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Theses and Dissertations 1. Thesis and Dissertation Collection, all items 


1998-12 


Navy Capabilities and Mobilization Plan 
(NCMP) Annex Q - Health Services Support: 
resource and end strength implications 


Palermo, Michael S. 


Monterey, California. Naval Postgraduate School 


http://hdl.handle.net/10945/8722 


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DUDLEY KNOX LIBRARY 
NAVAL POSTGRADUATE SCHOOL 
* SITEREY CA 93943-5101 














NAVAL POSTGRADUATE SCHOOL 
Monterey, California 





THESIS 


NAVY CAPABILITIES AND MOBILIZATION PLAN 
(NCMP) ANNEX Q - HEALTH SERVICES SUPPORT: 
RESOURCE AND END STRENGTH IMPLICATIONS 


by 


Michael S. Palermo, Jr. 


December 1998 
Principal Advisor: Richard Doyle 


Approved for public release; distribution is unlimited. 








| REPORT DOCUMENTATION PAGE 


ee ss eee 


Form Approved 
OMB No. 0704-0188 





information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for 
reducing this burden, to Washington headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, 
Suite 1204, Arlington, VA 22192-4302, anc to the Office of Management anc Budget, Paperwork Reduction Project (0794-0185) Washingtor: 
DC 20503. 


1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE 3. REPORT TYPE AND DATES COVERED 
December 1998 Master’s Thesis 


4. TITLE AND SUBTITLE : NAVY CAPABILITIES AND MOBILIZATION PLAN OU BERE 
(NCMP) ANNEX Q — HEALTH SERVICES SUPPORT: RESOURCE AND END 
STRENGTH IMPLICATIONS 


6. AUTHOR(S) Palermo, Jr., Michael S. 


7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 


instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of 


8. PERFORMING 
ORGANIZATION REPORT 


Naval Postgraduate School NUMBER 


Monterey, CA 93943-5000 


9. SPONSORING / MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/ 
MONITORING 
AGENCY REPORT NUMBER 


11. SUPPLEMENTARY NOTES The views expressed in this thesis are those of the author and do not reflect the official 
policy or position of the Department of Defense or the U.S. Government. 


12a. DISTRIBUTION / AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE 
Approved for public release; distribution is unlimited. 


13. ABSTRACT | 
Medical end strength and medical readiness policies have been impacted by post Cold War operations and 
downsizing of the Department of Defense (DoD). This study reviews Navy medicine's reengineering efforts 
intended to address these policies, focusing on the revision of the medical annex of the Navy Capabilities and 
Mobilization Plan (NCMP), used in support of DoD operational planning. It details the revision process, 
explaining the factors influencing the process, including the changes in medical doctrine, and the 
organizations involved. Data were obtained through interviews with key Navy planning and medical 
personnel and a review of DoD and Navy orders, publications and directives. The update of the medical 
annex has diminished the medical material supply support needed for the Casualty Receiving and Treatment 
Ships (CRTS), reducing weight and cargo space requirements, and producing some small budget savings as 
well. The update also provides a substantial reduction in the bed space capacity and medical personnel 
augment package supporting the new capabilities. 








14. SUBJECT TERMS Navy Capabilities and Mobilization Plan 






15. NUMBER 
OF PAGES 


97 


16. PRICE 
CODE 


17. SECURITY a CR CLASSIFICATION | ¡9 SECURITY E ga rd 
CLASSIFICATION OF REPORT CLASSIFICATION OF 


Unclassified ABSTRACT OF ABSTRACT 
Unclassified UL 


NSN 7540-01-280-5500 Standard Form 298 (Rev. 2-89) 
Prescribed by ANSI Std. 239-18 





Unclassified 








Approved for public release; distribution is unlimited. 


