecialty,arereadytoaccomplishtheirmissionpriortodeployment,andwillintegratewellintotheirlargerunit.Asdescribed,theMCTistheunitofeffectivenessdesignedtoalignAMEDDstrategyandcoreclinicalcompetencieswithcapabilityandcombathealthcaredelivery.TheMCTispatient-centeredandteam-driven,andthereforeshouldbetrainedandvalidatedbyanAMEDDCombatTrainingCentertoensurethattheyaretrainedonteamworkcompetenciesacrossthematuretheatercontinuum.TheproperlytrainedandpreparedMCTwillthendeployasahighlyproficient,specializedmedicalteamthatprovidesqualitycombathealthcare.TheseMCTsarethebuildingblocksthatformtheCSH.ThequalityoftheCSHcanbenobetterthanthecareproducedbytheMCTsthatdeliverpatient-centeredcombathealthcare.Moreover,thereisaproblemwithcurrentsourcingofmedicalunitsanddegradationofcriticalmedicalteamcapabilityandcapacityintheareasoftreatment,trauma,behavioralhealthandcriticalcare.Inparticular,thecurrentmanningandqualificationofmedicalunitsinArmyRegulation220-113doesnotaccuratelyidentifythecriticalmedicalmanningandqualificationsrequiredforEADmedicalforces.Therefore,TaskForce62MedicalBrigadeinIraqhasrecommendedanupdatetoArmyRegulation220-1totheUSArmyMedicalCommandtotrackcriticalmedicalteamsandqualificationcriteriatoensurethedeploymentofhighlytrainedmedicalteams.Tothisend,theAMEDDshoulddevelopandimplementtheMCTprocessinordertoensurethatunitsaretrainedandvalidatedpriortodeploymentintotheater.THEMCT:DEPLOYINGINACOUNTERINSURGENCYENVIRONMENTThematurationofthecombattheaterinIraqhasprovidedoptimalconditionsforthemedicaltaskforcetomakemajorimprovementsinhealthsystem-widequalityandmanagementpracticesinthecounterinsurgencyenvironment.Themedicaltaskforcehastakenadvantageofthisuniquetimeinhistorytoplaceaconcertedfocusoninstitutionalizingourcombathealthcaresupportsystem.ThemedicaltaskforceisimplementinganinitiativeusingtheCSHmodifiedtableoforganizationandequipmentasasourcingplatformtodevelopMCTsaspartofadeploymentmanningdocumenttosupportlevelII+andlevelIIIoperationalrequirementsacrosstheIraqtheaterofoperations.ThemedicaltaskforceisfocusingonthecapabilitiesrequiredandassigningspecificmedicalareasofconcentrationtorespectiveMCTstreatment,ancillary,surgical,criticalcare,specialtycare,andresuscitativebasedonthefunctionalareainordertooptimizestaffingforfull-spectrumoperations(normalstatetomasscasualtyevents).TomaketheAMEDDmoreagile,relevant,andflexible,asmallermodularorganizationaltransformationisneededtobettersupporttheMCTconceptandidentifyadditionalspecialtypersonnelskillidentifiersinordertofacilitatetask-organizingpersonneltorespectiveMCTs.Asaresult,theAMEDDcanoptimizeclinicalcapabilitywhiledecreasingtheclinicalcapacityrequired.Additionally,theMCTsshouldrotateasaunitteamratherthanhavingonlyaportionrotateintocombattheaterfor180days,whenothersservefor12to15months.

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62www.cs.amedd.army.mil/references_publications.aspxCONCLUSIONTheconditionoftheArmytodaycanonlybeunderstoodwhenoneconsiderswherewehavebeenandwherewearegoingThechangesintheworldhavemadeusrealizethattoultimatelybesuccessfulintheGlobalWaronTerror,wemusttransformourcapabilities.1(p4-1)FrancisJ.HarveyTodaysoperationalenvironmentinsupportingcounterinsurgencyoperationsrequiresgreatertacticalandoperationalflexibilityanddiversemedicalcapabilities.Theskillsandorganizationsrequiredforfullspectrummedicaloperationsaredifferentfromthoseofthepast.Combathealthcaredemandsagilityandthecapacityforrapidchangeinclinicalsystemsandprocesses.ThisdiscussionproposesthattheAMEDDbuilduponthelessonslearnedinIraqtomodularizethemedicalforcestructureanddevelophighlytrained,medicalcapabilityteamstobemoreagile,relevant,andflexible.TheAMEDDmustdevelopthecapacityforrapidchangeandflexibilityinhowmedicalunitsareled,trained,andemployedintheater.Teamworkisanessentialcomponentofthecombathealthcaredeliverysystem.ThisarticlesubmitsthattheAMEDDdevelopandimplementmedicalcapabilityteamsasthefrontlineclinicalmicrosystemforcaredeliveryandinitiatethedevelopmentofanAMEDDCombatTrainingCenterofExcellencetotrainandvalidatetheMCTs.Moreover,thecomplexityofcombathealthcaredemandsaresponsiveandcampaignquality(operationallysustaining)AMEDDwithjointexpeditionarycapability.TheMCT,atthefrontlineofhealthcaredelivery,canprovidetheagilityandresponsivenessnecessaryforpatient-centered,team-drivencarethatpromotesthebestpatientoutcomesinacounterinsurgencyenvironment.REFERENCES 1.FieldManual1:TheArmy.Washington,DC:USDeptoftheArmy;14June2005.2.NaglJA,PetraeusDH,AmosJF.TheUSArmy-MarineCorpsCounterinsurgencyFieldManual.Chicago,IL:UniversityofChicagoPress;2007:xii.3.MedicalCorpsProfessionalDevelopmentGuide.FortSamHouston,TX:USArmyMedicalDepartmentCenterandSchool;March2002:27.4.NelsonEC,etal.Microsystemsinhealthcare:part1.Learningfromhigh-performingfrontlineclinicalunits.JtCommJQualPatientSaf.2002;28:472-493.5.BensonH.JHQ168Chaosandcomplexity:applicationsforhealthcarequalityandpatientsafety.JHealthcQual.2005;27(5):4-10.6.QuinnJB.IntelligentEnterprise.NewYork:Simon&SchusterAdultPublishingGroup;1992.Citedby:KosnikLK,EspinosaJA.Microsystemsinhealthcare:part7.Themicrosystemasaplatformformergingstrategicplanningandoperations.JtCommJQualPatientSaf.2003;29:452-459.7.LeggatSG.Effectivehealthcareteamsrequireeffect-tiveteammembers:definingteamworkcompe-tencies.BMCHealthServRes.2007;7(17):1-10.8.TheJointCommissionpublisheda9partseriesofarticlesunderthetitleMicrosystemsinHealthCareinthepublicationJointCommissionJournalonQualityandSafety,whichappearedasfollows:2002Volume28Part1(Sep):2003Volume29Part2(Jan);Part3(Apr);Part4(May);Part5(Jun);Part6(Aug);Part7(Sep);Part8(Oct);Part9(Nov).9.CommitteeontheQualityofHealthcareinAmerica,InstituteofMedicine.CrossingtheQualityChasm.Washington,DC:NationalAcademyPress;2001.10.BataldenPB,NelsonEC,MohrJJ,GodfreyMM,HuberTP,KosnikL,AshlingK.Microsystemsinhealthcare:part5.Howleadersareleading.JtCommJQualPatientSaf.2003;29:297-308.11.WieckKE.Thereductionofmedicalerrorsthroughmindfulinterdependence.In:RosenthalMM,SutcliffeKM,eds.MedicalError:WhatDoWeKnow?WhatDoWeDo?.NewYork:JohnWileyandsons;2002:177-199.12.GardebringS.AReportbytheAcademicHealthCenterTaskForceonInterdisciplinaryHealthTeamDevelopment.MinneapolisMN:UniversityofMinnesota;1996.Availableat:http://www.ahc.umn.edu/tf/ihtd.13.ArmyRegulation220-1:UnitStatusReporting.Washington,DC:USDeptoftheArmy;December19,2006.AUTHORS Atthetimethisarticlewaswritten,COLClarkwasDeputyCommander,Nursing,andChief,ClinicalOperations,TaskForce62MedicalBrigade,Baghdad,Iraq.Atthetimethisarticlewaswritten,MAJVanSteenvortwastheFuturePlansOfficer(S5),TaskForce62MedicalBrigade,Baghdad,Iraq.MedicalCapabilityTeam:TheClinicalMicrosystemforCombatHealthcareDeliveryinCounterinsurgencyOperations

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OctoberDecember200863THEDEPLOYEDELECTRONICMEDICALRECORDOneoftheprincipalreasonsAmericasarmedforcesaresuccessfulinwarfareistheconfidenceeveryservicememberhasinthemilitaryhealthcaresystem.Soldiers,Marines,Sailors,andAirmenknowtheyhavethebestmedicalsystemavailableiftheyareinjured.Thisknowledgetranslatesasacombatmultiplieronmorethantheimmediatebattlefield;italsoaffectsrecruiting,retention,andFamilysupport.Witha97.5%survivalrateforallcasualtiesarrivingatourdeployedcombatsupporthospitals(CSH),themilitaryhealthcaresystemisprovidingthehighestsurvivalrateofanywarinhistory.Thisremarkablestatisticreflectshighlyonthequalityofourmedicalprofessionals:combatmedics,doctors,nurses,therapists,andthesupportingspecialistsandtechnicians.Inadditiontorecordlevelsofqualitycare,theDepartmentofDefense(DoD)medicalsystemalsohasthemostrobustelectronicmedicaldocumentationsystemevercreatedformilitaryapplications.EnsuringthatqualitydocumentationiscreatedandmaintainedisincumbentoneveryleaderintheArmyMedicalDepartment(AMEDD)andtheothercomponentsofthemilitaryhealthcaresystem(MHS).ThepurposeofthisarticleistoreviewthecurrentstateofelectronicmedicaldocumentationandoutlinesomeofthechallengesexperiencedintheIraqtheaterofoperations.Thediscussionconsistsof2elements:first,anevaluationofthedevelopmentofhealthinformationsystems(HIS)andasurveyofhowthestagewassetfortheexistingsituation;next,asynopsisofthecurrentHISchallengesandthesignificanceoftheselimitations.DEVELOPMENTOFHEALTHINFORMATIONSYSTEMSDuringtheGulfWarin1991,electronicmedicaldocumentationdidnotexist.Follow-oncareforVeteranswasdependentontheaccuracyandmaintenanceofpaperrecords.Oftentimes,medicaldocumentationatthepointofinjuryandinitialcarecouldnotbeobtainedorre-created.TheproblemswithdocumentationcontinuityandavailabilityresultedinDoDinitiativesintheresearchofelectronicmedicaldocumentationthroughoutthe1990s.OperationIraqiFreedom(OIF)providedtheopportunitytoimplementthefirstdeployedelectronicmedicalrecord(EMR).TheDefenseHealthInformationManagementSystem(DHIMS)developedsoftwareandprogramsfortheindividualservices.TheArmysimplementationoftheDHIMStoolsetiscalledMedicalCommunicationforCombatCasualtyCare(MC4).Deployedmedicalleadershipfacesnumerouschallengesandresponsibilitiesacrossthebattlespace,withthemostimportantbeingtheprovisionofcareanditssubsequentelectronicdocumentation.Thecontinuityofthiscaremustbecompletefromthepointofinjurythroughlong-termcarewiththeDepartmentofVeteransAffairs(VA).Theimportanceofinitialdocumentationcannotbeoverstated.IncompleteTheDeployedElectronicMedicalRecordMAJLeslieE.Smith,MS,USA ABSTRACTThisarticlereviewsthecurrentstateoftheelectronicmedicalrecordinthedeployedenvironment,withadiscussionofchallengesfacedinthecourseofmissionexecution.Focusdiscussionincludescurrentsystemarchitecture,systemintegration,interoperability,networking,andsecurityconcerns.TheDepartmentofDefenseelectronicmedicaldocumentationsystemdoesfunction,andrecordscarefromthepointofinjurythroughenduringcarewithintheVeteransHealthAdministration.However,thereisahighcostindollarsandman-hours,whichshouldbeaggressivelyaddressedandimproved. NOTE:TheOctober-December2006issueoftheArmyMedicalDepartmentJournalcontainsaspecialsectionof6articlesaddressingelectronicmedicalrecordswithintheDepartmentofDefenseingeneral,andArmymedicineinparticular.ThosearticlesarecomplementarytotheinformationpresentedbyMAJSmithinthisarticle.ThatissueoftheAMEDDJournalisavailableonlineathttp://www.cs.amedd.army.mil/dasqadownload.aspx?policyid=160.TheEditors

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64www.cs.amedd.army.mil/references_publications.aspxdocumentationthatonlybecomesdetaileduponacasualtysarrivalatMHShospitalsisakintowritingabookandskippingthefirstseveralchapters.SomeofthemostchallengingandcomplexinjuriesseenduringOIFaretheresultofblasttrauma.Therehavebeenhundredsofamputeesandcasesofmildtraumaticbraininjury.ProviderscaringfortheseinjuriesnotonlyneedtoknowthefirstfewchaptersofpreviouscaredeliveredtotheseSoldiers,theyalsoneedtoknowthemostdetailedstorythatcanbewritten.Imagineyourselfastherecipientofthiscare:howimportantwoulditbeforyoutoknowyourproviderismakingdecisionsbaseduponthedetailsthatwereelectronicallydocumentedatyourpointofinjury?Fromatop-downview,thecurrentstateofourelectronicmedicalrecordsystemcanbedescribedasseparate,stove-pipedsystemsandapplicationsacrossthespectrumofcare.Manyofthesesystemsaresmallandstandalone,whileafewarelargerbutstilllimitedintheirscopeandrange.Someofthesystemsinterfacewitheachotherandothersarecompletelydisconnected.ThelargesystemsincludeDHIMS,ArmedForcesHealthLongitudinalTechnologyAppli-cation(AHLTA1),andtheVeteransHealthInformationSystemsandTechnologyArchitecture(VistA),whilethesmalleronesareindependentinitiativesthatarefocusedonacertainspecialtyofcare.Workingwithandsupportinganonhomogeneouselec-tronicmedicalrecordsystemcanbeconfusing;however,byreflectingontherecenthistoryofinformationtechnology,thecurrentsituationisbetterunderstood.Thetrendinfluencingthecurrentstateistheincredibleratewithwhichinformationtechnologyhasimprovedincapability,aswellasitsrapidperme-ationthroughoutcultureandbusinessprocesses.Fifteenyearsago,desktopcomputersinworkareasandinhomesweretheexception,Microsoftwasjuststartingtoworkinnetworkingtechnology,andtheinternetwasinfrequentlyaccessedbytheaveragemilitaryprofessional.Duringthistime,theDoDbeganthedevelopmentofanelectronicmedicaldocumen-tationsolutionfordeployedforces.ThecurrentstateofourEMRisaproductoftheseeffortsandlimits.WhilesignificantprogresshasbeenmadeintheDoDEMR,thereisstillmuchroomforimprovement.Yinglingassertedthefollowing:Toprepareforcesforwar,thegeneralmustvisualizetheconditionsoffuturecombat.Toraisemilitaryforcesproperly,thegeneralmustvisualizethequalityandquantityofforcesneededinthenextwar.Toarmandequipmilitaryforcesproperly,thegeneralmustvisualizethematerielrequirementsoffutureengagements.Totrainmilitaryforcesproperly,thegeneralmustvisualizethehumandemandsonfuturebattlefields,andreplicatethoseconditionsinpeacetimeexercises.2ThesameprinciplesleadersapplytosuccessinwarfarecanbeappliedtoasuccessfulEMRvisualizationoffutureconditions,qualityandquantityofforces,requiredmaterial,andanassessmentofhumandemands.ThechallengestotheEMRhavebeenrootedinthesimultaneousdevelopmentofmultiplesystemsthatwerenotcentrallymanagedandcoordinated.Themultiplesystemsarearesultofseparateinitiativesstartedearlyintheinformationtechnologydevelopmentcurve,witheachhavingaseparatescopeandgoal.Thegarrison/peacetimeAHLTAfocusesonfixedfacilitycaretoDoDhealthcarebeneficiaries.TheVAsVistAhasmanymerits,butwasdesignedandisusedbyadepartmentoutsideofDoD,andthemultipletoolsdevelopedbyDHIMSaredesignedforuseinadeployedtheater.LargerHIStools,alongwithmanysmaller,independentHIStools,mustbeinte-gratedintoasingleportfolioofinteroperablesystemsthatgenerateahighquality,longitudinalEMR.Whilemanyinitiativeshavedemonstratedsuccessfromtheirrespectivevantagepoints,astrategicreviewofthedirection,capability,andcostoftheDoDEMRisneeded.CURRENTHEALTHINFORMATIONSYSTEMCHALLENGESWithinthemedicaltaskforce,providersusemultiplesystemsandexperiencefirsthandthechallengesassociatedwithimplementingelectronicdocumentation.Thisexperienceisuniquebecausethedocumentationofcarestartsonlyfromthepositionofthedeployedforce.Further,thedeployedforcehealthcaredocumentationmustfullynavigatetheentiremyriadofautomatedsystems,allthewaybacktotheClinicalDataRepository.TheDeployedElectronicMedicalRecord