NAVY CAPABILITIES AND MOBILIZATION PLAN (NCMP) 
ANNEX Q - HEALTH SERVICES SUPPORT: RESOURCE AND 
END STRENGTH IMPLICATIONS 


Michael S. Palermo, Ir: 
Major, United States Marine Corps 
B.S, St. John Fisher College, 1985 


Submitted in partial fulfillment of the 
requirements for the degree of 
MASTER OF SCIENCE IN MANAGEMENT 
from the 


NAVAL POSTGRADUATE SCHOOL 
i - December 1998 








DUDLEY KNOX LIBRARY 
NAVAL POSTGRADUATE SCHOOL 


ABSTRACT MONTEREY CA 93943-5101 


Medical end strength and medical readiness policies have been impacted by post 
Cold War operations and downsizing of the Department of Defense (DoD). This 
study reviews Navy medicine's reengineering efforts intended to address these 
policies, focusing on the revision of the medical annex of the Navy Capabilities 
and Mobilization Plan (NCMP), used in support of DoD operational planning. It 
details the revision process, explaining the factors influencing the process, 
including the changes in medical doctrine, and the organizations involved. Data 
were obtained through interviews with key Navy planning and medical personnel 
and a review of DoD and Navy orders, publications and directives. The update of 
the medical annex has diminished the medical material supply support needed for 
the Casualty Receiving and Treatment Ships (CRTS), reducing weight and cargo 
Space requirements, and producing some small budget savings as well. The update 
also provides a substantial reduction in the bed space capacity and medical 


personnel augment package supporting the new capabilities. 








I. 


HI. 


TABLE OF CONTENTS 


INTRODUCTION. .............2.0e.220e. m... Sn 2 l 
A. BACK GROUND E .. Se 1 
B. RESEARCHIOBIECTIVES T.19: ss. ER. 4 
E: ES A « 5 Se 4 
D. LIMITATIONS ee ee ne 5 
En METHAODOLOGY ...0 a ci ER 5 
Es ORGANIZALION sa u... Ann 6 
REVIEW OF NAVY READINESS REENGINEERING EFFORTS........... 7 
A. INTRODBUC TIONMOTACSRE MM nn 0 0 7 
ix Missions of Navy Medicine 2... a 8 
2. The Logiciot the TDHCSR Raa... rm 13 
B. READINESS REENGINBERINGIEREEORFTB..... 282... 17 
Ip Medical Readiness Strategic Plan (MRSP)........................... 18 
2: korce Medical Protection (EMP. een... 20 
> Readiness Reengineering Plan (RRP) EEE ER 2. E 
ts a Eo ERR ne... 26 
MILITARY PLANNING AND THE NAVY CAPABILITIES 
AND MOBILIZATION PLAN aaa erties 2. 0s vitae. cidade 29 
A. DEFENSEPLANNAG ae... n.d 29 
IE Joint Strategreblanmimeasystem (JISPS sa... e. 30 


vil 


IV. 


B. PIANO E isere isaac 


IL. Joint Operational Planning and Execution System 
CODE ET A 
BASIS FOR MILITARY PLANNING o.ccccccconoonononononcncconononencnnonos 


NN ra e: as. A A a i 
E Capabilities nia MA A 
2. Mobilization Planning Direction... ossos 
> Nay Casualty Rates a an a occ nos 
IE. ANNE X O MPROPOSEBIERNANÇGE Sm... snecesnensioses 
IE AENA eos ais atessmanisnaane 
2 Capabilities O E a 
EN Navy Casal ARG a 
G. A eeri 
UPDATE OF THE NAVY CAPABILITIES AND MOBILIZATION 
A nn... ee a aed 
A. RESRONSIBICI OR NOME re Bea 
B. EROCE S TOTEPDATE NCMP ae ee... 
E. DRIMVERSBEHIND UPDATE OF NCMP TSR ooo 
DA BIESBONS IBIEINZEORSANNE O A a 
E: EROCESSITOIER PARTNER nn sunsonsseneesenunncunennn 
je THE ROLE OF MEDICAL DOCTRINE IN THE UPDATE 


INE O e A eaaa 


er SUMMARY... O 66 


NE SUMMAR Y, CONCLUSIONS AND RECOMMENDATIONS FOR 


EUIADIRE SUPRA... ss aa 67 
A. SUMMARY aceite aço ai RSRS aa O AR 67 
B: CONCEUSIONS oee nono E 69 
C RECOMMENDATIONS FOR FUTURE STUDY T 2 ee 02 
APPENDIX A. MAJOR DOCTRINAL AND POLICY DEVELOPMENTS 
AFFECTING MEDICAL READINESS 198821999 ......... ae... > 
DELENDPEB. NEMP ANNEX PRESBONSIBIELTY a 0 RA a Br 
APPENDIX C. MILITARY HEALTH SYSTEM FIVE ECHELONS 
EST TER. o NL ee e re O NI 19 
LIST OF REFERENCES oeeie en risainia 1i aa. 81 
ENRIAL DISTRIBUTIONDEIS [ 2.622. AA TIO 85 








I. INTRODUCTION 


A. BACKGROUND 

The end of the Cold War presented numerous challenges to the assumptions 
that were fundamental to the process of military readiness planning. Major 
changes in post Cold War strategy led to changes in force structure, missions, and 
anticipated casualty rates. [Ref. 1] The United States Congress, in an effort to 
improve efficiency and save scarce resources, began to look at a post Cold War 
Department of Defense as a key area to reduce the budget. 

Additionally, the lessons learned from operations conducted in this past 
decade, from the single Major Regional Conflict (MRC) -- Desert Shield/Desert 
Storm, to current peacekeeping and humanitarian operations such as Haiti, Cuba, 
and Bosnia, have been plentiful. No area of the military environment has escaped 
scrutiny, including the health service support system. These lessons learned, in 
conjunction with the strategic implications of the end of the Cold War and the 
downsizing of the Department of Defense, have impacted medical end strength and 
medical readiness policies. 

As far back as 1985, Department of Defense medicine has been under 
revision. In the National Defense Authorization Act passed that year, Congress 


directed the Secretary of Defense to produce a plan for revising the organizational 


structure Of the military health care delivery system. [Ref. 2] This plan would 
enhance medical readiness by standardizing the methodology used to determine 
the number of personnel, force structure, and specialty mix necessary to support 
goals and objectives delineated in the Department of Defense’s annual Defense 
Planning Guidance (DPG). 

In Section 733 of the National Defense Authorization Act for fiscal years 
1992 and 1993, Congress directed the Department of Defense to conduct a study of 
the military medical care system. [Ref. 3] The Department of Defense was 
directed to determine the size and composition of the medical system needed to 
support the armed forces during a war, or lesser conflict, in the post Cold War era. 
The study challenged the Cold War assumption that all medical personnel 
employed during peacetime are needed for wartime. Its conclusion that wartime 
medical requirements are much lower — by as much as half — than the medical 
system programmed for fiscal year 1999 raises the question of whether U.S. 
military medical forces should be reduced to only those needed for wartime [Ref. 
4]. This study, commonly referred to as the 733 study, became a reference for 
many follow-on medical publications. 

The Navy’s initial response to these developments was the Total Health 
Care Support Readiness Requirement (THCSRR) model. This model was 


developed to precisely identify the readiness requirement for medical personnel 


(officer, enlisted, active and reserve) to support both the day-to-day mission of the 
Navy and the most demanding go-to-war missions. In order to implement 
THCSRR, as well as address other changing requirements, Navy medicine created 
the Readiness Reengineering Plan (RRP). The RRP has recently stood-up Navy 
medicine’s Readiness Reengineering Oversight Council (RROC), the Readiness 
Reengineering Task Force (RRTF) and its Tiger Teams (finance, operations, 
education and training, evaluation, marketing, fit force, project support), the 
Deployable Medical -Platforms Advisory Council (DMPAC), and the Naval Health 
Services Doctrine Board (NHSDB). 