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OctoberDecember200865THEARMYMEDICALDEPARTMENTJOURNALThechallengesofsuccessfullydocumentingcareintheEMRstartwithprovidertrainingandpreparationtoelectronicallydocumentpatientencounters.TheprincipalinterfacesusedareDHIMStools:AHLTA-Theater(AHLTA-T)usedtodocumentoutpatientcare,andtheTheaterMedicalInformationProgramCompositeHealthCareSystemCache(TC2),usedtodocumentinpatientcare.MC4fieldsthesesystemstotheArmywithtrainingavailableintheUnitedStatesthroughoneof3regionaloffices.Despitetherequirementtoelectronicallydocumentcare,trainingisnotmandatoryfordeployment,ratheritisonlyrecommended.Furthermore,noproficiencystandardexistsforusers.OneoftheprimarycomplaintsbydeployingprovidersistheirunfamiliaritywithMC4;theyfeelthatthepredeploymenttrainingtheyreceivedhasbeeninadequateinmanyareas.Toaddressthis,theAMEDDCenterandSchoolhasrecentlytakenresponsibilityfordevelopingMC4sustainmenttraining,toincludedefiningtasks,conditions,andstandards.ThemillionsofdollarsspentontheseparateEMRprogramsandtheexpectationforcontinuedexpendi-turesdemandconscientiousleaderstostrategicallyreviewthecurrentstateandengineeraplanforthefuture.Thecurrentplanisengineeredaroundtech-nologysolutionsanchoredinthepastthatarenoteasilyadaptabletoemergingrequirements.Forex-ample,theMC4distributedserverdesignhasaseparateAHLTA-TserveratallclinicsandCSHs.Additionally,thereareseparateinpatientTC2serversatalllevelIIICSHs.Theseseparateserversareeffectivelyisolatedislandsofcaredocumentation.Thisdistributedserverdesignpresentsmanychallenges.Themostsignificantismaintenanceandsecurity.Ahighlevelofdaily,weekly,andquarterlymaintenanceisrequiredoneachserverandapproximately1,000MC4laptops.ThemaintenancesupportplanforMC4computersreliesonnon-MOS*specificunitleveladministratorsassignedbythemedicalunit.ThisisusuallyaSoldierwithastrongcomputerbackground.TheunitleveladministratorsreceivetrainingandareexpectedtoperformessentialbackupsanddailymaintenancerequiredforsuccessfulEMRtransmission.GiventheapproximatelyonethousandMC4computersacrosstheIraqtheaterofoperation(ITO),thereareathousandpointsofpotentialfailure.Withinthedivisions,thesecondtierofsupportfallsuponthebattalionS6(communicationsandinformationtechnology)sectionsthatarenotpartoftheAMEDDandhavelittleornohealthcaremanagementknowledge.ThetoplevelofsupportforMC4isacontractorsupportstructuredistributedthroughouttheITO.TheseMC4contractorsworkdiligentlytomaintainacomplexsystemthathasmanytechnicalflaws.AnadditionalchallengeofthedistributedserverdesignisthatthespeedoftechnologyadvancesoutpacethespeedofDHIMSandMC4upgrades.Strictinformationassurance(IA)requirementsdemandsecurestrategicnetworks.SincethedeploymentofMC4in2003,theoperatingsystemhasbeenoutofdateandhasconsequentlybecomeaninformationassurancerisk.DeployedwithMicrosoftNTastheoperatingsystemin2003whenWindows2000wasthestandard,thecurrentversionofMC4includestheWindows2000operatingsystem,whileWindowsXPisthestandard.ThenextreleaseofMC4willhavetheXPoperatingsystem,howeverthequestionremainsastowhetherthisreleasewilloccurbeforethenextversionofWindowsbecomesthenewstandard.Thepointisthatinformationtechnologydevelopmentisadynamicenvironment,compoundedbythepitfallsandchallengesofIAsecurityrequirements.OurEMRplatformmustbeabletoadapttothefluidIAlandscape.Changingthedistributedserverdesignmodelcaneliminateorsignificantlyminimizethemaintenanceandsecurityrequirements.Aweb-basedinterfaceconnectingtoaremoteserverisaprovenmodelthatisnotonlysecure,butisalsoindependentofdeployedserverandclienthardwarerequirements.Web-basedinterfacestoremoteserversprovidemanyfunctionsacrossnumerousotherdisciplinesand,insomecases,aresuccessfullyusedaspartoftheDoDsolution.ExamplesincludetheTheaterMedicalDataStore(TMDS),andCorporateDentalApplication.Web-basedapplicationsarenotonlyanindustrystandard,butcomplywithIArequirementsanddonotrequiretheheavymaintenancecostindollarsandman-hoursthatispartofthecurrentdistributedserverdesign.Thecomparisonofthedistributedserversolutionandtheproposedweb-basedorthinclientsolutionfurthermakesthecaseforastrategicreviewofhowtoproceedforfutureHISdesignanddevelopment.However,challengesexist,suchasthetheaternetwork *MilitaryOccupationalSpecialty

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66www.cs.amedd.army.mil/references_publications.aspxinfrastructureavailableintheaterisnotalwaysrobustenoughtosupportextensivewebtraffic.Also,jointrequirementscallforanHISthatcanfunctiononshipswithextremelylimitedbandwidth.Thenextgenerationofhealthinformationsystemsshouldhaveacombinationofbothstandalonecapabilityandweb-basedflexibility.Additionally,thefuturesolutionmustrequireminimumusermaintenanceaswellashavetheabilitytokeepupwithchangingsecuritystandards.Thedevelopmentofsuchasolutionisachallengingendeavor,butonethatmustbepursued.SolutionsincludeamorerobustAHLTA-Mobiledevicecoupledwiththecontinueduseofverysmallapertureterminalsystems,andthepossibilityofthinclientsconnectedoveralocalareanetwork.PerhapsthemostsignificantchallengeinassessingtheviabilityofthetheaterEMRhasbeenthemeasurementofreliability.BetweenSeptemberandDecember2007,TaskForce62performed18auditsof1,284AHLTA-TencountersacrosstheITO.ThegoaloftheauditswastotestthereliabilityofAHLTA-TencountersreachingandbeingaccessibleinTMDS.Thestudyrevealeda93%reliabilityrateforafirsttimereferencetoTMDSforencounterresults.MostmissingencounterswererecoverablewithinDHIMS,ultimatelyshowingareliabilityrateof99%forsubsequentencounterreferences.Asof27July2008,4encountersremainmissing.Thereareseveralpotentialcausesofthisproblem.Lackofregularmaintenance(daily,weekly,monthlyoneachMC4computer)couldhavecontributedtosomeoftheseerrors.Anotherpotentialcauseofthe4remainingmissingencounters(andtheoneproposedbytheDHIMSandMC4technicalexperts)isthatanMC4configurationalteredtoadheretoIAsecurityrequirementscancauseencounterstobelost.Thesemodificationsincludeupdatingtheantivirusprogram,installingcommonaccesscardsoftware,andupdatingtheMicrosoftOfficeapplicationsoftware.AnotherpotentialcausefortheseerrorsistheinstabilityofAHLTA-TsoftwarethathasbeendescribedbyDHIMStechniciansasnotfaulttolerant.AfuturereleaseofAHLTA-Twillincludeanexpeditionaryframeworkdesignthatisexpectedtobemorefaulttolerantandeliminatemostofthesetransmissionerrors.OneoftheprincipalcomplaintsfromprovidersacrossnumerousdeploymentshasbeentheinterfacechallengesofTC2.Theconsensusisthatthearchaictextinterfaceisnotconducivetodocumentingcare.AgraphicaluserinterfaceiscurrentlyunderdevelopmentwithinDHIMSthatwillprovideafamiliarWindowsinteractiveenvironment.Thisupgrade,scheduledforreleaseincalendaryear2008,shouldfacilitatesomeeasingofelectronicmedicaldocumentationprocedures.Effortstoimproveandexpandtheinteroperabilityofthenumeroushealthinformationsystemsmustcontinue.TherecentmergeofthejointpatienttrackingapplicationandTMDSisagoodstep.AsDHIMScontinuestodevelopsolutions,focusshouldbeonasinglelogin.Manyofthedifferenthealthinformationsystemsaddressanichemedicalneed,andarenotstrategicallyintegratedintheportfolio.Underthecurrentdesign,atypicalproviderseekingtoproperlydelivercaremustlogontomultiplesystems,andsometimesmultiplecomputers.Eachoftheserequiresaseparateaccountloginandaseparateactiontoactivatetheapplication.Therearesometie-ins.However,theconstantisthatfulldeliveryofcare,andsubsequentdocumentation,iscomplicated;notintuitive,userfriendly,norconvenient;andindesperateneedoffurtherintegration.Abyproductofthesediscontinuoussystemsisthechallengeofprovidingdataqueriesforcommanddecisionsupport,whichresultsingreatfrustrationamongtheleadersofmilitaryhealthcare.Ingeneral,thesesystemsofferlimitedquerytools.Further,withtheseparationinherentinthecurrentdesign,theabilitytominedataacrosssystemsisproblematicatbest,andinsomescenariosimpossible.Inadditiontothemyriadofseparatesystems,CSHstaffersfindthetoolsandfunctionalityoftenlackingandinsufficientfortheirneeds.Thisresultsinworkaroundsolutions,suchasthedevelopmentofMicrosoftAccessDatabasesandExcelspreadsheetsthatareusedtotrackpertinentpatientdata.TheimpactisthatdatagatheredlocallyarenotcompletelycapturedintheEMR,andarenotreal-time.TherearecopiesoftheseworkflowdatatoolsinDHIMS,andthereareplanstoincorporatethemintofuturereleasesofDHIMSproducts.Theendresultofthedisparatemedicalsystemsusedtodocumentcare,combinedwiththelessthan100%TheDeployedElectronicMedicalRecord

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OctoberDecember200867THEARMYMEDICALDEPARTMENTJOURNALreliabilityofAHLTA-T,isanenvelopecontainingpapercopiesofaSoldiersmedicalrecordthatissentwiththeSoldierwhenheorsheisevacuatedfromtheater.PaperrecordsmovingwiththepatientisanindicationofhowmuchworkremainsintheimprovementofourEMR.SeparateHISsolutionsexistasaresultofthelackofoverarchingcorporatedirectionandencompassingguidancedrivingallhealthinformationsystems.Thesesolutionsaregoodideasthatdoservealegitimatemedicalneed,however,withoutpropercoordination,prioritization,governance,andintegrationwithalargerHISstrategicplan,navigatingthesesystemscausesfrustrationaswellasman-hourandmonetaryexpenseinefficiencies.The62ndMedicalBrigadeChiefofClinicalOperations,COLSuszClark,saiditbestasshedescribedourEMR,Thewaywedocumentcareisnotthewaywedelivercare.Understandinghowcareisdeliveredintheatermustbethedrivingforcebehindthedevelopmentofhealthinformationsystems.TheDHIMSorganization,responsibleforthedevelopmentofdeployedsystems,hasbeenveryresponsivetofeedbackandinputfromthe62ndMedicalBrigade,andhastakenstepstoimprovetheimmediateproductaswellasimplementchangesthatwillaffectfuturereleases.THEROADAHEADThecomplexityofDoDhealthinformationsystemsisextensive.TheonlywaytheAMEDDcansuccessfullyaddresstheseconcernsistocommunicatethroughdirecthumaninteractionandinvolvement.Thetheaterneedscanonlybefullyassessedfromtheperspectiveofthedeployedforcethefunctionalusers.TheleadershipofDHIMSandMC4shouldremainintheaterassessingtheapplicationoftheirtoolswhileinteractingwiththeSoldierswhousethesesystems.Asimportantasthelogicaldataconnectionsaretotheuseofthesetools,soarethehumanconnectionsthatmusttakeplacefortopdecisionmakerstofullycommunicatewiththeforwarddeployedproviders.Theabovediscussionpointsoutthechallengeswithhealthinformationsystemsthathealthcarepersonnelexperienceinthecourseofmissionexecutionin-theatertheultimatetestfortheutilityofanHIS.Therearetimesduringanoperationwhenitisappropriatetopullback,regroup,andevaluatethepotentialforanewplan.TheleadershipofDoDandAMEDDshouldassessourcurrentHISsolutionsfromtheperspectiveofthedeployedforce.Thecurrentdesignisneithercosteffectivenormanpowerefficient.Furthermore,itdoesnotfullysatisfythecurrentdocumentationrequirements.Justasgeneralsmustvisualizetheconditionsforfuturecombat,sotoomusttheevolvingtechnologylandscapebevisualizedandadaptivechangesmade.TheultimategoalofmilitaryhealthcaresystemdocumentationmustbeatopqualityelectronicmedicalrecordthatfacilitatescareoftheSoldierfromthepointofinjurythroughenduringcarewithintheVeteransHealthAdministration.REFERENCES 1.MoodyR,FreemanD.Thenewnameofthemilitaryelectronicmedicalrecord.ArmyMedDeptJ.October-December2006:40-41.2.YinglingP.Afailureofgeneralship.ArmedForcesJ.May2007.Availableat:http://www.armedforcesjournal.com/2007/05/2635198.AUTHOR WhenthisarticlewaswrittenMAJSmithwastheHealthInformationSystemsOfficer,62ndMedicalBrigade(TaskForce62),Baghdad,Iraq.

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68www.cs.amedd.army.mil/references_publications.aspxUSArmymedicalunitshavesupportedOperationIraqiFreedom(OIF)formorethan5years.USforceshavetransitionedfromconductingfullspectrumopera-tionstoprimarilycounterinsurgencyoperations.Asthesituationimprovedwithregardtostablepositioning,security,andtheimprovementofinfrastructurewithinourbases,therewas,unfortunately,littlestandardi-zationofthevariousaspectsofhealth-caresupport,includingmedicalequipment,beyondthatwhichtheindividualunitshadimplemented.1Eachnewlyarrivedunitessentiallyreinventedtheapproachtoexecutingthemissionthattheirpredecessorhadfollowedduringtheirtour.Withmaturationofthetheaterofoperations,theenvironmentbecamemoreconducivetoeffortstostandardizebothequipmentandsupplies.TheTaskForce62MedicalBrigadeHeadquartershadgreatsuccessinstandardizationeffortsandmadesubstantialprogressinthedevelopmentofastandardizedequipmentguideline.Thekeystosuccessinthisendeavorincludecommandemphasisandacombinedeffortbetweentheclinicalleadershipandlogisticiansworkingsynergisticallytoachievethesameendstate:standardizationofmedicalmateriel.CounterinsurgencyoperationsintheIraqtheaterdemonstratedthelethalityanddestructivenessoftheimprovisedexplosivedevices,explosivelyformedprojectiles,andindirectfire.Theresultingcasualtiesstimulatedthereengineeringoftacticalcombatcasualtycare.OIFrepresentsthefirstprotracted,large-scale,armedconflictsincetheadventofciviliantraumasystems.CollaborativeeffortsamongthejointmilitaryforcesoftheUnitedStatesinitiateddevelopmentofatheatertraumasysteminMay2004.TheimplementationofatheatertraumasystemdemonstratednumerousopportunitiestoimprovetheoutcomeofSoldierswoundedonthebattlefield.AsoftheendofJuly2008,therehadbeen30,490servicememberswoundedinaction.2ThecovenantoftheIraqtheatermedicaltaskforceistoprovidethehighestlevelandqualityofhealthcaretopatientsthattransitthecontinuumofcareinIraq.Thekeytothisistoensurethatthetheaterhastherightclinician,attherightplace,withtherightequipmenttopreservelifeandpreventsuffering.MedicalunitsdeployedinsupportoftheinitialphaseofOIFwithstandardizedMTO&E*medicalassemblages.Theassemblagesincludestandardizedunitsets,includingnonexpendable,durable,andexpendablemedicalsuppliesandequipment.Themedicalassemblagesweredesignedtoprovidetreatmentprimarilytoservicemembersingenerallygoodhealthconductingoffensiveordefensiveoperations.Thebaselineservicemedicalassemblagesandequipmentitemsarenotideallysuitedtooptimallysupportthebulkofthecurrentpatientcaseloadwithintheater.Withtheincreasinglystablesecuritysituation,operationsinIraqgraduallychangedtomostlystabilityoperations,withthefocusbeingoncounterinsurgencyoperations.Unitsprovidingmedicaltreatmentandhospitalizationdevelopednewequipmentrequirementsastheirmissionschanged.TherequirementtotreatcontractorsandIraqis,frominfantstotheelderly,droveequipmentneedsbeyondwhatstandardmedicalassemblagescouldprovide.Unitsorderedwhattheyrequiredtosupporttheirhealthcaremission,buttherewasnotaskforcelevelefforttostandardizeequipmentrequirementsacrossthemedicaltaskforce.Individualandpiecemealserviceandunitreplacementefforts,whilebringingneededandenhancedmedicalcarecapabilities,broughtsomenewmedicalequipmentitemsintothetheaterwithincompleteorpartiallogisticalsupporttails.Thisresultedinequipmentbeingnonmissioncapableforsignificantperiodsoftimeduetolackofmaintenanceandequipmentrepairparts.BasedontheTaskForce62MedicalBrigadeCommandersguidanceuponassumingthemedicalMedicalEquipmentStandardizationinaMaturingCombatTheaterLTCBruceSyvinski,MS,USACPTJasonHughes,MS,USA *ModifiedTableofOrganizationandEquipment:Definesthestructureandequipmentforamilitaryorganizationorunit,adaptedtothespecialcircumstancesofthatunit.

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OctoberDecember200869taskforcemission,theTaskForceDeputyCommanderforClinicalServices(DCCS)andtheS4(logistics)sectiondevelopedaplantoimplementamonthlytaskforcemedicalequipmentvalidationandstandard-izationboard(MEVSB)involvingboththeDCCSandmedicallogisticspersonnelofourdirectreportingunits.ArmyRegulation40-61statesmaterielstandardizationcansupportclinicaleffortsforutilizationmanagementanddevelopmentofoutcome-basedpathwaysandprotocols.3Establishmentoftheboardwouldimproveotheraspectsofhealthcarestandardizationwithinthetaskforce.TheMEVSBservesasamedicalequipmentstandardizationtoolforthemedicaltaskforcecommander.Asthenameimplies,theboardbothvalidatestheunitsrequirementandestablishesastandardizedmaterielsolution(ie,manufacturer,model).Theboardisguidedbythefollowingprinciples:Equipmentshouldsupportacapabilitywhichisappropriatetothemissionandroleintheater.Equipmentshouldrepresentaclearadvantagetothepatientand/ortheunitswesupport.Equipmentshouldbesustainablewithintheaterwithoutcreatingoverwhelmingsupportproblems.Equipmentshouldbeprocuredtobeusablebysubsequentrotations,nottosupportaone-timespecialskill.Equipmentshouldbestandardizedwithintheatertotheextentpossible.Taskforcesubordinateunitssubmitaletterofjusti-fication(LOJ),tojustifyanequipmentrequirementto(1)replaceunserviceable/uneconomicallyrepairableequipment,(2)replacelostequipment,or(3)replaceanexistingshortage.Theconditioncode,whichisusedtoidentifythedegreeofserviceability,condition,andcompletenessintermsofreadinessforissueanduse,mustbeverifiedbytheunitbiomedicalmaintenanceofficer.ThatdocumentationbecomespartoftheLOJprocess.Uponreceiptoftheletterofjustification,thetaskforceheadquartersstaffstherequestwiththeclinicaloperations,operations(S3),andlogistics(S4)sections.Thestaffingisfocusedonseveralconsiderations,including:clinicaljustification,currentlyusedequipment(ifapplicable),maintainability,sustainability,requiredtraining,andstandardization.Detailoneachoftheconsiderationsisshowninthegraphic(right).RequestsforequipmentnotpreviouslyapprovedbytheMEVSBwillbepreparedforpresentationatthenextscheduledboard.Minutesarerecordedforeachoftheboardproceedings.Onceequipmentrequestshavebeenvalidated,therequestingunitisprovidedwithawrittendocumentauthorizingthemtoordertheequipmentthroughtheirsupportingclassVIIIsupplysupportactivity.Todate,65typesofequipmenthavebeenstandardizedwithinthetaskforce.TheUSCentralCommand(CENTCOM)Surgeonfurtherimprovedstandardizationeffortswiththerecentvisitofanassessmentreviewteamofclinicalequipmentsubjectmatterexperts.TheArmyutilizesateamknownasthetechnologyassessmentandrequirementsanalysisteam.Inkeepingwiththisconcept,theCENTCOMSurgeonrequestedajointtechnologyassessmentforthepurposeofestablishingastandardizedtheatermedicalequipmentformulary.TheJointMedicalTechnologyAssessmentReviewTeam(JMTART)wascommissionedbyCENTCOMtoapplycommonlyacceptedpracticesthateachservicemedicallogisticsagencyusestosupporttheirUSbasedmedicaltreatmentfacilitiesinupgradingmedicaltechnology.TheJMTARTprovidedavaluableexternalperspectivetoassistthetheaterwithmedicalequipmentstandardization.TheJMTARTvisitedall9levelIIImedicaltreatmentfacilitiesintheCENTCOMareaofresponsibilityinJuneandJuly2008,andpresentedtheirrecommen-dationsinAugust2008.TaskForce62standardizationefforts,inconjunctionwiththoseoftheJMTART,havevalidatedmodernequipmentthatissupportableandwillbothreapfinancialsavingsandstreamlinefuturemedicaltaskforcestandardizationefforts.Standardizationandfollow-onlifecyclemanagementmustcontinueintheMedicalEquipmentRequestConsiderationsJustificationWhyisthisparticularequipmentrequired? OnHandwithintheTaskForce Isthisequipmentalreadyintheater?MaintainabilityWhoisqualifiedorwillmaintaintheequipment? Sustainability Howwilltheequipmentbesustained(repairparts)?TrainingRequiredWhatleveloftrainingisrequiredtooptimallyusetheequipment? Standardized Isthereastandardfortheequipment?