One outcome of these changes is a proposed revision of the Health Services 
Support annex, Annex Q, of the Navy Capabilities and Mobilization Plan (NCMP), 
OPNAVINST S3061.1D. The purpose of the NCMP is to provide policy guidance 
for the phased expansion of approved support forces in the U.S. Navy. The NCMP 
provides the basis for Navy mobilization planning in consonance with the Joint 
Strategic Capabilities Plan (JSCP). [Ref. 5] | 

However, the NCMP was last published in April 1993 and, although it 
contained references to the 733 study, it was prepared prior to the collection of 
lessons learned from Desert Shield/Desert Storm. Additional lessons learned from 
medical missions conducted in support of peacekeeping and humanitarian 


operations have also been collected since the last publication of the NCMP. 


U) 


B. RESEARCH OBJECTIVES 

The main objective of this thesis 1s to answer the primary research question: 
What are the resource and end strength implications of the update of the medical 
annex of the Navy Capabilities and Mobilization Plan? 


Secondarily, this thesis will also attempt to answer the following subsidiary 


questions: 
- How has Navy medicine reorganized since the end of the Cold War? 
- Within this context, what 1s the significance of the medical annex of 
the NCMP? 
- What process has been used to revise the medical annex of the 
NCMP? 
- What are the most significant impacts of the update to the medical 
annex of the NCMP? 
E. SCOPE 


This thesis will explore the background of the Navy Capabilities and 
Mobilization Plan (NCMP) and information concerning issues that brought about 
the proposed changes in the revision of the NCMP. This thesis will also include an 
examination of Navy medicine’s reengineering process as well as the Total Health 
Care Support Readiness Requirement (THCSRR) model. It will provide a 


comparison between the old Health Services Support annex, Annex P, and the new 


one, Annex Q. This thesis will attempt to identify the benefits the Department of 


Defense, and the Navy in particular, anticipates once the NCMP is implemented. 


D. LIMITATIONS 

The only limitation encountered in the research of this topic is that the Navy 
Capabilities and Mobilization Plan is in a draft version and not fully developed. 
This has limited the amount and type of documentation and information that is 
available for review. Much of the analysis conducted by this thesis on the medical 
end strength issue is based upon information that is a result of interviews 


conducted with key Navy personnel responsible for the Annex Q revision. 


E. METHODOLOGY 

Archival research methods were utilized to gather data for this thesis. 
Documents that were reviewed include, but were not limited to, Department of 
Defense reports, including Inspector General reports, GAO reports, congressional 
reports, pertinent Department of Defense directives and manuals, and interviews. 
Additional information was obtained through a review of current military 
periodicals, journals and the Internet. A comprehensive compilation of this data 
provided the basis for the information required to answer the research questions 


posed in this thesis. 


E: ORGANIZATION 

The first chapter of this thesis provides an introduction to the topic. The 
remaining chapters will strive to answer the primary research question as well as 
the subsidiary research questions. 

Chapter II presents a review of the Navy Readiness Reengineering efforts to 
date, to include an introduction to the Total Health Care Support Readiness 
Requirement (THCSRR) model. 

Chapter III will provide an introduction to the Navy Capabilities and 
Mobilization Plan (NCMP). This chapter will also provide a comparison of the old 
Health Services Support annex, Annex P, to that of the new one, Annex Q. 

Chapter IV will discuss the process of updating the NCMP and its content 
and drivers. 

Chapter V will conclude this thesis with a summary, conclusions, and 


recommendations for future study. 


IH. REVIEW OF NAVY READINESS REENGINEERING EFFORTS 


This chapter will take a closer look at Navy medicine”s response to changes 
that have impacted the Military Health System. Specifically, 1t will examine the 
Total Health Care Support Readiness Requirement (THCSRR) model and its 
component parts. It will also present a review of the Navy Readiness 


Reengineering efforts to date. 


A. INTRODUCTION TO THCSRR 

The National Defense Authorization Act for fiscal years 1992 and 1993 
directed the Department of Defense to conduct an analysis of the fundamental 
economic issues bearing on the size of the military medical care system. [Ref. 3] 

This legislation was the product of several factors, most notably the 

end of the Cold War and the subsequent downsizing of the 


Department of Defense and the continued growth in the cost of the 
military health care benefit. [Ref. 6] 


The resulting study, conducted by the Office of the Secretary of Defense, 
Program Analysis and Evaluation, commonly called the “733 study,” concluded 
that only half of the active-duty physicians projected to be available in Fiscal Year 
1999 would be required to meet wartime demands. [Ref. 4] This assessment, 
coming on the heels of the findings of the Base Force, the first Medical Readiness 


Strategic Plan (MRSP) in 1988, and the lessons learned in Operation Desert 


Shield/Desert Storm, further increased pressures to “rightsize” the military medical 
care system. 

To meet the challenge for Navy medicine, the Surgeon General of the Navy 
commissioned detailed reviews of the Navy’s medical readiness requirements. 
The Center for Naval Analysis (CNA) was asked to “define Navy medical 
manpower requirements that were not covered in the 733 study.” [Ref. 7] The 
Office of the Surgeon General subsequently developed a new model, combining 
and revising the wartime portion of the 733 study and the CNA study. The Navy’s 
new model, a response to budgeting and legislative pressures to downsize, was the 
Total Health Care Support Readiness Requirements (THCSRR) model. This 
model allows Ne medicine to accurately determine and en active duty 
manpower readiness requirements for the two readiness missions assigned to Navy 
medicine — wartime and day-to-day operational support to the fleet and Fleet 
Marine Force (FMF). The key to understanding how Navy medicine addresses its 
manpower readiness requirements is to examine the two missions of Navy 
medicine. 

1. Missions of Navy Medicine 

a. Readiness Mission 
The two missions of Navy medicine are termed the readiness mission 


and the peacetime benefit mission. The readiness mission is comprised of two 


elements. The first of these, and one component of THCSRR, is to provide 
resources to meet Navy wartime medical requirements. The wartime mission is 
driven by Defense Planning Guidance that specifies the need to provide medical 
care in a scenario defined by two nearly simultaneous major regional conflicts 
(MRCs). 
The 733 study categorized wartime requirements as either workload- 

based or structure-based. 

Workload-based wartime medical requirements were constructed 

using force levels, arrival times, and combat intensities outlined in 


the Illustrative Planning Scenarios of the Defense Planning Guidance 
for fiscal years 1994-1999. [Ref. 7] 


Using the guidelines provided by the Defense Planning Guidance, 
the Navy used an analytical tool known as the “Medical Planning Module (MPM)” 
to simulate admissions and define medical requirements. Input parameters for the 
MPM include wounded in action (WIA) rates, disease and non-battle injury 
(DNBI) rates, and evacuation policy. A DNBI rate was determined based on 
inputs from the Military Departments and historical information on Korea, 
Vietnam and Operation Desert Storm. [Ref. 7] WIA rates for the 733 study were 
based on Department specific cias: For the Navy, casualty rates were 
taken from the Navy Capabilities and Mobilization Plan (NCMP). “Casualty 


estimates are critical to the determination of wartime medical requirements.” [Ref. 


6] Evacuation policy is a function of decisions made by operational commanders 
concerning the maximum number of days of noneffectiveness a patient may be 
held for treatment within the theater of operation. Casualties that cannot be 
returned to active duty status within this time frame are evacuated. [Ref. 7] 

Structure-based wartime requirements involve all medical personnel 
organic to specific units needed during wartime or to sustain wartime units. Many 
of these requirements were extracted from the Total Force Manpower Management 
System (TEMMS), commonly known as the “billet file.” [Ref. 7] Wartime billets 
are linked directly to ships and Fleet Marine Force units through “Required 
Operational Capability and Projected Operational Environment (ROC/POE) for the 
Navy and Table of Organization and Equipment (TO&E) for the Marine Corps.” 
[Ref. 8] 

The wartime mission for Navy medicine also includes mobilizing 
two hospital ships, numerous fleet hospitals, providing augmentation of medical 
personnel to certain classes of ships, supporting the fleet and the Marine Corps” 
operations ashore and afloat, and maintaining outside of the Continental United 
States (OCONUS) military treatment facilities (MTFs) and dental treatment 
facilities (DTFs). 