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70www.cs.amedd.army.mil/references_publications.aspxtheatertosustaintheUSstandardhealthcarethatourservicemembersandDoDciviliansdeserve.Futuremedicaltaskforceheadquartersmustemploymedicalequipmentstandardizationeffortsearlyintheirdeploymentasameanstobothmanagethequalityofhealthcaredelivered,andstayontherelevantandcapableedgeofthetechnologycurve.Commanders,clinicians,andseniorleadersshouldunderstandthetoolstheyhaveavailabletoensuremedicalequipmentlife-cyclemanagementandstandardizationtomaintainthefleetofstate-of-the-artmedicalequipmentinamaturingcombattheaterofoperations.REFERENCES 1.SyvinskiB,ElliottJ.Combatcasualtycareonthetechnologycurve:medicalequipmentstandardizationinamaturingcombattheater.MilMedTechnol.2008;5:34-37.Availableat:http://www.mmt-kmi.com/article.cfm?DocID=2499.2.OfficeoftheSecretaryofDefenseStatisticalInformationAnalysisDivisionpage.DoDPersonnelandProcurementStatisticsWebsite.Militarycasualtyinformation..Availableat:http://siadapp.dmdc.osd.mil/personnel/CASUALTY/castop.htm.AccessedAugust17,2008.3.ArmyRegulation40-61:MedicalLogisticsPolicies.Washington,DC:USDeptoftheArmy;January28,2005:12.AUTHORS Atthetimethisarticlewaswritten,LTCSyvinskiwastheTaskForce62MedicalBrigadeLogisticsOfficer(S4),Baghdad,Iraq.Atthetimethisarticlewaswritten,CPTHugheswastheTaskForce62MedicalBrigadeDeputyLogisticsOfficer(S4),Baghdad,Iraq.MedicalEquipmentStandardizationinaMaturingCombatTheater

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OctoberDecember200871Weallapproachthesubjectofethicsdifferently.Foreveryindividualthereisaninterpretationofwhatisrightandwhatiswrong;weallcomefromdifferentbackgroundsanddifferentbeliefsystems.However,inorderforanorganization,anyorganization,tobesuccessful,itmustrelyonasetofcorevaluesandbeliefsthatareadoptedcorporatelyandsharedindividually.ThisisparticularlytrueintheUnitedStatesArmytheArmyrequirespredictability.AsjuniorSoldiersandleaders,wearetaughtearlytheimportanceofbeingintherightplace,attherighttime,intherightuniform.TheknowledgethatthoseservingtoourleftandrightareknownquantitiesisanessentialkeytoourArmysoperations,inpeaceandinwar.Thispredictabilityextendstoourethicsandvalues;knowingyourpeersshareandembracethesameethicalstandardiscrucialtothemaintenanceofgoodorderanddisciplinewithintheArmy,theArmyMedicalDepartment,anddeployedunits.TheCommander,TaskForce62MedicalBrigade(TF62MED),identifiedarequirementforatrainingmodeltoaddressethicallapseswithinthetaskforce.Thepurposeofthismodelwastoexplain,inplainlanguage,someofthecommonethicalfailuresthatsubjectedSoldierstodisciplinaryactionundertheUniformCodeofMilitaryJustice,*includingperhapsevenprison,andalwaysputatriskcareers,marriages,freedom,andsometimesevenlives.AsshowninFigure1,thetaskforceexperiencedahighlevel,relativetounitstrength,ofofficerandseniornoncom-missionedofficermisconduct.Incidentsofadultery,inappropriaterelationships,andtheuseofalcoholandpornographyinviolationofGeneralOrderNumber1werefrequent.InasingleTF62MEDunit,everyofficerwasrelieved.Theactsofmisconductandtheresultingpunishmentswererankindifferent.TF62MEDinitiatedUCMJactionagainstSoldiersofeveryrank,fromcoloneltoprivate.Thequestionbecame:Why?Thetaskforcecommanderdirectedanexaminationofthemisconductoccurringacrossthetaskforce.HebelievedthatunderstandingthereasoningandmethodologybehindethicalfailuresandmisconductcouldleadtoatrainingmodulewhichwouldexplaintoeverySoldiercurrentlyin,orentering,TF62MEDhowtoavoidcommonmistakes.CertainpredictablebehaviorleadstocertainpredictableresultsexaminingtheUCMJcasefilesofthosewhohadalreadyfailedcouldprovideinsightintohowtomitigatefutureactsofindisciplineacrossthetaskforce.AppliedEthicsinaCombatTheaterofOperationsMAJFrederickC.Jackson,MS,USA Figure1.TF62MEDUCMJlegalactionspertainingtoallegedseniorenlisted(E8,E9)andofficermisconductduringdeployment(August2007throughJuly2008). GeneralOfficerArticle15Proceedings(n=8)Investigations(n=48)GeneralOfficerMemorandaofReprimand(n=23) *TheUniformCodeofMilitaryJustice(UCMJ),afederallaw,1isthejudicialcodewhichpertainstomembersoftheUnitedStatesmilitary.UndertheUCMJ,militarypersonnelcanbecharged,tried,andconvictedofarangeofcrimes,includingbothcommon-lawcrimes(eg,arson)andmilitary-specificcrimes(eg,desertion).USArmy5thCorpsGeneralOrderNumber1(03/19/2003).

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72www.cs.amedd.army.mil/references_publications.aspxAnethicalvaluesystemiscrucialtohelpingArmyMedicalDepartmentpersonnelavoidsomeoftheethicallandminestheywillencounterwhiledeployedinsupportofOperationIraqiFreedom.Actsofindisciplineusuallyresultinpunitiveaction,buttheyalsohavethesecondaryeffectofinvaluabletimelosttomissionperformance,asinvestigatingofficersarepulledfromoperationalduties,unitsfacethedisruptionsofinvestigationsunderArmyRegulation15-6,2andgoodorderanddiscipline,trust,andcamaraderiearedamaged.Theeffectsofundisciplinedactsarewideranging.Thechain-teaching*module,AppliedEthicalFrame-work,apartofTF62MEDsoverallcombathealthsupportsystem,themodelofwhichisshownasFigure2,wastheresultoftheCommandersdesiretoaddressactsofindisciplineacrossthetaskforce.Theappliedethicalframeworkcovers7ethicaltrainingmodules,andincludesseveralcasestudiesofactualfailuresonthepartofSoldiersandleaders.Wedesignedtheappliedethicalframeworktrainingapproachfromtheperspectivethat:theteachingwouldbeaccessibletoallranks;itwouldtakelessthan50minutestodeliver;itwouldbevisuallyinteresting;andtheoveralltoneofthebriefwastoaidincriticalthinking,butnotscoldtheSoldiers.The7modulesoftheAppliedEthicalFrameworktrainingpackagewerecoreethics,thepatient-centrictaskforcemodule,financialstewardship,ambas-sadorship,personalcourageandintegrity,behaviorinaccordancewithArmyRegulation600-20,3sexualharassment,andinappropriaterelationships.TheremainderofthisarticledescribestheAppliedEthicalFrameworktrainingpackageanditspurposeinprovidingassistancetoSoldiersinbuilding,maintaining,andremainingwithinasoundandprovenethicalframework.THECOREETHICSMODULETheethicalframeworkisabasicenablerofsuccessfortheTF62MEDcombathealthcaresupportsystem.Itisvital,thereforethaneachindividualsvaluessupportactionswhichmaintainthatethicalframework.TF62MEDbasesitsethicalframeworkontheideaofFamily,leadership,ambassadorshipandgrowth(F.L.A.G.)(seeFigure3),whichrepresenttheArmyvaluesinaction.PartoftheTF62MEDCommanderscontinuousoperationalfocuswastheinculcationofF.L.A.G.acrossthetaskforcefootprint.IftheArmyvaluesandF.L.A.G.eachdescribewhatweshoulddo,thenthecoremodulemustaddresssomereasonswhywevaryfromsoundethicalpracticesandcommitactsofindiscipline.Thefocusoftheappliedethicalframeworkwastoreach2typesofSoldiers:1.Soldierswhojustdonotknowtheregulationsandpolicies.WewantedtheseSoldierstoknowthattheArmyhasaregulationforeverything;findasupervisororleaderandask.2.Soldierswhojustdonotunderstandtheletterorthespiritoftheregulation.Again,wewantedthemtoknowtoaskaleader;alternatively,theycouldaskanequalopportunityorinspectorgeneralrepresentativesomeonewillhavetheanswertothequestion.Unfortunately,wealsoidentifiedthethirdtypeofSoldier:theSoldierwhowillnotcomply.ThiswasthesmartSoldier;theSoldierforwhomArmyregulationsandcommandpoliciesdidnotapply.Weoftenencounteredthisindividual.ThecasefilesoftheMulti-NationalCorps-IraqJudgeAdvocateGeneralarefilledwiththestoriesofthoseSoldierswhowouldnotcomply.WhattheseSoldiersfailtounderstandisthattheArmyhasbeeninIraqforawhile;everytypeofmisconducthasbeenseen,recognized,andsubjectedtotheUniformCodeofMilitaryJustice.Whatwewereabletopullfromthecasefileswerethespecificpatternsofbehaviorthatresultedinactsofindiscipline.Justabouteveryinvestigation,Article15proceeding,orcourts-martialcenteredononeof3things:power,money,and/orsex.WeareSoldiers,butwearealso *Chain-teachisamethodofunittraininginwhichdesignatedunitmembersfirstreceivethetraining,afterwhichitistheirresponsibilitytotrainanotherlevelofpersonnel,whointurnwillcontinuetrainingothers.Thetrainingcontinuesinapyramidfashionuntilallpersonnelrequiringsuchtraininghavereceivedit.Nonjudicialpunishment(NJP)referstocertainlimitedpunishmentswhichcanbeawardedforminordisciplinaryoffensesbyacommandingofficerorofficerinchargetomembersofhis/hercommand.Article15oftheUniformCodeofMilitaryJustice,andPartVoftheManualforCourts-Martial,4constitutethebasiclawconcerningNJPprocedures.ThelegalprotectionaffordedanindividualsubjecttoNJPproceedingsismorecompletethanisthecasefornonpunitivemeasures,but,bydesign,islessextensivethanforcourts-martial.AppliedEthicsinaCombatTheaterofOperations

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OctoberDecember200873THEARMYMEDICALDEPARTMENTJOURNAL human.Bynotmaintainingtheappropriateboundaries,wesubjectourselvestothetemptationsofpower,money,and/orsex.UndertheUCMJ,wecannotbepunishedfortemptation,however,succumbingtotemptation,committingtheactofindiscipline,ispunishableundertheUCMJ.Weneededamethodologyofidentifyingandmitigatingimprovisedethicaldecision-making.TheTF62MEDCommanderinsistedthateverydecisionmadebyhissubordinatecommanderswouldbeabletowithstandinspectorgeneralinquiry,equalopportunityquestioning,andcongressionalandcivilianauthorityoversight.Inshort,heinsistedontransparencyasthekeytoorganizationalintegrity.Withtransparencyinmind,welaidoutthestepsto E N D S W A Y S M E A N S O u t c o m e s D e l i v e r y S y s t e m s A p p l i c a t i o n s E n a b l e r s & P r o g r a m s Resources Force&HumanResourceManagement FiscalStewardship MedicalIM/ITMHSAcquisition,Research/Development,Infrastructure CustomerandStakeholderPerspective OptimizeReturntoDuty&ConserveCombatPower MaximizeWellPresentforDuty&ReduceDNBI ImprovedHealthStatus,PublicConfidence,IncreasedCapabilityandCapacity WarriorHealthcareSystem ForceHealthProtectionSystems MedicalCivil-MilitaryOperations Hospitalization,Surgery,Diagnostic&SpecialtyCare PreventiveMedicineSystems DetaineeHealthcareSystem Primary&DentalCareSystems VeterinaryCareSystems Pro-MEET,CooperativeMedicalEngagements Trauma&ChronicCareCPGs MentalHealthCareandBuildingResiliency FacilitateImprovedAccesstoIraqiHealthServices MedicalRegulationandClinicalIntegration FacilitateTimelyIraqiPatientTransfers/DischargesfromUStoIraqiFacilities InternalProcessesandSystems LearningandGrowth ClinicalQualityManagement ElectronicClinicalDocumentation DevelopAdaptiveLeaders ContinuingEducation&Training OrganizationalAssessment ComprehensiveRiskManagement Logistics&MaintenanceManagement HealthFacilitiesPlanning&Management MoralCompass,EthicalSystemFramework AgileJoint/MultinationalC2Structure&Methods Efficiency,Effectiveness,OutcomeMeasurement&AccountabilitySystemsAmbassadorshipFamilyLeadershipGrowth ProtecttheHealthofUS&CoalitionForcesEnhanceGOICredibilitybySupportingSelf-reliantIraqiPublicHealthSystemsProvideWorld-ClassWarriorHealthcaretoUS&CoalitionForces Figure2.TheTaskForce62MedicalBrigademodelfordevelopmentandexecutionoftheCombatHealthcareSupportSystem.Themodelwasconceivedanddesignedtooptimizehealthcaresupportinthematurecombattheaterwhileoperatinginacounterinsurgencyenvironment.

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74www.cs.amedd.army.mil/references_publications.aspxachieveethicalfailurepointsfollowingthesimplemantra,itiswhatitis.Ethicalviolationsbeginatthetopofaslipperyslope.ApatternofbehaviorandthoughtleadstoconclusionsnotinlinewithArmyregulationsandpolicies.Wefoundthatanindividualstartsactingbasedonthinking(assuming)orfeeling.Theseindividualswerenotwellgroundedinthestandards,regulations,andpoliciesthatgovernourorganization.Instead,theyoperatedongutfeelings.Next,wesawatendencytosituationalizeethics;wesawstatementssuchasweareatwarorweareinIraq.TheindividualsconvincedthemselvesthatArmystandardsofbehaviornolongerappliedoutsideofthecontinentalUnitedStates(CONUS)garrisonenvironment,when,infact,thoseveryArmystandardsofbehaviorweredesignedtohelpusmaintaindisciplineincombatandundercombatconditions.Self-justificationwasanotherfrequentlyobservedbehavior.Soldiersconvincedthemselves,usuallyininstancesofinappropriaterelationships,thatsomehowitwasOK.Overandover,incaseaftercase,thesetypebehaviorsappeared:thinkingorfeeling,situationalizedethics,andselfjustification.Wesawtheseasthestepsleadingtothetriggeringofimprovisedethicaldecision-making.TheteachingofappliedethicalframeworkstressedtoSoldierstheimportanceofsettinglimitsasrepresentedinFigure4,ofconductinganhonestself-assessmentandestablishingstrongboundariestoguidethemselves.Byremainingwithinastrongethicalframework,SoldierswouldbeabletoavoidthoseactionswhichviolatedArmyregulationsandpolicies.Westressedtheroleofperceptionsasavitalcomponentofthestrongethicalframework.Asindividuals,wecannotcontrolpeerorgroupperceptions.However,ouractionsplayanimportantroleinshapinggroupandpeerperceptions.Byhavingastrongethicalframework,onewhichdidnotedgeupagainstorshortcutArmyregulationsandpolicies,weensurethatourpeershavethecorrectperceptionsofouractions.TheappliedethicalframeworkaddressedtheroleofhonestAppliedEthicsinaCombatTheaterofOperations ArmyRegulationsandPoliciesArmyRegulationsandPoliciesFigure4.IllustrationofthelimitsofArmyregulationsandpolicieswhichformtheboundariesoftheSoldiersethicalframework,preventingincidentsofmisconduct,orper-ceptionsthereof. Figure3.Reproductionofthein-theaterposterdisplayingthetenetsoftheF.L.A.G.institutionalphilosophydevelopedbytheTF62MedicalBrigadeasthefoundationforthecombathealthcaresupportsystem. IwillneverleaveafallencomradeWenotonlyfightfortheConstitutionandourDemocracy,Wefightforeachother.Familiestakecareofeachotherandtreatoneanotherwithdignityandrespect.YouenlistSoldiers,Sailors,Airmen,andMarines,butreenlistFamilies.IwillneveracceptdefeatNooneismoreprofessionalthanI.Leadfromthefrontwithpersonalandorganizationalintegrity.LeadershipisaTEAMsport-counsel,coach,andmentor.IwillalwaysplacethemissionfirstDuty,Honor,Country!Yourcharactermusthonorournation,yourservice,unitandFamily.Ethicalconductandmedicaldiplomacyareforcemultipliers.IwillneverquitKnowyourjob,doyourbest,anddevelopyourabilitiestotheutmost.Alwaysseektoimproveyourphysicalandspiritualfitness.Wearealearningorganizationandmustmaintainaperpetualquestforknowledge.SOHELPMEGOD! Family,Leadership,Ambassadorship,andGrowth Yourlifeisnotimportantexceptfor theimpactithasonanotherlifeJackieRobinson

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OctoberDecember200875THEARMYMEDICALDEPARTMENTJOURNALidentificationofpersonallimitations,selfknowledge,establishingblocksagainsttemptation,andcommitmenttoastrongethicalframeworkaskeytoavoidingimprovisedethicaldecision-making.Finally,Soldiersaretaughtownershipaspartofthecoremodule;ownershipofArmyvaluesandownershipofpersonalresponsibility.TheTF62MEDCommanderoftenstatedthatweareentitledtoourownopinions,butnotourownsetoffacts.UltimatelyasSoldiers,ArmyregulationsandtheUniformCodeofMilitaryJusticedetermineswhatisrightandwhatiswrong.Wemustensurethatourbehavior,actualandperceived,isabovereproach.APATIENT-CENTRICTASKFORCEMODULEThemedicaltaskforceinthetheatreofoperationsisapatient-centricorganization.Butwhatdoesthatmean?Itmeansthepatientmilitary,civilian,anddetaineeisthesolereasonwearethere.Ourcorebusinessistomeetthemedicalneedsofourpatientsonthebattlefield.Assuch,eachmemberofthemedicaltaskforcewasassignedtheindividualresponsibilitytoactaspatientadvocates;theappliedethicalframeworktaughtthatwedemonstratepatientadvocacyinanumberofways.Westartwithpatientprivacy.SoldiersweretaughttoaskhowmuchdoIreallyneedtorevealaboutapatient.Oneofthegreatestbarrierstocareistheperceptionthatsometreatmentsorproceduresareembarrassing.Mentalhealthandtheneedtomaintainaresilientforceisonesuchcategoryofcarewestrivetodestigmatize.Intheirtrainingasmedicalprofessionals,Soldiersweretaughtthattheyaretheguardiansofpatientprivacy,andthatpatientprivacyisnotonlyaright,itisalaw.Westressthatcommandershavealimitedrighttoknow,especiallywhenanissuemayimpacttheoverallhealthoftheircommands,butthatSoldiersneedtobevigilant,and,whenerring,toerronthesideofpatientrights.Next,Soldiersaretaughttoviewpatientsascustomersnotrobots.Soldiersaretaughttoalwaysaimtobethebest;thatwemeasuredourcareagainstevidence-basedstandardsandbesthealthcarepracticesascodifiedbytactics,techniques,andproceduresinCONUS-basedmedicaltreatmentfacilities.Theappliedethicalframeworkdefinedthisasthequalityofcarewedeliver.TheTF62MEDCommandercommittedthetaskforcetobuildingacombathealthcaresupportsystemwhichwouldvalidateourstatedmissionofprovidingworldclasshealthcare.Keytoworldclasshealthcarewastherecognitionofthedignityofhumanlife.Soldierslearntotreateachlifeasuniqueandprecious.Soldiersreceiveinstructionsondetaineecare.Theinstructionswerebluntandtothepoint:whendetaineesareunderourcare,thentheyarepatients,period.Themedicaltaskforcedoesnotsupport2standardsofmedicalethics;oneforourguysandoneforthoseguys.Ourmedicalethicisnotsituational,andassuch,thedeliveryofdetaineecareisnodifferentfromthecareweprovideourSoldiers,Marines,Sailors,andAirmen.FINANCIALSTEWARDSHIPMODULEThefactssurroundingfinancialimproprietyareusuallyverysimple.Mostinstancesoffinancialimproprietyinvolvesmalldollaramounts,andrepresentamisuseofgovernmentresourcesforpurposestheindividualcouldhaveeasilymetwithhisorherownmeans.Somefinancialimproprietieswereevenapprovedbysuperiors.Nonetheless,Soldiersareexpectedtousetheirownjudgmentandshouldnotrelysolelyonthejudgmentoftheirsuperiorswhenitcomestoethicalconduct.Ethicsareanindividualresponsibility.Ascustodiansofthetaxpayerdollar,Soldiersaretaughttoconservethenationsfinancialstrength.Partofthisprocessistheestablishmentofsoundfinancialcontrols,orplacingapolicingmechanismupfrontinthatprocess.IntheIraqtheaterofoperations,weutilizebulkfundingactualUScashtomeetoperationalneeds.Thisaccesstocashcouldrepresentatemptation,butitisatemptationSoldiersavoidbyactivelyseekingtobekeptaccountable.WeteachSoldiersthatournationspendssome$80billionayearprosecutingtheGlobalWaronTerror.AlargepartofthatmoneyendsupinIraq.Partofconservingthefinancialstrengthrequiresaskingsimplequestions:Doesthispurchasefurthermydeployedmission?CanIdeferthispurchase?Isthereacheaperoption?OurnationwillspendwhatittakestowintheGlobalWaronTerror,butitshouldnotbeforcedtopayforourpersonaldesires.Theresourceswehavearenotinfinite,noraretheyforpersonaluse.