The second element of the readiness mission of Navy medicine, and 


another component of THCSRR, is the day-to-day operational support 


10 


requirement. The day-to-day operational component has “at its foundation a study 
completed in 1994 by the Center for Naval Analysis (CNA).” [Ref. 7] The basic 
premise of the CNA analysis is that there are certain billets and locations in the 
Navy medical community that must be filled for the Navy to perform its mission 
on a daily basis. These fall into two categories: the Peacetime Operational Force 
(POF) and the Continental United States (CONUS) rotation base needed to support 
thesBOF, 

The Peacetime Operational Force category is comprised of billets 
with the fleet and Fleet Marine Forces OCONUS and those located in isolated sites 
within the United States (ICONUS). Fleet and Fleet Marine Force billets are 
similar to the organic billets previously discussed, but POF billets include only 
those which are required during peacetime. 

Rotation base billets must be added to the day-to-day requirement 
because it is expected that personnel serving in operational 


assignments will be replaced periodically by personnel serving in 
non-operational billets. [Ref. 6] 


To determine the Peacetime Operational Force, THCSRR focuses on 
personnel authorized in the billet file. 
The CONUS rotation based category is needed to support the 


Peacetime Operational Force. The rotation base provides a pool of skilled and 


11 


trained active duty medical personnel from which to draw upon to relieve the 
Peacetime Operational Force billets. 

An analytical tool called set theory was then applied to the data sets 
derived from the wartime medical requirements and the day-to-day operational 
support requirements. The objective was to find the “union” of the two data sets. 
Thus if the wartime and day-to-day requirements for General Surgeons were 100 
and 50 respectively, the union of these two sets would be 100, the larger number. 
“The fundamental notion is that if a billet was needed for either the wartime or the 
day-to-day requirement, it had to be included in Navy medical end strength.” [Ref. 
6] 

b. Peacetime Health Benefit Mission 

The second mission of Navy medicine is the peacetime health benefit 
mission. This mission provides health care for 2.5 million beneficiaries through 
either direct care or the TRICARE system. While both missions are imperative to 
Navy medicine, it is the first mission, the wartime and day-to-day operational 
requirements that determines the number of active duty Navy personnel in 
uniform. The THCSRR does not address the peacetime benefit mission. 

It is only because of these two readiness requirements that Navy 
personnel are available to support the second mission, the peacetime 


benefit mission, providing medical and dental care in the CONUS 
medical treatment facilities and dental treatment facilities. [Ref. 9] 


12 


2: The Logic of the THCSRR 

The THCSRR model has two main components. The first component 
derives active duty manpower readiness requirements necessary to complete both 
readiness requirements. The second component programs the sustainment 
requirements needed to maintain the readiness manpower requirements for future 
years. The fact that certain billets are inherent in Navy medicine’s readiness 
mission (wartime and day-to-day) prohibits the simple addition of the two sets of 
readiness requirements. 

a. Medical Operational Support Requirements (MOSR) 

The first component of the THCSRR is known as the Medical 
Operational Support Requirement (MOSR). The MOSR is obtained from a union 
of the manpower readiness requirements, denoted in both the wartime and day-to- 
day operational studies, at the subspecialty level. Through this union, the MOSR 
filters out redundancies yet is able to maintain unique billets. 

The MOSR is derived by combining two databases. The first 
database included active duty requirements from the 733 study. The second 
database included active duty requirements from the CNA study, to include the 
rotation base needed to support this operational requirement. 