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76www.cs.amedd.army.mil/references_publications.aspxAMBASSADORSHIPMODULEThismodulestressesthatallSoldierswillbehaveasambassadorsfortheirunit,theArmyMedicalDepartment,theArmy,andournation.Soldiersaretaughtthattheenemyisintelligentandanopportunist.Heunderstandsthathewillnotdefeatusconventionally,thelikelihoodofAlQaedaandasso-ciatedmilitiasrollingtanksdownthestreetsofNewYorkCityapproacheszero.Theenemyknowsthis,sohowdoesheplantodefeatus?Heseekstodefeatusstrategicallythroughinformationaloperations.Theenemylovespropagandaandspreadsitateveryopportunity.Creatingnegativepropagandaaboutourforcesdoes5thingsfortheenemy:1.Itallowshimtodestroyourinternationallegitimacy.2.Itallowshimtoerodeourdomesticsupport.3.Itallowshimtowintheheartsandmindsoflocalnationals.4.Itallowshimtocauseustodoubtourmission.5.Itallowshimtowinsupporttohisside.Theenemyspreadshispropagandathroughtechnologyandtried-and-truemethodsfromtheprintingpresstosimplewordofmouth.Everytimewecommitsomeunethicalact,wegivetheenemyastrategicwin.Eventheperceptionofimproprietyinjuresourcause.AsWinstonChurchillobserved,Aliegetshalfwayaroundtheworldbeforethetruthhasachancetogetitspantson.5Ambassadorshipisoneofourresponses.Ambassa-dorshipishowweconductourselvesandhowweperform.Ultimately,ambassadorshipisthestorywetellthroughouractions.Akeyandessentialpartofhowwedemonstrateambassadorshipisinthetreatmentofourpatientsfairlyincompliancewithacceptedmedicalstandards.Anymaltreatmentofpatientsisanunforcederrorthatgivestheenemyastrategicwin.PERSONALCOURAGEANDINTEGRITYMODULETheappliedethicalframeworkpackageteachestheimportanceofpersonalcourageandintegrity.TheintentistomakeeverySoldierastakeholderintheprocessofsoundbehavior.Soldiersareencouragedtodisplaypersonalcourageandintegritybyreportingethicallapsesandfailures,withoutfearofretribution.ThetrainingmodulestressestoSoldiersthatiftheethicalframeworkiswhatyouknowtoberight,thenpersonalcourageandintegrityiswhatyoudowiththatknowledge.Peoplewilloftenactoutagainstperceivedinjustices;providedtheydonotpersonallyhavetotakeresponsibility.Thetrainingstressesasimpleruleofthumb:Ifyoudonothavethecourageofyourconvictions,itisbecauseyoudonothaveconvictions.Personalcourageisdoingwhatisrightandcorrectingwhatiswrong,nomatterthecost.Personalcourageisnotdependentonwhoyouhangaroundwith,whatyourpositionisorwhereyouare.Personalcourageistheabilitytotakeownershipofwhatisright.PersonalcouragekeepstheArmystrong.Asanorganization,wearerespectedbecausewhatwedoisopentoinspection,always.Wedonothide.TheArmyhasmanymanagementcontrols,andSoldierswereencouragedtousethosecontrols.ARMYCOMMANDPOLICYBASEDBEHAVIORMODULEArmyRegulation600-203addressesourmostimpor-tantresource,ourpeople.Ittellsusmilitarydisciplineisfoundeduponself-discipline,respectforproperlyconstitutedauthority,andtheembracingoftheprofessionalArmyethicwithitssupportingindividualvalues.3(p21)ThatexcerptclearlyexplainstheArmysconceptforgoodorderanddiscipline.Again,theArmyhasregulationsforeverything.Commandersdonothavetomakeupourvalues,ourethics,orgoodorderanddisciplineaswegoalong.Ninetimesoutten,thelackofmilitarycourtesyfamiliarityandSoldierconductiswhatstartstheballrollingtowardsunethicalbehavior.Militaryauthoritymustbeexercisedpromptly,firmly,courteously,andfairly.ArmyRegulation600-20providesaprohibitiononrelationshipsbetweenSoldiersofdifferentranks.ThetrendintheaterforSoldiersdeviatingfromthoseprohibitionsshowsthefollowing:Compromiseorappeartocompromise,actualorperceived,involveorappeartoinvolve,actualorclearlyAppliedEthicsinaCombatTheaterofOperations

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OctoberDecember200877THEARMYMEDICALDEPARTMENTJOURNALpredictable.Perceptionsofouractions,whichareoftenheardontherumormill,arejustasimportantastheactionsthemselves.Leadersmustensurethatperceptionsandrealitieslineup.Leadersmaintaingoodorderanddisciplineinseveralways:Theyaddressallproblemswhenraised,anddosodirectlyandpromptly.TheyunderstandthatthereisnograceperiodforcompliancewithArmyregulations.Theyknowthatperceptionisasinjurioustogoodorderanddisciplineasactualacts.Theydealwithissuesbeforetheybecomeproblems.Leadershipisanactionverb,notapositionortitle.Leadersmustconstantlyacttoensuregoodorderanddisciplinearemaintainedwithintheirunits.SEXUALHARASSMENTMODULEWhenacommandrespondstocomplaintsofsexualharassment,theleadersoftenhearthatSoldiers,whethertheyarevictims,witnesses,orperpetrators,thoughttheactswereallajoke.Withsexualharassment,thecloseranindividualgetstotheline,theeasieritisforactionstobeviewedbyanimpartialobserverassexualharassment.SexualharassmentisaviolationofArmyRegulation600-20.Likemanyoftheissuesdiscussedabove,beingaperpetratorofsexualharassmentcanlandaSoldierinthedangerzoneofanimprovisedethicaldecision.WhatgetsaSoldierintotherealmofsexualharassmentisarepeatedpatternofbehaviorthattargetsthesamepersonorgroupsofpersons,againandagain.TheArmybreakssexualharassmentinto3categories.Verbalandnonverbalpatternsoftenbuildintosomesortofphysicalactofharassment.ThemaltreatmentofSoldiers(whichiswhatsexualharassmentreallyis)willneverbetolerated.Armypolicyseekstohandlecases,especiallyunintentionalcases,ofsexualharassmentatthelowestlevelpossible.Thesearetheinformalapproaches.Usingthedirect(talking),indirect(letterwriting),orthirdpartyapproach(havingapeerspeakononesbehalf)willusuallydothejob.Butifthebehaviorcontinues,orifthereisanidentifiablepattern,itshouldbereportedtothechainofcommand.Thekeyisthatthebehaviorstopsimmediately.Thereisnograceperiod.INAPPROPRIATERELATIONSHIPMODULEInappropriaterelationshipsareperhapsthemostcorrosiveformofethicalviolationswesaw.InappropriaterelationshipsbetweenSoldiersofdifferentranks,Soldierswhoweremarried,andSoldiersinpositionsofauthorityandtrustdidgravedamagetothegoodorderanddisciplineofunitswheretheserelationshipstookplace.Eachinappropriaterelationshipbasicallyfollowsthesamedepressingpattern.Theappliedethicalframeworkidentified10keyindicators,showninFigure5,thataninappropriaterelationshipwasincipientoralreadyongoing.Theseindicatorsconsistentlyrepeatedthemselves.Theywereknownpatternswithinunits,theywererevealedduringinvestigationsormentionedduringrebuttalstoArticle Figure5.The10keyindicatorsofthepotentialfor,orexistenceof,aninappropriaterelationship,asdescribedbytheTF62MEDethicalframeworktrainingpackage.EarnanArticle15ProcedureforAdultery/Fraternization!ClassicBehaviors1.Oppositegendered"workoutpartners"or"smokingbuddies"2.Constantly"hangingaround"theworkareaoftheotherperson3.Sendingorreceivingemailsandinstantmessagechatsofafamiliarorsuggestivenature4.Spendingtimealoneawayfromone'sassignedplaceofduty5.Hiding:attemptstowipecleancomputerharddrives,meeting"off-site,"unexplainedabsencesduringthedutyday6.Displayingcasualfamiliarityintheworkplaceeitherthroughverbalorbodylanguage:usingfirstornicknames,touching,backrubs,"orleaningcloselyinawaythatviolatesnormallyestablishedpersonalspace7.Havingconversationsthatareintimate(sensitive,personal,notnecessarilysexual)whichendwhenotherscomenear8.VisitingthequartersofSoldiersoftheoppositegenderalone9.Findingthatspecialpersonwhoisa"reallygoodlistenerwhounderstandswhatI'mgoingthrough"10.Itiscommonforonetouseintimacytogetsex,whiletheotherusessextogetintimacy.Thoughtherearemanyothersignsnotlistedhere,the cumulativeeffectofengaginginthesepredictivebehaviorsnormallyleadstoinappropriaterelationships.

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78www.cs.amedd.army.mil/references_publications.aspx15proceduresorrequestsforleniency.Inappropriaterelationshipsoccurredacrossallranksandgrades,buttheyallfollowedthesameinevitablepattern.Thechainofcommandshouldtrytostopindividualsfromgoingdownthispath.Thereshouldbesomeinitialcounseling.IftheSoldierunderstandsandcomplies,thenthedesiredresultisreached.Ifnot,thecommandershouldissueanocontactorder.IftheSoldierunderstandsandcomplies,thefinalstepisavoided.Mostinappropriaterelationshipsdonotcometolightuntilneartheendofthetour.TherehaveevenbeencasesofredeployingSoldiersreturnedtoBaghdad,fromKuwait,tofacedisciplinaryaction.Mostcasesofinappropriaterelationshipsarebroughttolightinthecourseofunrelatedinvestigationsorevents.Again,thisisthepattern,overandover.CONCLUSIONOurtrainingstressesthattheproblemisnottemptation.Theproblem,suchasinappropriaterelationships,comesfromsuccumbingtotemptation.Soldiersfailedwhentheyallowedpersonalwantstoovercometheiroaths,theirArmyvalues,andexternalcommitments.Wehavetemptations.Appliedethicsrequiresindentifyingthosetemptationsupfrontandmitigatingthem.Armyregulationsmakenoallowancesforpassiveethicalfailures.Thereareallkindsoftemptationsinatheaterofoperations.Noonehaseverbeenpunishedforbeingtempted.Whatispunishableissuccumbingtothattemptation.Everyonehasethicalfailurepoints.Someofthosepointsarewheretemptationovercomesourdefenses.Eachindividualneedstoconductanhonestself-assessmentandidentifyhisorherspecifictemptationsandfailurepoints.Then,establishfencesbetweenthemandthefailures.Changewhatyoudo,whereyougo,orwithwhomyouassociate.Maintainanethicalsituationalawarenessandbeontheconstantlookoutfortemptationsthatcouldendyourcareer,destroyyourhonorandfamilylife,orevenplaceyouinprison.Controlyourindividualethicalframework.Anindividualsbehavioriswhatshapestheperceptionsofunitleadershipandpeers.Ultimately,forSoldiers,ArmyregulationsandtheUniformCodeofMilitaryJusticedeterminewhatisrightandwhatiswrong.Wemustensurethatourbehavior,actualandperceived,isabovereproach.Ethicsisanactivity.Thevaluesandethicsweprofessarealsowhatwemustcontinuetopracticeandusedaily.WedothisbygroundingourselvesintheletterandspiritofArmyregulationsandpolicies.Armyregulationsaddressnotjusttheaction,butalsotheperceptionsofthoseactions.Wemustensurethatweuseastrongethicalframeworkwhichwillensureperceptionsofothersareinlinewithyouractions.Finally,althoughdeployed,ourethicsarebaseduponwhoweare,notwhereweare.SetYourEthicalBarHigh!MakeSureYouClearItEveryTime!ACKNOWLEDGEMENT IthankCOLDavidBudinger,TaskForce62DeputyCommandingOfficer,andLTCKatherineChiapulisfortheircollaborationandassistanceinthedesignandimplementationoftheAppliedEthicalFrameworktrainingmodulediscussedinthisarticle.REFERENCES 1.64Stat.109,10USC,ch47.2.ArmyRegulation15-6:PoliciesforInvestigatingOfficersandBoardsofOfficers.Washington,DC:USDeptoftheArmy;October2,2006.3.ArmyRegulation600-20:ArmyCommandPolicy.Washington,DC:USDeptoftheArmy;March18,2008.4.ManualforCourts-Martial,UnitedStates(2008Edition).Washington,DC;JointServiceCommitteeonMilitaryJustice,USDeptofDefense;February21,2008.Availableat:http://www.apd.army.mil/pdffiles/mcm.pdf.5.HumesJC,NixonRM.TheWitandWisdomofWinstonChurchill.NewYork:HarperCollinsPublishers;1995.AUTHOR Whenthisarticlewaswritten,MAJJacksonwastheCommander,HeadquartersCompany,TaskForce62MedicalBrigade,Baghdad,Iraq.AppliedEthicsinaCombatTheaterofOperations

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OctoberDecember200879INTRODUCTIONMilitaryhealthcareinadeployedenvironmentparallelsmanyofthesamecharacteristicsKeating1usedtodescribecivilianhealthcareorganizations:turbulentenvironments,constrainedresources,expensivemodernizationrequirements,andever-changingcustomerexpectations,justtonameafew.However,evenmoreoverwhelmingisthe100%to200%turnoverinpersonneleveryyearduetounitrotations;cumbersome,bureaucraticacquisitionregulations;andapoliticallychargedclimate,nottomentiontheveryrealanddangerousenvironmentthatispervasivethroughoutIraq.Medicalforcesrepre-sentedmerely4%ofthetotalforcesinOperationIraqiFreedom(OIF)in20042andthereisacutepoliticalpressuretoreducethemilitaryforcenumbersandthemedicalfootprintingeneral.IntestimonytotheHouseAppropriationsCommitteeinApril2007,ADMWilliamFallon,CommanderoftheUSCentralCommandsaidOurMILCON[militaryconstruction]programiscriticaltocontinuedcombatoperationsandposturingforcesforthefutureTheseinitiativesprovidecriticaloperational,safety,health,andqualityoflifesupporttoourservicemembersservinginOperationsIraqiFreedominIraqandEnduringFreedominAfghanistan.3TheMILCONprovidestheresourcesthatcommandersinIraqrequiredtoachievetheiroperationalprioritiesandenableconsolidationofthemilitarypresenceinIraq.3Militaryoperationsinacounterinsurgencyenvironmentpresentuniquechallengestomedicalpersonnel.Likelogisticsupport,medicalorhealthservicesupporttocounterinsurgencyoperationsisoftenaccomplishedfrombasesorforwardoperatingbasesthatproviderelativelysecurelocations.4Placementofmedicalfacilities,hospitalsinparticular,isextremelyimportantinthatgeography,timeanddistance,trooppopulationdensities,andthemedicalregulatingwithinthecombathealthsupportsystemintheIraqtheaterofoperations(ITO).Itisthisdiversityofphenomenathatcanarisethoughtheinteractionofsimplecomponentsthattendstomaketheinteractionsofhospitalsandothermedicalunitscomplex.Inotherwords,thewholeismorethanthesumoftheparts.5HealthFacilitiesPlanning:DeterminingInfrastructureRequirementsforFormandFunctionfromClinicalandOperationalCapabilitiesMAJDonChapman,MS,USALTCKristenL.Palaschak,AN,USA ABSTRACTThisarticledescribesthepracticalapplicationofdocumentingtheoperationalconceptandscopeofservicesformilitarycombathospitalsprovidingjointhealthservicesupportduringOperationIraqiFreedom.Duetotherapidchangesthattakeplaceinhealthcareingeneral,and,inparticular,inalarge,rapidlymaturingmilitarytheaterofoperations,aclearoperationalconceptandaccuratescopeofservicesisessentialforhospitalcommandersandmedicalplanners.Ahighlystructured,yetflexiblecollaborativeapproachtohealthfacilityrequirementsdevelopmentbeginswithaclinicalconceptofoperations(CONOPS).Initial,up-frontinvestmentoftimeintherequirementsprocess,andsubsequentreviewsandrevisionsresultinadefinitivedescriptionoftheclinicalandoperationalrequirements.Thoserequirementsinturnbecometheauthoritativesourceforspace,buildingsystems,equipment,functionalarrangements,andfinancialjustification.ArecentcasestudyhighlightstheutilityoftheCONOPSdocumentintranslatingthenecessaryclinicalcapabilitiesandcapacitiesintofacilityspaceandbuildingsystemsrequiredtosupporttheminaverytightscheduledrivenprocessnormallynotassociatedwiththemilitaryconstructionprogramandinparticularmedicalprojects.

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80www.cs.amedd.army.mil/references_publications.aspxAclinicalconceptofoperations(CONOPS)isatoolthatcanaidinvestigationandunderstandingofthekeycapabilities,scopeofservices,andinteractionswithinamedicaltreatmentfacility(MTF).TheCONOPSisafoundationaldocumentwhichhelpsdirectthedesigndevelopmentofahealthfacilityproject.Itisaforwardlookingdocumentarticulatingtothedesignconsultantsawordpictureofthefuturefacilityandscopeofservicestobeprovidedintheneworremodeledspace.Thenarrativeistheformattowritethestoryofhowanareaoperates.Thenarrativeshouldallowthereadertowalkthroughthenewareaandseetheoperationinaction.Itshouldcontainanddescribetheintegrationofeachofthefollowingfunctionalelements,allinsupportoftheservicesoffered:Ineffect,theCONOPShelpstosimplifythecomplexitythatsurroundsday-to-dayoperationsofahospitalorganization.Also,itprovidessubstanceandunityintheplanningbetweenmultidisciplinaryfunctionalareasthatcannotbejustassumedbythemedicalplanner,clinician,engineer,orlogistician.BACKGROUNDBasesandconstructionintheITOaregovernedbyUSCentralCommandRegulation415-1,6alsocalledTheSandBook.BaseswithintheITOarecategorizedascontingencybases,andaredefinedassitestosupportimmediatecontingencyoperationsthataretemporaryinnature.6Thereare3subcategoriesoutlinedinTheSandBook:ContingencyOperationBases(COB):Itspurposeistypicallyacommandandcontrolhuband/orregionallogisticshub;characterizedbyadvancedinfrastructureforfacilitiesandcommunicationsfortheexpecteddurationoftheoperation.ContingencyOperationSites(COS):Capableofprovidinglocalandregionaloperations,security,and/orhumanitarianassistancerelief.Thesitesizeandcapabilitiesarescalabletosupportrotationofforcesorprolongedcontingencyoperations.Characterizedbylimitedinfrastructureandmaybedependentoncontractedservices.ContingencyOperationLocations(COL):Capableofquickresponsetooperations,security,civicassistance,orhumanitarianassistancerelief.ACOLwillbedependentuponCOSorCOBforlogisticalsupport;characterizedbystarkinfrastructureprimarilydependentoncontractedservicesorfieldfacilities.Contingencybasecampsupportconstructionischaracterizedasbeingeitherinitial,temporary,orsemipermanent:Initial:Initialstandardincludesexpeditionary(unitorganicandmilitaryserviceprovidedequipmentandsystems)uptoinitialfacilitiesdesignedandconstructedonanexpedientbasisandcharacterizedasaustererequiringminimalengineereffort.Initialstandardisintendedforimmediateoperationalunitsforalimitedtime(lessthan6months)andmayrequirereplacementbymoresubstantialanddurablefacilitiessubjecttoCentralCommand(CENTCOM)approvalifexceedingtheinitialstandard.Temporary:Temporarystandardincreasesefficiencyofsustainedoperationsforuseupto24months.Temporarystandardsprovideawiderselectionofminimumfacilities,therebyincreasingtheefficiency,safety,durability,morale,andhealthstandardsofpersonnelonoperations.Semipermanent:Designedandconstructedwithfinishes,materials,andsystemsselectedformoderateenergyefficiency,maintenance,andlife-cyclecostwithalifeexpectancyofmorethan2years,butlessthan25years.Overtime,militarymedicalunitshaveforthemostpartgraduallytransitionedfromthelargesemimobiledeployablemedicalsystem(DEPMEDS)comprisedofexpandabletacticalsheltersandframetentsintobuildingsofopportunityormodulartrailerfacilities.WhiledeliberateplanningbytheMulti-NationalForce-IraqSurgeonandMedicalCommandoccurredforkeyhospitals,muchofthistransitionoccurredinanadhocbasis,witheachmedicalunitlefttofendforitself,sometimeswiththeassistanceofthebasecampmayorscell.Thegradualshiftintoslightlymoredurable,cleanable,andmaintainablefacilitieshelpedmitigatetheexposuretotheharshenvironmentalHealthFacilitiesPlanning:DeterminingInfrastructureRequirementsforFormandFunctionfromClinicalandOperationalCapabilitiesmissionpopulationservedscopeofservicesmanpowerequipmentsupplytrafficpatternsproceduralpoliciesadjacencies

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OctoberDecember200881THEARMYMEDICALDEPARTMENTJOURNALconditionsthatchallengemaintenanceefforts,shortenmedicalequipmentlifecycles,stressinfectioncontrolprogramsofanyhospitalovertheextendedlengthoftheateroperations.Additionally,infrastructurerequirementshaveincreasedduetotheintroductionofnewequipmentasoutlinedbySyvinskiandElliott,throughthecollectiveeffortsoftheMilitaryHealthSystem-Forwardanduseofstate-of-the-arttechnology,conditionsaresetforacontinualincreaseinhostilesurvivabilityasseenfrom78.3%in1991to90%in2007.2Thenewequipmentintroductionshavebeenbasedontheactualhealthcarerequirementsofthepopulationbeingsupported,andtheskillsetsoftheassignedclinicalstaff.InAugust2007,ontheheelsofthetransitionofauthorityceremonywhenTaskForce62MedicalBrigadetookoverthecommandandcontrolofallechelons-above-divisionmedicalforcesinIraq,anopportunitytoreplacethelastremainingDEPMEDShospitalpresenteditself.Afteridentifyingtheobviousneedtoreplacethedilapidateddeployablehospitalonthebase,theCOBSpeicherreceivedfundsfromacancelledmilitaryconstructionproject.However,timewasoftheessenceastheprojectwasalreadyacoupleofmonthsbehindschedulecomparedtotheotherfiscalyear2007projects.Also,therequireddocumentationwhichdescribestheproposedproject,theoperationalrequirement,thecurrentsituation,andtheimpactifnotprovidedhadnotbeencompletedatthatpoint.Thehospitallogisticsofficerandtheutilitieswarrantofficermeasuredeveryroom,tent,vestibule,andISO*expandabletacticalshelterthatcomprisedthehospitalatthattime.Theysubmittedthisastherequirementforthenewhospital.Whileintuitively,aone-for-onereplacementseemslikeanacceptablesolutiontomostpeople,thelogicandtheassumptionsuponwhichitisbasedareflawed.Byreplacinglikeinkindspacerequirements,thehospitalwouldlockintheexistinginefficiencies,functionalinadequacies,andotherdeficiencieschallenginghealthcaredeliverytoday.Thetotalspacerequirementinitiallyidentifiedjustbymeasuringinteriordimensionswasjustover30,000sqft.HoweveraftervalidatingthespacerequirementsderivedfromtheCONOPSusingDepartmentofDefensespaceplanningcriteria,thetotalspacerequiredbeforedesignalternativeswereconsideredjumpedto60,000sqft.Inadequatespacecriteriacombinedwiththefactthatinteriordimensionsrepresentnetratherthangrosssquarefeet,thespacerequirementdramaticallyunderestimatedthefullspacerequirementsby30,000sqft,withthenettogrossratioalonerepresenting20,000sqft.Throughcooperativediscussionswithafocusonreachingthegoalsoftheproject,adecisionwasproposedbytheArmyCorpsofEngineersTransAtlanticProgramCentertoincorporatetwo6,000sqftoptionsthat,ifexercised,wouldbringtheprojectuptoatotalmaximum42,000grosssqft.Theremainderoftheshortfall,ornearly18,000sqft,wouldbeaddressedbyreusingthe2existinghardstandbuildings,reusingafewspecificDEPMEDScontainers,andeliminatingortrimmingsomescopethroughadeliberateprocessthatconsidereddesignalternativesdiscussedlater.Atthe35%designreview,itwasdecidedtoplananddesignthefull42,000squarefootprojectdocumentedinthespaceprogramfordesignderivedfromtheCONOPS.ThisdecisionmakingprocesswassuccessfulbecausethebrigadehealthfacilityplannerandthehospitalleadershiphadaverygoodunderstandingoftheclinicalandotherfunctionalrequirementsduetoawelldocumentedCONOPS.TheCONOPSguidedtheentiredesignprocessandwasreferredtofrequentlywhencertaindesigndecisionswerenecessary.DRAFTINGTHECLINICALCONCEPTOFOPERATIONSThenext2dayswerespentwiththeofficerandnoncommissionedofficer-in-chargeofeachsectionwithinthehospital,conductingintensiveinterviewsanddocumentingtherelevantinformation.Thesediscussionsprovidedinsightintotheexistinghospital(system)inplaceandalreadyoperating.Thisisimportantbecausewewerenotdesigninganewhospital,butreplacinganexistingfacility.Transforming,replacing,modernizing,orrelocatinganexistingsystem(orinthiscaseafacility)isvastlydifferentthanstartingfromscratch.7Thereareexistingcontextualissuesrequiringconsideration,suchascurrentconditions,staff,equipment,policies,procedures,andwhatthedesiredendstatemissionandcapabilitiesareatprojectcompletion.Thesecontextualissuesconstrainthenumberofpotentialsolutionsavailable,butoftenthereisstillroomforsmall, *InternationalOrganizationforStandardization

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82www.cs.amedd.army.mil/references_publications.aspxincrementalimprovements,aswellaslargescalechangeswithinthescopeoftheproject.Theseopportunitiescanonlybegleanedbyfirstdocumentingwhatiscurrentlydone,andthenwhatcanandshouldbeimproved.Determiningtheoperational,clinical,quality,orcapabilityshortfallsisabsolutelynecessaryinordertoimproveoperations.Itrequiresgreattactandjudgmenttodeterminewhatgapsshouldbeaddressedbytheproject.Thefacilityisonlyoneaspectorcomponentinacomplexsystemofsystemscomprisedofpeople,technology,policies,procedures,informationtechnology,logistics,maintenance,andcommandandcontrolsystems.Caremustbetakennottolookfordeficienciesthatdonotexistorareinconsequentialinthegrandscheme.Judgmentmustbeexercisedintryingtoresolvelargerproblemswherefacilityconstraintsthoughttobetheproblemarereallyonlysymptomsratherthanthesourceofthemalady.TheclinicalCONOPSservesasanexcellenttool.Itisdesignedtoguidediscussionthroughaseriesofquestionsthatteaseoutthenecessaryinformation.Italsodocumentsotherissuesthatmaybeinvisibletohospitalleadershipandstaffduetothecomplexityoftheenvironment,allowingthoseissuestobebroughttotheirattentionlaterasnecessary.Whileformatsvary,theimportantpointtorememberabouttheCONOPSisthatitservestodocumentthevisionforthefuturefacilityandthescopeofservicestobeprovidedintheneworremodeledspace.ItshouldbenotedthattheCONOPSisnotadescriptionofthephysicalfacility.Althoughdrawingpicturesmayhelpthestaffdevelopthenarrative,apreferredfloorplanisnotpartofthedocument.Theformatisdesignedfortheclinical,administrative,andlogisticalstafftodocumenttheiroperationalrequirementsandexplainhowtheyenvisiontheoperationofthehospital.AnexampleCONOPSformatisprovidedasapotentialtemplatethatcanbemodifiedforaspecificsituation.Thetemplateisaseriesofquestionsthat,whenanswered,canbereformattedandeditedintoastandalonenarrativedescribinginfairlyspecificdetailtheintendedscopeofservices,procedures,andadjacencies,anddesiredimprovementsupontheconclusionoftheproject.COMPONENTSOFACONCEPTOFOPERATIONSMission.Restatethecurrent(unclassified)missionstatementforthemedicaltreatmentfacilityandeverysectionwithinthefacilityingeneralterms.Thisisusuallystraightforwardfortheoverallfacility,butoftenrequiressomethoughtforindividualsections.Officialmissionsoftheorganizationincludestypeofpatients,levelofcare,andanyothermissionrequirementsimpactingtheoperationorongoingdesignoftherenovatedfacility.PopulationServed.Thisidentifiestheservedpopulation,ortowhomtheMTFprovideshealthcareservices,andcanbebrokenoutbypercentagesforeachcategory.InadeployedenvironmentthereislessofafocusonwhetherthepatientisActiveDuty,Reservist,dependent,orretiree,andmoreonwhethertheyareaUSservicemember,coalitionforce,USgovernmentcivilian,localnational,contractor,detainee,orothers.Itshouldincludegenderratiosandagesoftheservedpopulation.Also,thissectionidentifiesanyprojectionsofincreasesordecreasesinthesupportedpopulationduetobaseclosures,consolidations,oropenings.ScopeofServices.Thescopeofservicessectionisprobablythesinglemostimportantpartofthedocument.Ifcarefulconsiderationanddetailarenotincludedinthissection,itisverylikelythatthefacilitywhichisdesignedandbuiltwillnotproperlysupportthefullmedicalmissionrequirements.ThissectionalsoprovidesappropriateboundariesonthescopeoftheprojecttopreventincludingcapabilitiesandrequirementsthatarenotappropriateorexceedtheresourcesoftheMTF.Thescopeofservicesstatementsshouldnotonlydiscussservicescurrentlyprovided,butalsothoseserviceswhichhavecommandendorsementandarenotcurrentlyprovided,andidentifyiftheproblemisduetoequipment,space,and/orpersonnel.Manpower.CurrentArmyMedicalDepartmentfacil-itymasterplanningreliesonmanpowerasonekeyinputvariableindeterminingtheappropriatesizeandshapeofafacility.Byaligningthefacilitytopersonnelrequirements,andaligningpositionstomissionandcapabilities,theresourcescloselyfollow.Facilityplannerswillnotprogramspaceforserviceswherestaffingdoesnotexist,orisnotforecasted.Additionalconsiderationsrequiringdiscussionincludeidentificationofborrowedmilitarymanpowerpositions,volunteers,students,research,andanyotheruniquetypesofpersonnel.OrganizationalstructureHealthFacilitiesPlanning:DeterminingInfrastructureRequirementsforFormandFunctionfromClinicalandOperationalCapabilities

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OctoberDecember200883THEARMYMEDICALDEPARTMENTJOURNALand/orproductlineaffiliationsshouldbediscussedwithinthisparagraph.Attachamanningdocumenttosupplementtheinformationprovided.EquipmentIssues.TheSpaceandEquipmentProgrammingSystemprovidesacomprehensiveroom-by-roomequipmentlistdrawnfromacurrentdatabase.Theremightbespecificequipmentrequirementstomeetpatientsneedsinthefuture.Brieflydescribethoserequirementsandanytrainingneededtousetheequipment.IftheMTFiscurrentlyincapableofprovidingafullrangeofservicesduetoalackofequipment,itshouldbedocumented.Ifadraftequipmentroomcontentlisthasbeendeveloped,referenceithere,orreferenceandincludeitasanattachment.Remember,iftheeffortisarenovationproject,frequentlytheequipmentmustbemovedandusedintheswingspace.Supply.Considerationsofchangingsupplyrequirementsnecessaryforpatientcaretreatmentandproceduresaredocumentedinthissection.Officeandadministrativesuppliesarediscussed.Thisparagraphalsooutlineschangesintypesofsuppliesbeingused(eg,disposableversusreusable)thatwillaffectstoragespaceandrestockingprocedures.Newequipmentand/ornewservicesmaysignificantlydrivelogisticalrequirementsand,inturn,resourcerequirements.Identifywho(byposition)withinthesectionisresponsibleforsupplies.TrafficPatterns.Onlyafterthepreviousparagraphshavebeenfairlywelldevelopedcanthissectionbetackledeffectively.Atthispoint,detaileddescriptionsoftrafficflowforpatients,staff,materialsandsupplies,andwastemanagementisrequired.Afteridentifyingthehightrafficareasandchoke-points,determineifanyprocessescanbemodifiedtoavoidcross-trafficand/orconstrictedareas(laboratory,radiology,check-in,pharmacywaiting,etc).Describehowwayfindingshouldbehandledineacharea(eg,signagepackage,colorschemes).Answerthesesamequestionsfortransition(swing)spaceifapplicable.Procedural.Givencurrentoperations,describewhatworkswellwithinthedepartmentandshouldbecontinued.Considerwhatisdysfunctionaltopreventthosehabitsfromcontinuinginthenewfootprint.Provideexamplesofwhatworkaroundshadtobedevelopedinorderforthestafftoaccomplishtheirjobs,andfortheMTFtofulfillitsmission.Discussdifferentwaysofperformingthecurrentoperationthatwouldimproveservicestotheprimarycustomer,thepatient.Whiletacticalstandingoperatingproceduresmaybeusefulincompletingthissection,avoidusingthemverbatim,especiallyifthoseproceduresalreadyhavebeenmodified,orwillrequiremodificationtoworkinafixedfacility.Adjacencies.Adjacenciesdescribethephysicallocationofspacestooneanother.Thereareatleast4typesofadjacenciesthatshouldbediscussedinthissection:department;functionalarea;roomtofunctionalarea;androom-to-room.First,identifywhichdepartmentsshouldbenexttoeachother(eg,radiologyandemergencycare).Nextdiscussfunctionalareasthatshouldbeadjacent(eg,immunizationtoprimarycare).Then,determinewhatroomsshouldbealignedwithfunctionalareas(eg,isolationroomnearthereceptionandwaitingspacesordentalchairstox-ray).Finally,associateroomsthathaveadjacencyrequirementssuchastoiletsnexttoultrasoundandtreatmentrooms.ComposingadetailedclinicalCONOPSforanythinglargerthanaverysmallaidstationcanbeanoverwhelmingtask.Thecollectionofinformationcantakedaysorevenweeks,andverylikelywillrequirefollow-upquestionsandclarifications.Assuch,theCONOPSshouldbeconsideredalivingdocument,requiringperiodicupdatingasmorefactsbecomeavailableandassumptionsarevalidated.Itislikelythatthescopeoftheprojectmaygrowandcontractovertimedependinguponmission,cost,schedule,andotherinfluences.Therefore,itisrecommendedthatthehospitalinitiallycompletetheCONOPSdevelopmentprocessasthoroughlyandquicklyaspossibletodocumentthepreliminarydescriptionofthefacilityprojectsgoals.Thedraftshouldthenbereviewedbybothhospitalpersonnelandthehealthfacilityplanner.ThisallowsthehealthfacilityplannertocontinuewiththeremainingplanningprocesseswhilethehospitalcompletesanotheriterationoftheCONOPSdevelopment.Eachtimethedocumentisadvanced,goalscanbereformulated,prioritiescanbedevelopedandthescopeoftheprojectadjusted.8Ifconstraintsintermsofapprovedscopeorfundingrequireeliminationofspace,thenalternativestrategiescanbedevelopedtoaddressthoseitemsasseparateprojectsasnecessary.