A union of the requirements from these two studies resulted in a 
third set of requirements that define the minimum number of fully 


trained active duty personnel required to accomplish both 
requirements. [Ref. 9] 


b. Sustainment 
Once the MOSR has been defined, giving us our first component, the 
second component of the THCSRR model can be determined by quantifying a 
sustainment requirement for the MOSR. Sustainment requirements allow for a 
continuous flow of qualified personnel into MOSR specified jobs as personnel 
attrite (either from the Navy or from their current skill level to a higher skill level). 
‘Sustainment is composed of four elements: loss rates; training billets; mission 
continuity; and Transients, Patients, Prisoners, and Holding (TPP&H).” [Ref. 7] 
Loss rates are used to determine the number of medical personnel that must be 
recruited into the system to replace losses. 
Training billets include Graduate Medical Education (GME) training 
billets and GME residency programs with the Residency Review 


Committee (RRC) of the American Council for GME (ACGME). 
[Ref. 7] 


Mission continuity includes staff billets that provide the appropriate 
stability, senior credibility and experience for the rotation base. The TPP&H 
element incorporates personnel who are either in the hospital, in the process of 
moving, on legal or administrative hold, or in prison. 

The sustainment requirement is the calculated number of billets 


required for officers and enlisted in training and must be added to the MOSR. 


14 


Therefore, adding the MOSR and the sustainment component together completes 
the THCSRR model and provides the total active manpower readiness requirement 


for Navy medicine. This is shown in Figure 1. 


Active Component 


ER 


i «e 
RN 





+ Sustainment 





e, ORE 2 
me SIS 
u Zi er 
a gra, ra >) d k 
z 4 LM Ss Sf tage i = 
e A un E $ = 
e cin ny Doa 5 7 uo i 
a LO ATA E, Ea n o 





Figure 1. Total Healthcare Support Readiness Requirement 
(THCSRR) Model Defined 


C. Strengths and Weaknesses 

The THCSRR model has its benefits as well as some problems. The 
model is dynamic and it is able to accommodate changes made to the Department 
of Defense missions it is designed to support. The THCSRR model also has the 
capability to demonstrate the impact of changes in Navy medicine’s mission 
priorities. 


As the Department of Defense, the Joint Chiefs of Staff and the 
services make adjustments in strategic planning and force structure, 


IS 


the THCSRR model can be used to generate new estimates for Navy 
medical personnel. [Ref.6] 


Finally, the THCSRR model is valid in that the subspecialty-level 
union of wartime and day-to-day operational mission requirements allows Navy 
medicine to have credible requirements to present to Department of Defense and 
congressional manpower experts. The THCSRR model has been adopted by JCS, 
ASD (HA), OSD and other services as “the medical force structure sizing model 
for medical readiness manpower requirements.” [Ref. 6] 

There are also some potential problems with the THCSRR model 
that deserve some attention. Many of the critical data input parameters may be 
known only imprecisely and are determined in part by current capabilities and 
institutional incentives. Data input has an enormous impact on results of the 
model, especially in the complicated arena of manpower. 

Lastly, the THCSRR model was a response to the 733 study. But the 
733 study neglected the day-to-day operational mission of Navy medicine. As a 
result, the study was too narrow and did not fully define the continuum of Navy 
medicine. The 733 study 1s static, designed to provide a snapshot in time of the 
military health service support system, whereas the THCSRR is designed to be a 
dynamic model, capable of providing current information on medical readiness 


requirements. 


16 


Regardless of these issues, the Navy was the first of the military 
services’ Medical Departments to have such a requirements model. Its 
implementation, through the Readiness Reengineering Plan, was important to: 


ensure that Navy medicine will be able to meet its readiness mission. 


B. READINESS REENGINEERING EFFORTS 

Since the end of the Cold War there has been considerable change in 
national security strategies, military requirements and missions, and health care in 
the nation. These changes have impacted the Military Health System (MHS); they 
are the environments within which military medicine operates. Change, and the 
turmoil created by change, will likely continue into the future. 