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84www.cs.amedd.army.mil/references_publications.aspxAttemptingtocompleteaCONOPSinasingledraftwithoutmovingthroughthestepsinthefacilityplanningprocesswilllikelyresultinprojectdelays,suboptimization,wastedtimeandmoney(particularlywhenfacedwithcostconstraints),andinsomecasesmayleadtoearlyprojectfailure.8Alltoofrequentlyhospitalleadershipdefinestheproblemasneedingabetterbuilding,usuallyqualifiedwithanexpansioninspace,whichconstrainsthedefinitionoftheproblemandthepotentialsolutionstooearly.Tomitigatethis,theCONOPSservesasanorganizedanddetailedmethodologytoidentifyandexplaintheprojectgoals(provisionofclinicalcapabilities)thatshouldbeaddressedinthestatementofworkforthefacilityproject.THESPACEPROGRAMFORDESIGNThenextstepoftheoverallfacilityplanningprocessisdevelopmentofaprogramfordesign(PFD).ThePFDisaroombyroom,departmentbydepartmentlistingofspacerequirementsfortheentirefacility.ThePFDistieddirectlytoandderivedfromtheCONOPS.ThePFDtranslatestheclinicalandoperationalcapabilities,personnel,andotherfunctionalrequirementsoutlinedintheCONOPSintospacerequirementsforthearchitecttodevelopaworkablesolutionordesign.Unfortunately,throughouttheITO,constructionprojects,includingthoseformedicalpurposes,arecompletedeverydaywithverylittleconsiderationoftheclinicalandproceduralimplications.Engineersandcliniciansjumpstraighttothesolutionbydrawingwhattheythinktheywantwithoutreallydefiningtheproblemstatementorgoalsoftheproject.Manyprojectsaretocorrectdeficienciesfrompreviousprojects,likelyduetopoorupfrontplanningandrequirementsdevelopment.Thisbecomesaviciouscycleandintheenddrivesupcosts,increasesfrustration,andreducesoverallefficiencyoftheentirehealthcaresystem.TheenvironmentinwhichmedicalorganizationsoperatewithintheITOistumultuous.Unitandindividualrotations,enemyactions,constraintsonpermanentconstruction,andvaryingmethodsandprioritiesofmedicalandnonmedicalleadershipmakemedicalprojectsextremelydifficult.TheCONOPSprovidesahistoricalrecordofthedecisionstakentodeveloptheprojectandgenerallystabilizestheoverallprojectdevelopmentprocess.Finally,theCONOPSservestovalidatethePFDaswellasprovidejustificationtooperationalandmedicalplanners,militaryleadership,andresourcemanagers.Whendecisionmakersarefacedwithtoughdecisionsonprojectscope,theCONOPSinformsandenablesthemaboutalternativescenariostosatisfytheoperationalandclinicalspacerequirements.WhenaCONOPSdoesnotexist,thisbecomesariskyguessinggamewithunpredictableresultsthataredifficulttoanticipate,letalonemitigate.LateadjustmentstoaprojectwithoutaCONOPS,whichleavesthedecisionmakersuninformed,couldmeandelayingorevenjeopardizingtheprojectsviability.CASESTUDY:DEPMEDSHOSPITALREPLACEMENTATCONTINGENCYOPERATIONSBASESPEICHERExistingConditionsTheexistinglevelIIIhospitalatCOBSpeicherconsistedofamixtureofexpeditionarystructures(DEPMEDSISOcontainers,andTEMPER[Figure1]),andexistingsinglestory,hardstandbuildingsoccupiedbythehospital.SomeimprovementshavebeenmadetotheMTF(CT*scanneradded,microbiologyaddedtothelaboratory),butgenerallytheDEPMEDSISOsandTEMPERhadexceededtheirservicelivesandrequirereplacement.Figure2isanaerialviewofthathospitalshowinghowDEPMEDSHealthFacilitiesPlanning:DeterminingInfrastructureRequirementsforFormandFunctionfromClinicalandOperationalCapabilities *ComputerizedAxialTomography Figure1.TEMPER(Tent,ExtendedModularPersonnel)

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OctoberDecember200885THEARMYMEDICALDEPARTMENTJOURNALandTEMPERlayoutonthesitebetweenthe2existinghardstandbuildings.Thesiteidentifiedforthenewfacilitywouldbetotheleftoftheareaillustratedinthefigure.Powergenerationisprovidedbyacombinationofprimepower,commercial,andmilitarygenerators.Both220V50Hzand110V60HzpoweraremaintainedinthebuildingduetolargequantitiesofDEPMEDISOandmedicalequipmentrequiring110Vpower.Theharshenvironmentandheavyelectricalloadsfromthehospitalexceedtheavailablepowercapacityandtherearefrequentpowerfailures.Thesearequicklyresolvedthroughatriple-redundantmixofcommercialandmilitarygenerators,buttheresourcesandefforttomaintainthatredundancyaresignificantandunsustainable.InherentdeficienciesintheDEPMEDSareinadequatedustcontrol,noiseabatement,andlackofprivacy,elementsunacceptableinanyhospital.Twobuildingmethodologieswerediscussedindetailduringthedesigncharette.*Thefirstwasthecommonprecedentofthetrailerhospital.Whilequickandcheap,itwasjudgedasinferiortothatofapreengineeredbuilding(PEB),similartotheonerecentlyconstructedatLogisticsSupportAreaAnaconda,nearBalad.APEBisalarge,temporarymetalbuildingwithaninteriorthatcanbeconfiguredtosuittheapplication.ThePEBwasdeterminedtobethebestvalueforthemoneyandwouldovercomemanyoftheshortcomingsexperiencedbybothexpeditionaryandtrailerhospitals.Thistypeofconstructionwouldprovidecleanablesurfaces,reducinginfectionratesandimprovingoutcomes.Itwouldalsoreduceexposuretoexcessivenoiselevelsforthepatientsandstaff,anenvironmentalfactorwhichhasalsobeenshowntoleadtomorefavorableoutcomes,suchaslesspainmedicationandfasterrecoveryrates.Itwouldprovideamorerobustinfrastructuretosupportimprovedhealthcarecapabilitiesandextendlifecyclemanagementofthestate-of-the-artmedicalequipmentinamatur-ingcombattheaterofoperations.TimelineDay1Arrived,ContingencyOperatingBaseSpeicherMeetingwithSpeicherFacilityEngineerTeamMeetingwithCorpsofEngineersTourofhospitalDay2Conductedindividualmeetingswiththe18sectionsthatcomprisethehospitalDay3Completedinterviewsandfollow-upwithkeystaffConsolidatedkeycapabilitiesidentifiedduringinterviewsintoasingledocumentIntegratedandvalidatedfunctionalrelationshipsintoadjacenciesDevelopedthespaceprogramfordesignbasedupontheclinicalcapabilitiesPreparationandcoordinationThedesignprocessbeganwithaninitialmeetingatCOBSpeicherwiththeCorpsofEngineersdesignteamfromtheTransAtlanticProgramCentertoconductthedesigncharette.Thismeetingwasusefulinunderstandingthepurposeandscopeoftheprojectandconstraintsduetofundingandschedule.Anearlyideaofthedesignteamwastoselectarecentlycompletedhospitalprojectandduplicatethatfacilityatthislocation.Howeverinanarticleonasystems-based *Afinal,intensiveefforttofinishaprojectbeforeadeadline.Source:RandomHouseUnabridgedDictionary.NewYork,NY:RandomHouse,Inc;2006. Figure2.AerialviewofthehospitalatCOBSpeicherpriortoconstructionofthereplacementpreengineeredbuildings.

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86www.cs.amedd.army.mil/references_publications.aspxmethodologyforanalyzingorganizationalstructureandperformanceimprovementwithinhealthcare,KeatingpositsEveryorganizationinthehealthsector,fromsmallclinictonationalhealthservice,canbeviewedasacomplexsystem,integratingpeopleandtechnologythroughrelationshipstoachievedesiredpurposes.1Therefore,whileintuitivelythissoundslikeaverypracticalidea,forthosewhoarenotfamiliarwithmedicalprojects,aswellasmedicalpersonnelwhoarenotfamiliarwithfacilityrequirements,itisfraughtwithassumptionsandpotentialdisappointment.Theunderlyingassumptionsandkeycriteriadrivingtheappealofcookie-cuttermedicalfacilitiesisthatwhateverisbuiltisanimprovementtowhatiscurrentlythere.Justbecauseasolutionworkedinonecontextdoesnotmeanthatitwilltransfertoanewlocation,organization,andsituationwithdifferentpersonnel,equipment,financialresources,andoperationalenvironment,andproducethesameoutcome.Duetothecharacteristicsthatdifferentiatecomplexsystemsfromsimplesystems,itfollowsthatsolutionsforcomplexproblemsshouldnotbeduplicatedbymakingassumptionsthatoversimplifythesystem.7Therefore,replicatingapreexistingdesignorperformingasiteadaptationisnotalwaysthebestsolution.Thetechnicalandadministrativecoordinationandpointsofcollaborationwerediscussedandatentativeplanandasequenceofeventswereoutlinedtorefinetheprojectscopeandgatherthekeydatarequiredtoproperlyplantheproject.Thisconcludedtheinitialpreparatoryandcoordinationportion.Thenextphaseinvolveddatagatheringandanalysisrequirements,beginningwithatourandorientationtotheexistinghospitalcomplex.Attheconclusionofthetourofboththeexistinghospitalandaterrainwalkoftheproposedfuturesiteadjacenttothehospital,finaladministrativecoordinationoccurredwithboththebasefacilityengineerandCorpsofEngineerprogrammanager.Scopeoftheproject,costplanningfactors,andtheoverallprogrammedamountoftheprojectweretentativelyestablished,withmechanismsinplacetorevisitasknowledgeoftheprojectrequirementsweredefinedandjustified.PreparationoftheCONOPS:TheValueItProvidesAfterestablishingatentativeplantofinalizethescopeoftheprojectforthedesignteam,interviewswiththehospitalstaffwereconducted.Pertinentinformationwascapturedfromthe399thCombatSupportHospital(CSH)stafffromeachoftheir18sections.NotestakenfromtheseinterviewsweretranscribedintotheinitialdraftoftheCONOPS.Thefollowingday,eachsectionwasprovidedtheopportunitytoreviewandamendtheirsection.Keydatapointssuchasrecommendedstaffingpositionsandsurgical,inpatient,outpatient,andancillaryworkloaddatawereobtainedforthepreviousyeartovalidatecapacities.Thatdatawasusedtoproperlysizeareaswithinthehospital,suchaswaitingrooms,numberofexamrooms,andnumberofbeds.Laboratory,pharmacy,radiologicalworkload,andotherkeydatapointswereobtainedinordertodeterminetherightmixofservicesandprojectcapacity.Infact,thedatagathered,coupledwithhistoricalbedcensus,resultedinthedecreaseof4intermediatecareinpatientbeds.Thiswasnotanarbitraryreduction,butafullyinformedandstaffeddecisionbecauseofthetransparencyandvisibilitywhichallowedplanners,leadership,andclinicianstofeelcomfortablewiththedecision.Anotherexampleofaninformeddecisionresultedlaterintheactualdesignofthefacilitywhenitbecameapparentthatsomescopereductionwasrequired.Dentalserviceswereinitiallyincludedwithinthefootprintoftheacutecareclinic.However,collaborationwiththedentalcompanyleadershiprevealedagreaterneedtoconsolidatedentalassetsratherthanlocateacoupleofchairswithinthehospital.Whiletherewasnotroomwithinthescopeofthisproject,adeliberatedecisionwasmadetodeveloptherequirementsandjustificationforaseparate,standalonedentalclinictoprovidethenecessarycapacityandefficienciesfordentalcareneededonCOBSpeicher.ThiswouldnothavebeenpossiblewithoutthelaterinsightthattheCONOPSprovided.Anaddedvalueisthatcontinuityhasalreadybeenrealizedasthe399thCSHhasbeenreplacedbythe325thCSH,whichwassubsequentlyreplacedbythe345thCSH.AtleastonemoreCSHwillrotateintoCOBSpeicherbeforethefacilityiscomplete.Theturnover(400%)ofpersonnelbythehospitalandthegarrisonisquitehighbyanystandard.TheCONOPSHealthFacilitiesPlanning:DeterminingInfrastructureRequirementsforFormandFunctionfromClinicalandOperationalCapabilities

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OctoberDecember200887THEARMYMEDICALDEPARTMENTJOURNALprovidesawrittencontinuityofdecisionsonthemedicalservicesofferedwithinthehospital,andhasreducedthenumberoftotalchangesinscopenormallyassociatedwithpoorlydefinedprojects,orprojectswhereturnoverinleadershipresultsinshiftsinmissionandvisionoftheorganization.SUMMARYANDCONCLUSIONTheclinicalCONOPSisafoundationaldocumentwhichhelpsdirectthedesignanddevelopmentofahealthfacilityproject.Itisaforward-lookingdocumentarticulatingtothedesignconsultantsawordpictureofthefuturefacilityandscopeofservicestobeprovidedintheneworremodeledspace.Thenarrativeistheformattowritethestoryabouttheoperations.Itservestovalidatetheprojectaswellasprovidejustificationtooperationalandmedicalplanners,militaryleadership,andresourcemanagers.Whenfacedwithresourceconstraints,theCONOPSallowsinformeddecisionsandenablesalternativescenariostosatisfytheoperationalandclinicalspacerequirements.WhiledraftingtheCONOPSappears,onthesurface,tobeaformidabletasktocomplete,itreallyinvolvesansweringquestionsabouteverydayprocedures,processes,equipment,andfunctionscarriedoutbythestaffmembersofthehospital.Inotherwords,thehospitalstaffhastoexplainwhattheydototakecareofpatientsnow,andhowtheywouldliketoprovideimprovedcareinthefuture.Sincethevalueofthehospitalanditscumulativecontributiontothehealthservicesupportplaninsupportofcontingencyoperationsismorethanthesumofitsparts,documentingtheactivitiescarriedoutandtheimprovementsenvisionedexistsasacriticaltasktobecompletedintheearlystagesofanyfacilityimprovementproject.REFERENCES 1.KeatingCB.Asystems-basedmethodologyforstructuralanalysisofhealthcareoperations.JManagMed.2000;14:179-198.2.SyvinskiB,ElliottJ.Combatcasualtycareonthetechnologycurve:medicalequipmentstandardizationinamaturingcombattheater.MilMedTechnol.2008;5:34-37.Availableat:http://www.mmt-kmi.com/article.cfm?DocID=2499.3.FallonWJ.StatementofAdmiralWilliamJ.Fallon,USNavy,CommanderUSCentralCommandBeforetheHouseAppropriationsCommitteeSubcommitteeonMilitaryConstructiononMilitaryConstructioninUSCentralCommand.April17,2007.Availableat:http://www.dod.mil/dodgc/olc/docs/testFallon070417.pdf.4.FieldManual3-24:Counterinsurgency.Washington,DC:USDeptoftheArmy;December15,2006:p3-2.5.FloodRL,CarsonER.DealingwithComplexity:AnIntroductiontotheTheoryandApplicationofSystemsScience.2nded.NewYork:PlenumPress;1993:31.6.USCentralCommandRegulation415-1:ConstructionandBaseCampDevelopmentintheUSACENTCOMAreaofResponsibilityTheSandbook.Tampa,Florida:Headquarters,USCentralCommand;December17,2007.Note:Accesstothisdocumentisrestricted.7.KeatingCB,FernandezA,JacobsD,KauffmannP.Amethodologyforanalysisofcomplexsociotechnicalprocesses.BusProcessManagJ.2001;7:33-50.8.GibsonJE,SchererWT,GibsonWF.HowToDoSystemsAnalysis.Hoboken,NewJersey:JohnWiley&Sons,Inc;1991:33-34.AUTHORS Atthetimethisarticlewaswritten,MAJChapmanwastheHealthFacilityEngineer,62ndMedicalBrigade(TaskForce62),CampVictory,Baghdad,Iraq.LTCPalaschakisChief,Clinical/TechnicalService,USArmyHealthFacilitiesPlanningAgency,FallsChurch,Virginia.

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88www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONInSeptember2007,TaskForce261MultifunctionalMedicalBattalion,headquarteredatJointBaseBalad,assumedcommandandcontrolofthe561standthe257thMedicalCompanies(DentalServices),aspartoftheirlargermissiontoprovidesynchronized,world-class,echelon-above-brigadecombatteam(EABCT)healthcareacrosstheIraqtheaterofoperations.The257thMedicalCompanyfromFortBraggwasimmediatelyreplacedbytheReserveComponents307thMedicalCompany.The673rdMedicalCompanyfromFt.Lewisreplacedthe561stMedicalCompanyinDecember2007.Inadditiontothe2dentalcompanies,TaskForce261staskorganizationincluded5areasupportmedicalcompanies,eachwithanorganicdentalcorpsofficerandenlisteddentaltechnician,2groundambulancecompanies,4optometrydetachments,oneforwardsurgicalandoneheadandnecksurgicalteam,andtheheadquartersdetachment.Eachdentalcompanywasgivenageographicareaofresponsibility,withonecompanyprimarilyoperatinginnorthernIraq,responsiblefortheoperationofdentalclinicsat6locations,withaflagshipclinicatJointBaseBalad,andtheotherinsouthernIraq,with6(later7)clinics,includingaflagshipfacilityatCampLiberty,VictoryBaseComplex,Baghdad(Figure1).BothcompaniesmaintainedacommandpostatJointBaseBalad,andworkedtogethertomeetthetaskforcesvisionofDedicatedtoEstablishingaProfessionalHealthcareSystem.Onedentalcompanywasgivenadministrativecontrolofa3-personoptometrydetachmentatonelocation,atestamenttotheincreasingplug-and-playnatureoftheArmyMedicalDepartment.STARTINGPOINTPreviouslydeployeddentalcompaniesandbattaliontaskforcesperformedpioneeringwork,initiatingthetransitionfromgeneratorpowered,mobilefacilitiesusingdeployablefieldequipment,tofixedclinicswithplumbing,primepower,anddurableequipment.BySeptember2007,MultinationalCorps-Iraqsmedicalbrigadetaskforcehadestablishedacomprehensiveandenduringdentalcarefootprint,withEABCTdentalcarelocatedat12enduringforwardoperatingbases(FOBs.)Constructionhadbeencompletedattheflagshiplocationsforeachdentalcompany.CampLibertysclinicwasequippedwith8dentalchairs,sterilization,laboratory,anddigitalradiography,includingpanographiccapability.JointBaseBaladsclinicwasnearlyoperational,openingwith8functioningdentaloperatories,laterincreasingcapacityto18operatories,andalsohadsterilization,ExpandingaProfessionalDentalCareSystem:ExperiencesofTaskForce261MultifunctionalMedicalBattalionDuringOperationIraqiFreedom07-09LTC(P)FrankL.Christopher,MC,USALTCCraigG.Patterson,DC,USASGMGregoryM.Smith,USACW4MarkA.Smith,MS,USACPTJamesW.Cobb,DC,USACPTJenniferA.Pollard,MS,USA ABSTRACTDuringOperationIraqiFreedom07-09,TaskForce261MultifunctionalMedicalBattalionmanagedanextensivedentalcaresystemstretchingthroughouttheIraqtheaterofoperations.WeillustrateseveraloftheuniquechallengesfacedbyTaskForce261sheadquartersanditsdentalandareasupportcompanies,anddescribetheremediesemplacedbytheTaskForce.Personnelstructure,theevacuationchain,supplyandfacilitymanagement,dentalcivil-militaryoperations,detaineecare,informationtechnologyapplications,andpublichealthinitiativesarediscussedindetail.

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OctoberDecember200889laboratory,anddigitalplaneandpanographiccapabilities.Othercliniclocationsvariedfrommodularbuildingstohardenedpreconflictbuildings,moststillworkingonfieldcompressorsandgenerator-basedpower.PROVIDERVARIABILITYDentalcompaniesarestaffedwithDentalCorpsprovidersbasedupontheirstationandcomponent.ActivecomponentcompaniesarepredominatelyresourcedthroughtheProfessionalFillerSystem(PROFIS),*whichrotatesprovidersfromUSArmyMedicalCommandfacilitiesfor6to15months,andinwhichspecialtysubstitutionsmaybemade.Forexample,acomprehensivedentistbilletmaybefilledbyanendodontistfor6months,thenreplacedwithaprosthodontist.ActiveDutycompaniesoriginatingfromUSArmyEuropearestaffedwithdentistswhodeployforthedurationoftheunitsdeployment,usually12or15months.Reservecomponentcompaniesrotatetheirentireprovidersetevery90days,alsowithspecialtysubstitutionspermitted.Areasupportmedicalcompanydentalofficersdeployfortheentiredurationoftheunitsdeployment,typically12or15months.ThenewPROFISpolicy,releasedinJanuary2008,limitsactivedutyPROFISproviderdeployments.Itwasgreetedwithmixedemotionbythoseofficersalreadyintheater.WhileapositivestepforwardtodecreasedeploymenttimeforPROFISproviders,agreatdealofinequityseemedtoapplyasdentalofficersserved6monthsor15months,dependingonwhatdayonearrivedintheater.Manyofthe15-monthproviderswillhaveseennumerousdentalofficersrotateinandoutoftheaterbecausetheirdeploymentdatewaspostedafterthecutoffdate.Theendresultisagreatdealofpersonnelturbulence,witharesultingrequirementtocloselymanagespecialtycaredentists,placingthematthehighestvolumefacilitiestomaximizetheirefficiencyandreduceevacuations,yetensuringcontinuityofcareasdeploymentsoccur.SYNCHRONIZATIONWITHAREASUPPORTMEDICALCOMPANIESThe5areasupportmedicalcompanies(ASMCs)withinTaskForce261wereresponsibleforprovidinglevelIImedicalcareatkeytroopconcentrationareas,inadditiontolevelIcareatoutlyingareas.EachASMCdeployedtoIraqwithbothaDentalCorpsofficerandadentalspecialist.AtJointBaseBaladandCampLiberty,theASMCdentistandspecialistintegratedintothestaffoftheflagshipclinics.Thesamearrangementwasmadeatoneotherhighvolumelocation.Atthe2otherASMCs,wheretherewassignificantgeographicdispersionbetweentheASMCsclinicandthedentalcompanysclinic,ASMCdentalpersonnelmaintainedasingle-chaircapacitywithinthelevelIImedicalclinic.Atalllocations,aseniordentalofficerwasidentifiedbyTaskForce261(TF261)tosuperviseandsynchronizecare,maximizingefficiencyofavailablepersonnelanddentists,andprovidingprofessionaldevelopmentalopportunitiesforjuniorpersonnel. TaskForce261MMB AreaSupportMedicalCompany(5) MedicalCompanyDentalServices NorthernIraq MedicalCompanyDentalServices SouthernIraq FlagshipDentalClinic DentalClinic(6) FlagshipDentalClinic DentalClinic(5) DentalOfficerDentalSpecialistStaffingProfile(total):AreaSupportMedicalCompanies:5DentalCorpsOfficers5DentalSpecialistsDentalServicesCompanies:28DentalCorpsOfficers56DentalSpecialists(includinghygienistsandlaboratoryspecialists) Figure1.DentalsupportorganizationoftheTaskForce261MultifunctionalMedicalBattalion(September2007). *PROFISpredesignatesqualifiedActiveDutyhealthprofessionalsservinginTableofDistributionandAllowanceunitstofillActiveDutyandearlydeployingandforwarddeployedunitsofForcesCommand,WesternCommand,andthemedicalcommandsoutsideofthecontinentalUnitedStatesuponmobilizationorupontheexecutionofacontingencyoperation.1Prescribestheorganizationalstructure,personnelandequipmentauthorizations,andrequirementsofamilitaryunittoperformaspecificmissionforwhichthereisnoappropriatetableoforganizationandequipment(thedocumentwhichdefinesthestructureandequipmentforamilitaryorganizationorunit).

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90www.cs.amedd.army.mil/references_publications.aspxHUB-AND-SPOKEMODELOFSPECIALTYDENTALCAREOneofthemajorgoalsofTF261sdentalelementswastobuilduponthesuccessofprecedingunitstominimizethenumberofSoldiersevacuatedoutoftheaterforspecialtyorcomplexdentalcare.Thesimplestandmostsuccessfulstrategywastoemplacespecialtycaredentistsateachofthe2companyflagshipclinics,ensuringthatasprovidersrotatedinandoutoftheater,specialtycareaccesswasmaintainedateachfacility.Thisoccasionallyresultedinarequirementtobalancespecialistsamongcompanies.Thenextchallengewastomarketthischange,theavailabilityofspecialtycareatthe2hublocations,todentalofficersacrossIraq,includingatthebrigadecombatteamlevel,tosisterservices,andtocoalitionforces.Thisprocesswasaidedbythetheaterdentalconsultantandthe62ndMedicalBrigadesseniordentalnoncommissionedofficer(NCO)whoupdatedanddistributedthetheaterdentalproviderlisttoeachdentalofficerintheater.Finally,coordinationforpatientmovement,housing,treatment,andreturntohomeforwardoperatingbase(FOB)wasrequired(Figure2).Patientsseenatanyoutlyingclinicwerereferredtotheflagshipclinicwithinthegeographicresponsibilityofoneofthe2dentalcompanies.Thereceivingclinic,throughasinglescreeningandcoordinatingprovider,arrangedhousingandcarewiththeappropriatespecialtyprovider.Itistheresponsibilityofthereferringclinic,thepatientsunit,andthepatienttoensurethatdentalrecords,includingradiographs(ifavailable)areavailableatthespecialtycareappointment.Ifoneflagshipcliniclackedaparticularspecialty,itwoulduseacomprehensivedentisttoscreenthepatient,and,ifneeded,refertotheotherflagshipclinic.TheseoccurrenceswereexceptionallyrareduringTF261sdeploymenttoIraq.Utilizationofthehub-and-spokemodel,withclosecooperationbetweenreferringandacceptingdentalofficers,dramaticallyimprovedaccesstospecialtydentalcareacrossIraq,andvirtuallyeliminatedevacuationsoutoftheater.DEVELOPMENTOFTHEDENTALFACILITYADVISORYBOARDUponcompletionoftheinitialbattlefieldsurveysofTF261dentalfacilities,itbecameevidenttotheleadershipthattherewasarequirementtoprovidedynamicoversightoftheconversionfromfieldtofixedfacilitiesandequipment,andtoensurethatdentalofficersandspecialistswereintegratedintothedecision-makingcyclewhenplanningnewconstructionorrenovationofdentalclinics.Mostoftheexistingfacilitieshadbeenestablishedinpre-warbuildings,modularbuildings,ordeployablemedicalsystemscontainers,leadingtoinefficienciesindesign,ergonomics,andpatientflow.TheDentalFacilityAdvisoryBoard(DFAB)wascharteredtoguidethewayaheadasclinicswererenovatedorconstructed,providingengineersandFOBmayorcellswithrecommendationstomaximizetheefficientuseofspace,ensuresufficientdentalchairsandoperatoriestosupportthecurrentandfutureinstallationpopulation,andprovidetechnicalinput,includinguniquecompressor,sterilizer,plumbing,andmedicalgasrequirements.TheDFABconsistedoftheseniordentalcompanycommander(actingalsoasTheaterDentalConsultant),thejuniordentalcompanycommander,thedeputycommanderforclinical Figure2.ThehubandspokeorganizationestablishedbyTaskForce261toprovidespecialtydentalcareacrosstheIraqtheaterofoperations. ExpandingaProfessionalDentalCareSystem:ExperiencesofTaskForce261MultifunctionalMedicalBattalionDuringOperationIraqiFreedom07-09

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OctoberDecember200891THEARMYMEDICALDEPARTMENTJOURNALservicesforeachdentalcompany,thebattalionseniordentalNCO,thebattalionmedicalmaintenanceofficer(alsoservingasfacilitiesmanager)andseniorNCO,andthebattalionmedicalsupplyofficerandseniorNCO.MeetingfirstinJanuary2008andmonthlythereafter,theDFABcontinuouslyresearchedanticipatedtroopshiftsanddevelopedcomprehensivescopesofworkforeachdentalclinicinthetaskforcefootprint.Asanexample,workonanewdesignfora6chairclinicatContingencyOperatingBase(COB)Endurancetomeetprojectedpopulationshiftsinthecomingyearhadalreadybeenstarted.ThisclinicdesignwaslateracceptedbytheDFABastheblueprintforastandardizedmedium-sizeclinicdesignwhichcouldbelaterused,expanded,orcontractedatdifferentlocationstosupportthecurrentandfuturepopulationatrisk.TheDFABwillcontinuetoworkcloselywithinstallationmayorcellsandTF261facilityengineersandplannerstoprovideinformationandclinicalrelevancetofuturedentalfacilityconstructionprojects.THECORPORATEDENTALAPPLICATIONLikeourpredecessor,wecontinuedusingtheCorporateDentalApplication(CDA),acomprehensiveworkloadandreadinessreportingsystemdevelopedbytheUSArmyDentalCommand(DENCOM)andusedthroughouttheArmyDentalCareSystem.Theapplicationisinternetbasedanduserfriendly.InthefairlymatureenvironmentofIraq,sufficientbandwidthispresenttosupportCDAatallcarelocations.Additionally,theDENCOMCDAteamisavailabletoprovideend-usersupportfortheapplication.Uponassumingthemission,TF261recognizedthatasignificantportionofdentalprofessionaltimeandresourceswerebeingusedinthecareofcontractedpersonnel,apotentiallyreimbursableexpense.Atthetime,contractorswerenotincludedinCDAspatientcarecategories,insteadbeinglumpedtogetherundertheothercategory,whichincludeddetaineesandothermiscellaneousgroups.WorkingthroughtheDENCOMschiefinformationofficer,wewereabletogetamodificationtotheCDAthatseparatedindividualpatientcategoriesforUSandforeigncon-tractors(Figure3).Thisallowedourdentalcomman-derstobettertrackexpenditureofdentalresourcesthroughoutthetheaterofoperation,andprovidedsituationalawarenessofthetimeandcostassociatedwithcontractorcare.ThecentralmanagementofEABCTdentalcareunderonetaskforceallowedbetterdatacollectionanddecision-making.Priortoourarrivalintheater,dentalproviderlocationintheCDAdatabasewassomewhatunorganized.SomeareasupportanddentalcompanyproviderswerereportingtheirdataunderthegenericSouthwestAsiaDentalClinic,withseparateduplicateentriesundertheirrespectiveunits.Theseinaccuracieswerecompoundedbytheconstantturnaroundofpersonnelrotatingat90-and180-days,whichmadeitdifficulttopullandcompileaccurateworkloaddataforeachprovideroreachindividuallocation.TogetherwiththeDENCOMCDAstaff,thetheaterdentalleadershipconductedaneducationandqualitymanagementcampaign,ensuringallproviderswerecorrectlymappedtotheirindividualunits.Taskforcedentalpersonnelthenusedaninternaltrackingmatrixtolinktheirworkloadtotheirrespectivesatellitelocation.ThisdataallowedtheTaskForcecommandertoeasilyidentifyworkloadtrendsand 3500 3000 2500 2000 1500 1000 500 0 SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Figure3.CategoryofpatientsseenatTaskForce261DentalClinics,Sep2007Jun2008.DataextractedfromUSDentalCommandCorporateDentalApplication.

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92www.cs.amedd.army.mil/references_publications.aspxmakerequiredstaffingdecisions(Figure4).AnaddedbenefittousingCDAistheabilitytocalculatetherelativedollarvalueofcarerendered,basedonthecurrentdentalterminologycodesbuiltintothedatabase.Eachdentalprocedureisassignedaweightedvalue,withavalueof1.00beingequivalentto100dollars.Thisallowscommanderstoseetherelativedollarvalueofservicesrenderedwitheachworkloadrollup(Figure5).CHALLENGESOFIN-THEATERDIGITALDENTALRADIOGRAPHYTheabilityfordentalproviderstoview,use,retrieve,andtransmitradiographicimagesforclinicalpracticeisunderstoodasthestandardofcarewhenevaluatingandexaminingpatients.DepartmentofDefenseInstruction6490.032states:Totheextentfeasible,deploymenthealthdatawillbecollectedandmaintainedinDoD-approvedautomatedhealthinformationmanagementsystems.Informationshallbesharedasbroadlyaspossible(exceptwherelimitedbylaw,policy,orsecurityclassification),andanydataproducedasaresultoftheassignedresponsibilitiesshallbevisible,accessible,andunderstandabletotherestoftheDepartmentasappropriate....DuringtheTaskForcesinitialassessmentofourdentalclinicalinformaticsinfrastructure,theinabilitytouploadandstoredigitaldentalradiographstotheCorporateDentalSystem(CDS)forreviewthroughCDAemergedasoneoftheprimaryconcernsforproviders.AstheIraqtheaterhasmatured,manySoldiershaveservedmultipledeployments,andhavehadextensivedentalcarein-theater.Alldentalradiographicimageshadpreviouslybeenstoredonthelocalharddrivesofimagingsystemsusedattheindividualclinics.Aseachunitorclinicteamtransitionedinandoutoftheater,theimageswerecarriedhomeonunitequipment,orremainedstoredonmediaresidingintheclinic.Further,asharddrivesfilledandstoragespacediminished,thousandsofimagesweredeleted.TherearecurrentlynomeanstosenddentalradiographsstoredateachtheaterfacilitytotheArmysrepositoryatFortSamHouston,Texas.However,theDigitalEnterpriseViewingandAcquisitionApplication(DEVAA),theDENCOMcorporatesolutioninthesustainingbase,hasthecapabilitytoaccomplishthistask.TF261begannecessarycoordinationwiththeDENCOMDEVAASustainmentManagertodeterminethesystemandnetworkrequirementstomakethisinitiativeareality.AsTF261andtheTheaterDentalConsultantbeganaggressivecooperationwiththeMultinationalCorps-Iraq(MNC-I)informationassurancenetworkengineerstoimplementDEVAAattheirdentalclinics,itbecameclearthatthiswasaprojectbestdevelopedincoordinationwiththesisterservices,asthecapabilitytotransmitlocallyarchivedimagerytoeachservicesrepositoryiscrucial,asallcomponentssharethesemedicalresourcesinthe Figure4.Monthlyworkload(rawnumbers)atTaskForce261DentalFacilities,Sep2007Jun2008. APR JUN MAY MAR FEB JAN DEC NOV OCT SEP 0 5000 10000 15000 20000 Figure5.RelativevalueoftheworkloadatTaskForce261DentalFacilities,Sep2007Jun2008. $1,600,000 $1,400,000 $1,200,000 $1,000,000 $800,000 $600,000 $400,000 $200,000 $0 $1,800,000 SEP OCT NOV DEC JAN FEB MAR APR MAY JUN ExpandingaProfessionalDentalCareSystem:ExperiencesofTaskForce261MultifunctionalMedicalBattalionDuringOperationIraqiFreedom07-09

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OctoberDecember200893THEARMYMEDICALDEPARTMENTJOURNALIraqtheaterofoperations.TF261garneredsupportfromtheTaskForce62MedicalBrigade,anddevelopedaseriesofbriefingsandinformationpapersfortheMNC-IHealthInformationSystemsOfficer,whothenworkedwiththeCENTCOMmedicalchiefinformationofficertosponsorthisinitiative.AttheJune2008TheaterFunctionalWorkingGroupmeeting,thecochairsrequestedthattheintegratedrequirementsdesign,jointcapabilitiesintegrationdevelopmentsystemsstaffconductacapabilitiesbasedanalysis(CBA)fordigitaldentalimagingintheater.ThisCBAcoversananalysisofthefunctionalarea,needs,andrecommendedsolutionsfortheaterdigitalimaging.ItisthehopeofTF261thatthisgrassrootseffortwillultimatelyresultinasolutionforthecurrentcapabilitygapthatexistsinjointservicedentaldigitalimaging.STANDARDIZATIONOFDENTALSUPPLYCHAINSANDSUPPLYMANAGEMENTEvenbeforeTF261assumeditsmissioninIraq,theTheaterDentalConsultantanddentalcompanycommandershaddeterminedthattheclassVIIIsupplysystemtheninplacewasfartoocumbersometofacilitateeffectivesupplychainmanagementandstocklevels.Ithadbecomestandardpracticeforindividualclinicstoorderasmuchofanitemaspossible,andstockpilematerialsforlateruse.Additionally,manyproviderswouldorderspecificsuppliesanddurableequipmenttoaccommodatetheirparticulartreatmentpeculiarities.Whentheproviderrotatedoutoftheareaorredeployed,anewproviderwouldstarttheprocessagain,leavingunused,excesssuppliesontheshelvestoexpire.AtthetimeTF261begantoprovidedentalcare,over9,000individuallinesofsupplywereavailabletothedentalcompanies,anamountfartoounwieldyforthemedicallogisticsunitstostockatthetheaterscentralclassVIIIwarehouse.Thesepracticeshadbecomecommonplaceandwerecounterproductiveineffectivelyestablishinglogisticalsupport.Themedicallogisticssystemworksontheprinciplethatthemoreanitemisordered,themoreavailableitmustbeforthecustomer,anditisstockpiledattheaterandstrategiclogisticsdepots.Anindividuallineitemmustbeorderedatleast6timesinoneyearforthatitemtobecarriedinwarehousesasaroutinelystockeditem.Whenanitemisnotorderedwiththatfrequency,itisdroppedfromtheroutinesupplychannels,andthecustomermustinitiateanewitemrequest,startinga3-monthprocessofapprovalsandverification,afrustrationtoproviders.Clearly,amoreeffectiveandlesscumbersomedentalclassVIIIsupplysystemhadtobeestablished.ThestandardizationofclassVIIIdentalsuppliesacrossallfacilitiesbecameatoppriorityfortheTaskForce.Thefirststepwastoestablishstandardoperatingproceduresforthemanagementofdentalsupplyrooms,withseveralgoalsinmind.First,supplydisciplinehadtobeestablishedasacommanderspriority,tobemeasuredandperiodicallyreviewed.Second,minimizethetotalnumberofdentallinesofsupplyavailable,eliminatinginfrequentlyusedequipmentandstandardizingoperativeandinterventionalequipmentsets.Third,effectivelymanageeachfacilityssupplyroom,establish30-daybenchmarkstocklevels,turninexistingexcessforredistribution,andidentifywhatshelflevelwilltriggerareorder.Fourth,maximizeproactiveorderingefficiencybyleveragingexistingtechnologyandsystems,specificallytheDefenseMedicalLogisticsStandardSupportCustomerAssistanceModule(DCAM),asamanagementtooltoidentify,assess,track,andfacilitatetheproperflowofsuppliesacrossthetheater.Fifth,maximizeuseofgovernmentassetsandpreventfraud,waste,andabuse.Sixth,providethecustomerwiththebestlogisticalsupportpossiblethroughtraining,follow-uponidentifiedconcerns,andreliablecommunication.Finally,establishandmaintaineffectivemanagerialcontrolandprovidechecksandbalancesatthecompanylevel.ThispolicywasgraduallyimplementedatTF261facilities,andintroducedintotheentiretheaterbytheTheaterDentalConsultantforimplementationacrossthetheater,includingNavyandAirForcedentalassets.Thesecondgoalwasachievedbythedevelopmentofastandardizedlistofcloseto300classVIIIitems,carvedoutofover9,000lineitemsavailable.Thisstandardizedsupplylistencompassedallcriticalareasoftreatment,andincludedsterilization,hygiene,andsubspecialtyrequirements.Thelistwasdevelopedandrefinedbyacommitteeofdentistsfrombothdentalcompanies,supplyspecialists,andmedicallogisticiansinTF261,aswellasthe56thMultifunctionalMedicalBattalionTaskForce.ThemedicallogisticsspecialistsatbothTF261dentalcompaniesareengagedandusingDCAMtothe

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94www.cs.amedd.army.mil/references_publications.aspxfullest,processingmorethan190requisitionspermonth.Clinicrepresentativesacrossthetheatersubmitordersasneededviaemailortelephonetotheircompanysmedicallogisticsspecialist,whoentertheorderintotheDCAMsystemusingcodesthatallowdirectshipmenttothecustomersinstallation.Thisemploymentofcentralizedmanagementimposesahighlevelofcommandsupplydiscipline,anddecreasestheincidenceofwasteandexcess.Earlyin2008,the2dentalcompaniesturnedinacumulativetotalofmorethan$480,000inexcessmaterial,whichwasredistributedthroughoutthetheater.Atthetimeofinception,thecentralmedicalclassVIIIwarehousehadtheitemsrequestedbythe2TF261dentalcompaniesavailableonly7%ofthetime.ThisextremelylowdemandaccommodationratewassignificantlybelowtheDepartmentoftheArmysgoalof60%.Within4months,theaccommodationratehadescalatedtoanaverageof58%forthe2companies.Finally,bystockingthesmallerlistoflineitemsontheshelf,theorder-to-receipttimewasdecreasedfromanoriginal30-60daysto6-9days.Furtherprogramsuccessisevidentinanalltimehighcustomerdemandsatisfactionrate,whichhasimprovedfrom18%toover90%sincetheprogramsinception.PROVISIONOFDENTALCARETOTHEDETAINEEPOPULATIONTF261sdentalcompanieswerealsotaskedtoaugmentthesplit-basedcombatsupporthospitalchargedwithprovidinghealthcaretodetaineeshousedattheaterinternmentfacilities.Thedetaineepopulationpresentsuniquechallengestothedentalofficersandtechniciansassignedtotheselocations,andrequireuniquecompassionandpatience.USArmydoctrine,specificallySpecialText4-02.46,MedicalSupporttoDetaineeOperations,*providesguidancefortheprovisionofdentalcaretothedetaineepopulation.Inaccordancewiththesepolicies,detaineesareentitledtooperationaldentalcare,definedasemergencyandessentialdentalcare,whichisinclusiveofrestoration,minororalsurgery,endodontic,periodontic,andprosthodonticprocedures,aswellasprophylaxis.Aninitialdentalscreeningexaminationisperformedonalldetaineesandmadepartofthedentalrecord.However,thisscreeningistypicallyperformedbyaphysicianextender,notadentalofficer.Currently,TF261sdentalpersonneldetailedtodetaineecarearedevelopingaprocedurebywhichalldetaineesarescreenedbyadentist.Detaineesarealsoperiodicallyscreened,andmaybereferredforadditionaldentalcarebasedonconsultsfromotherprovidersorbyadetaineepresentingatsickcall.Inpatientsmayalsogeneratedentalconsults.Thelanguagebarrierisoftenthemostchallengingaspectofprovidingdetaineecare.Despitethepresenceoftranslators,theinabilitytocommunicatedirectlywiththepatienthindersthehistorydevelopment,examination,andtreatmentphasesoftheencounter.BoththelanguagebarrierandtheArmyuniformmaybedetrimentaltowardstheestablishmentofpatientconfidence.Itisourexperiencethatthescreeningexaminationrepresentsthefirstvisittoadentistformanyofthedetainees.Asthewholeexperienceisforeigntothem,exceptionalpatienceisrequiredontheproviderspart,andfrequentlyextraordinaryselflessnessandcompassionmustbedisplayedtoreassurethepatientthatthedentalcaresystemistheretoprovideforthem,regardlessoftheactionsleadingtotheirinternment.Suchlimitedexposuretodentalcaremeansthatthedetaineepopulationhastremendousneed.Thepopulationsgeneraldentalhealthcanbestbecharacterizedasexceptionallypoor.Badlyinfected,brokenteeth,largecariesburdens,andunrelentingperiodontaldiseaseareendemic.Theoverwhelmingneedforcomprehensivedentalcaremakesthescreeningprocessessential.Thisprocessishinderedbythelogisticsofdetaineemovement.Detaineesmustbeaccompaniedbyguards,and,asasecurityprecaution,onlyafixednumberofdetaineesareallowedintheentirefacilitycomplexatanyonetime.Dentalinstrumentsmustbeinaccessibletodetainees,andthedetaineescannothaveeasyaccesstoexits.Thenumberofdetaineesrequiringdentalcarecaneasilyexceedtheallowablenumberofdetaineesinthefacility,andthisinturncanquicklyleadtoalargebacklog.Asaresult,thedentalofficermusttriagepatientsappropriately,withthemajorityofthecareprovidedbeingemergentorurgentinnature.OnsomeExpandingaProfessionalDentalCareSystem:ExperiencesofTaskForce261MultifunctionalMedicalBattalionDuringOperationIraqiFreedom07-09 *InternalArmydocument,notreadilyaccessiblebythegeneralpublic.

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OctoberDecember200895THEARMYMEDICALDEPARTMENTJOURNALoccasions,detaineeswillrequesttoattenddentalsickcall,onlytorefusetreatmentwhentheygetthereatripintothetreatmentfacilityisseenasasocialevent,abreakinthemonotonyofconfinedlivingintheinternmentcenter.Theseaspects,incombination,presentachallengetothedentalprovidersingettingthecaretothepopulationwiththegreatestneed.Functionally,therestrictionsofmovement,thetremendousdemandforcare,andthelanguagerestrictionshinderaccomplishmentofthegoalofprovidingessentialdentalcaretotheentiredetaineepopulation.Thereremainsasignificantmismatchbetweensupplyanddemand.Assuch,detaineeswho,underidealconditionswithunlimitedresourceswouldreceivemoredefinitiveandcomplexprocedures,typicallyundergosimpleextractiontopreventpainandsuffering,andmitigatetheneedforcomplicatedfollow-upcare.TF261,togetherwithothertheaterdentalassets,continuestostrivetomeetthegoalofprovidingthesamelevelofessentialdentalcaretothedetaineepopulation,inclusiveofendodontic,periodontic,prosthodontic,andprophylacticcare,asthatprovidedtocoalitionforces.Todosowillrequireaninfluxofpersonnel,equipment,andasupportingguardforceatourdetaineecarefacilities.Treatingalldetaineeswithdignityandrespectisacriticaltenetoftheoveralldentalcareplan.Detaineesshouldknowthattheywillreceivequalitycareatourtheaterinternmentfacilities,receivethepharmaceuticalsrequiredtorelievepainandtreatinfection,andhavetherighttoinformedconsent,andtorefusetreatment.PUBLICHEALTHANDPREVENTIVEMEDICINEINITIATIVESUPPORTSoftdrinks,sportsdrinks,andenergydrinksareofferedinabundanceinalldiningfacilities(DFACs)andpostexchangesacrosstheater.ThesedrinksarefreetotheSoldiersattheDFACs,andreadilyavailableateveryturn.Heat,longhours,theoperationaltempo,andnumerousotheractivitiesencourageconsumptionofhighquantitiesofthesecariogenicbeverages.Thehighnumberofdeploymentsandinfrequentdentalcareduringdeploymentarewithoutquestionmerging,resultinginasignificantincreaseinthecariesandtreatment-needbacklogsthatareoccurringatredeploymentclinics.TheneedforeffectivepreventivemeasurestocountertheassaulthasledtheArmytoseeksolutions.TheOfficeofTheSurgeonGeneral,theArmyCenterforHealthPromotionandPreventiveMedicine,andtheArmyDentalCommandusedinputfromdentalunitsinbothIraqandAfghanistantorequestandreceiveapprovalfromtheArmyG-4toprocurexylitolgumformassdistributionintheaterDFACs.Xylitolgumusehasbeenproventobeextremelyeffectiveinreducingcariesby30-85%.FirstputintoMeals,ReadytoEat(MRE)in2004,3withamaturingtheaterandinfrequentMREuseitwasdecidedthatthegumshouldbeavailableinDFACs.Fieldedinsummer2008,thexylitolgumcampaignhasbeensupportedandadvertisedbyeachTF261clinicthroughdirectcontactwiththelocalDFACs.TheTaskForcehasbeenabletoassistinthedistributionofpromotionmaterials,flyers,andpostersinthelocaldentalclinicsanddiningfacilitiestoincreaseuse.Additionally,thetimingofthegumsfieldingcoincidedwiththefirstMedicalBrigadeHealthFair,supportedbyTF261dentalassets.TheMedicalBrigadespremierhealthfairwasheldinAprilattheAlFawPalace(Multi-NationalCorps-Iraq(MNC-I)Headquarters)inBaghdad.ThedentalboothwassupportedbyTF261dentalassets,includingdentists,hygienists,anddentalassistants,whotalkedwithkeyleadersaboutdentaltopicsandissuesintheater.Awholehostofeducational,thought-provokingmaterialswerepresentedanddiscussed.Freesamplesoftoothbrushes,toothpaste,floss,andxylitolgumweredistributed.Hygienedemonstrationswereprovidedalongwithstaticdisplays.Thedentalsectionwasvotedthefavoritebyparticipantsofthehealthfair.Fromthedentalperspective,akeyfeatureofthesecondhealthfairwastheimportanceofsupportforthexylitolguminitiative.ThesignificanceofhavingkeyleadersworkingatMNC-Iawareofthexylitolcampaignandotherongoingdentalcareissueswillnodoubtpaydividendsasthisandotherinitiativesmoveforward.ESTABLISHINGAPARTNERSHIPWITHOURIRAQICOLLEAGUESOneofthecriticalmissionsofTF261wastoworktogetherwiththe62ndMedicalBrigadeandMNC-ItoassistourIraqicolleagues,bothintheMinistryofDefenseandtheMinistryofHealth,todevelopself-supportingsystemstoprovidecomprehensivehealthcaretotheIraqipopulace.

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96www.cs.amedd.army.mil/references_publications.aspxExpandingaProfessionalDentalCareSystem:ExperiencesofTaskForce261MultifunctionalMedicalBattalionDuringOperationIraqiFreedom07-09TF261sstaffincludedDrKhalid,*anativeIraqidentist,trainedintheUnitedKingdom,who,inconjunctionwithanappointedmastersergeant,coordinatedallofTF261spartnershipswithourIraqicounterparts.Earlyinthedeployment,DrKhalidmadecontactwiththeseniordentalofficersintheIraqiGroundForcesCommand(IGFC),theIraqiAirForce,andtheMinistryofHealth.Within6weeksofassumingthemissionin-theater,theTF261conductedthefirstinaseriesofcontinuingdentaleducation(CDE)programsattheMedicalBrigadeHeadquarters,VictoryBaseComplexinBaghdadwithlecturesonforensicodontologyandbonypathologyofthecraniofacialskeleton.FortheremainderofTF261sdeploymenttoIraq,additionalCDEeventswerepresentedevery6to8weeks,ledbythedentalcompanies,witheventsinBaghdad,Tallil,andBalad.EacheventexperiencedincreasedparticipationfromourIraqicolleagues.Eventually,CDEeventswereplannedbytheMinistries,withlecturesdevelopedandgivenbyIraqidentalofficers,andincludedotherCoalitionForces,includingRomanian,Polish,Austra-lian,andBritishdentalofficersandspecialists.TheprofessionalinteractionbetweenmembersoftheTaskForceandtheIraqiGroundForcesCommandwererecognizedbytheIGFCCommandSurgeon,BrigadierGeneral(Dr)JowadMadhi,astheepitomeofcooperationbetweenCoalitionandIraqiforces.BrigadierGeneralMadhiandDrKhalidlaterworkedtogethertodevelopnumerousotherprogramswithinthelargerTaskForce,includingcombatlifesavertraining,developmentofagroundambulanceandemergencymedicalresponsesystem,andstandardizationofbattalion-levelaidstations,allusingtheinterpersonalnetworksfirstestablishedbythedentalleadership.CONCLUSIONThroughthecoordinatedandsynchronizedeffortofavarietyofsubjectmatterexpertsatcompanyandbattalionlevel,TF261MultifunctionalMedicalBattalionwassuccessfulinimprovingthedeliveryofdentalcareacrosstheIraqtheaterofoperations,usingmultiplestrategiestosystemizeandstandardizepersonnelutilization,equipmentsupplyandstorage,theevacuationchain,informationtechnologysolutions,andpreventivemedicineefforts.Carewasalsooptimizedforthedetaineepopulation,andourIraqicolleaguesbecamepartofthecombineddentalcareeffortthroughoutIraq.Consolidatingdentalassetsunderoneheadquartersallowedeffectiveandseamlesscommandandcontrolofallefforts,alloweddevelopmentofatruedentalcaresystem,andensuredmissioncompletion.REFERENCES 1.MedicalCorpsProfessionalDevelopmentGuide.FortSamHouston,TX:USArmyMedicalDepartmentCenterandSchool;March2002:27.2.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006:3.3.ScottAEJr.Xylitolchewinggum:arecommendedadditiontotheMREpackage.ArmyMedDeptJ.January-March2006:56-58.AUTHORS Whenthisarticlewaswritten,thecoauthorswereassignedasfollows:LTC(P)ChristopherwasCommander,TaskForce261MultifunctionalMedicalBattalion(FortBragg,NC)deployedtoJointBaseBalad,Iraq.LTCPattersonwas(andis)Commander,673rdMedicalCompany(DentalServices)(FortLewis,WA)deployedtoJointBaseBalad,Iraq.SGMSmithwasSeniorClinicalOperationsNCO,TaskForce261MultifunctionalMedicalBattalion(FortBragg,NC)deployedtoJointBaseBalad,Iraq.CW4SmithwasChief,MedicalLogistics,TaskForce261MultifunctionalMedicalBattalion(FortBragg,NC)deployedtoJointBaseBalad,Iraq.CPTCobbwasassignedtothe464thMedicalCompany(DentalServices)(Landstuhl,Germany)andwasdeployedasOfficer-in-Charge,TheaterInternmentFacilityDentalClinic,CampBucca,Iraq.CPTPollardwasaBattleCaptain,TaskForce261MultifunctionalMedicalBattalion(FortBragg,NC)deployedtoJointBaseBalad,Iraq. *Namechangedforsecurityreasons.

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SUBMISSIONOFMANUSCRIPTSTOTHEARMYMEDICALDEPARTMENTJOURNALTheUnitedStatesArmyMedicalDepartmentJournalispublishedquarterlytoexpandknowledgeofdomesticandinternationalmilitarymedicalissuesandtechnologicaladvances;promotecollaborativepartnershipsamongtheServices,components,Corps,andspecialties;conveyclinicalandhealthservicesupportinformation;andprovideaprofessional,highquality,peerreviewedprintmediumtoencouragedialogueconcerninghealthcareissuesandinitiatives.REVIEWPOLICYAllmanuscriptswillbereviewedbytheAMEDDJournalsEditorialReviewBoardand,ifrequired,forwardedtotheappropriatesubjectmatterexpertforfurtherreviewandassessment.IDENTIFICATIONOFPOTENTIALCONFLICTSOFINTEREST1.Relatedtoindividualauthorscommitments:Eachauthorisresponsibleforthefulldisclosureofallfinancialandpersonalrelationshipsthatmightbiastheworkorinformationpresentedinthemanuscript.Topreventambiguity,authorsmuststateexplicitlywhetherpotentialconflictsdoordonotexist.Authorsshoulddosointhemanuscriptonaconflict-of-interestnotificationsectiononthetitlepage,providingadditionaldetail,ifnecessary,inacoverletterthataccompaniesthemanuscript.2.Assistance:AuthorsshouldidentifyIndividualswhoprovidewritingorotherassistanceanddisclosethefundingsourceforthisassistance,ifany.3.Investigators:Potentialconflictsmustbedisclosedtostudyparticipants.Authorsmustclearlystatewhethertheyhavedonesointhemanuscript.4.Relatedtoprojectsupport:Authorsshoulddescribetheroleofthestudysponsor,ifany,instudydesign;collection,analysis,andinterpretationofdata;writingthereport;andthedecisiontosubmitthereportforpublication.Ifthesupportingsourcehadnosuchinvolvement,theauthorsshouldsostate.PROTECTIONOFHUMANSUBJECTSANDANIMALSINRESEARCHWhenreportingexperimentsonhumansubjects,authorsmustindicatewhethertheproceduresfollowedwereinaccordancewiththeethicalstandardsoftheresponsiblecommitteeonhumanexperimentation(institutionalandnational)andwiththeHelsinkiDeclarationof1975,asrevisedin2000.IfdoubtexistswhethertheresearchwasconductedinaccordancewiththeHelsinkiDeclaration,theauthorsmustexplaintherationalefortheirapproachanddemonstratethattheinstitutionalreviewbodyexplicitlyapprovedthedoubtfulaspectsofthestudy.Whenreportingexperimentsonanimals,authorsshouldindicatewhethertheinstitutionalandnationalguideforthecareanduseoflaboratoryanimalswasfollowed.GUIDELINESFORMANUSCRIPTSUBMISSIONS1.Articlesshouldbesubmittedindigitalformat,preferablyanMSWorddocument,eitherasanemailattachment(withillustrations,etc),orbymailonCDorfloppydiskaccompaniedbyoneprintedcopyofthemanuscript.Ideally,amanuscriptshouldbenolongerthan24double-spacedpages.However,exceptionswillalwaysbeconsideredonacase-by-casebasis.Ingeneral,4double-spacedMSWordpagesproduceasinglepageof2columntextintheAMEDDJournalproductionformat.2.TheAmericanMedicalAssociationManualofStylegovernsformattinginthepreparationoftextandreferences.Allarticlesshouldconformtothoseguidelinesascloselyaspossible.Abbreviations/acronymsshouldbelimitedasmuchaspossible.Inclusionofalistofarticleacronymsandabbreviationscanbeveryhelpfulinthereviewprocessandisstronglyencouraged.3.Acompletelistofreferencescitedinthearticlemust beprovidedwiththemanuscript.ThefollowingisasynopsisoftheAmericanMedicalAssociationreferenceformat:Referencecitationsofpublishedarticlesmustincludetheauthorssurnamesandinitials,articletitle,publicationtitle,yearofpublication,volume,andpagenumbers.Referencecitationsofbooksmustincludetheauthorssurnamesandinitials,booktitle,volumeand/oreditionifappropriate,placeofpublication,publisher,yearofcopyright,andspecificpagenumbersifcited.Referencecitationsforpresentations,unpublishedpapers,conferences,symposia,etc,mustincludeasmuchidentifyinginformationaspossible(location,dates,presenters,sponsors,titles).4.Eithercolororblackandwhitephotographsmaybesubmittedwiththemanuscript.Colorproducesthebestprintreproductionquality,butpleaseavoidexcessiveuseofmultiplecolorsandshading.Digitalgraphicformats(JPG,GIF,BMP)andMSWordphotofilesarepreferred.Printsofphotographsareacceptable.PleasedonotsendphotosembeddedinPowerPoint.Imagessubmittedonslides,negatives,orcopiesofX-rayfilmwillnotbepublished.Forclarity,pleasemarkthetopofeachphotographicprintontheback.Tapecaptionstothebackofphotosorsubmitthemonaseparatesheet.Ensurecaptionsandphotosareindexedtoeachother.Clearlyindicatethedesiredpositionofeachphotowithinthemanuscript.5.Theauthorsnames,ranksoracademic/certificationcredentials,titlesorpositions,currentunitofassignment,andcontactinformationmust beincludedonthetitlepageofthemanuscript.6.Submitmanuscriptsto:EDITOR,AMEDDJOURNALATTN:MCCSDT2423FSH-HOODSTFORTSAMHOUSTON,TX78234-5078 DSN471-6301Comm210-221-6301Email:amedd.journal@amedd.army.mil