Within this environment, 

[tlhe MHS must meet the requirements and responsibilities of its 

twin missions: care and treatment for our troops wherever and 

whenever they need it (the readiness mission), and a high quality, 


cost-effective and accessible health care benefit for our other 
beneficiaries (the peacetime benefit mission). [Ref. 10] 


Lessons learned from the Gulf War suggested that the level of medical 
readiness by each of the services was inadequate. [Refs. 11, 12, 13] In response to 
the criticism, the Department of Defense, along with the services, embarked upon 
initiatives to correct shortfalls in wartime medical capabilities and improve 


medical readiness. Congress, also addressing some medical shortcomings, 


D 


established the Defense Health Program in 1992 to centralize the budget for all 
military medicine. 
The assumption behind the Defense Health Program is that the 
Department of Defense and Congress will be better able to 


understand, and therefore manage, spending for military healthcare if 
the programs were aggregated and therefore, more visible. [Ref. 6] 


Those shifts required the development of a new joint health system strategy 
that maximized the synergistic effects of the services’ medical elements through 
jointly coordinated, comprehensively planned and mutually supportive medical 
operations. 

1. Medical Readiness Strategic Plan (MRSP) 

In order to meet these requirements and to support both the wartime and 
health benefit missions of the MHS, the Department of Defense developed a 
medical plan. 

In 1988, the Department of Defense published the first Medical 

Readiness Strategic Plan (MRSP) in response to a Congressional 

mandate to develop an integrated master plan’for curing the ills of 


the wartime medical readiness system by the end of Fiscal Year (FY) 
1992. [Ref. 14] 


The strategy of the MRSP is to continuously improve overall medical 
capabilities to provide health services support to the Armed Forces. 
Not long after the original MRSP was fielded, efforts to implement the plan 


were “overcome by major world and national events, which radically altered the 


global security picture, and ultimately reshaped our National Military Strategy.” 
[Ref. 14] These events were of such magnitude that “by 1995, a second edition 
had been prepared, reflecting much of what was then understood about the post 
Cold War security environment and the new health service support requirements.” 
[Ref. 6] While developing new chapters for the MRSP, it was recognized that the 
original chapters were becoming dated and a series of panels was conducted to 
review the original chapters. 

The third and most recent version of the MRSP was released in 1998 and is 
titled the MRSP 1998-2004. This latest edition makes accommodations for 
advances in technology and further reductions in the Armed Forces. It revises 
Strategy to “take a medicine from the concept of definitive no in a theater 
of operations to one of essential care in theater, enhanced aeromedical evacuation 
and definitive care in the U.S.” [Ref. 10] The new concept fully supports the 
Chairman of the Joint Chiefs of Staff’s Joint Vision 2010, which was published in 
1996. It provides for a healthy, fit and medically ready force with the ability to 
counter the health threat to the deployed force, and the provision of critical care 
and management for combat casualties. This is known as Force Medical 


Protection. 


19 


Dis Force Medical Protection (FMP) 

Force Medical Protection is defined as “a unified strategy that protects 
service members from all health and environmental hazards associated with ' 
military service.” [Ref. 15] It provides focus for a unity of effort and relies upon 
all the capabilities of the Military Health System for successful implementation. 
Force Medical Protection is best viewed as building upon a J-4 developed joint 
medical doctrine called the Joint Health Service Support (JHSS) 2010. It can be 
viewed as extending “the scope of joint medical doctrine and putting considerably 
more emphasis upon protecting forces from medical threats, especially within the 
combat theater.” [Ref. 6] The three pillars of Force Medical Protection, Healthy 
and Fit Force, Casualty Prevention, and Casualty Care and Management, are the 
basis for the Navy’s Naval Force Health Protection for the 21St a (NFHP- 
21) concept. 

The NFHP-21 is an enabler to the Navy and Marine Corps operational 
concepts Forward from the Sea and Operational Maneuver from the Sea, 
respectively, and is congruent with the National Military Strategy and Joint Vision 
2010. The NFHP-21 concept represents a dynamic continuum that combines: 

[pJeacetime engagement to create and maintain a healthy and fit 

force; a wartime deterrence to prevent casualties from disease and 

non-battle injury; and casualty care and management processes to 


minimize the medical logistics tail and to rapidly stabilize and 
transport casualties to the right level. [Ref. 16] 


20 


The MRSP and the services” medical reengineering programs “are 
addressing common goals: to be lighter, smaller, more mobile, and adaptable to 
different mission requirements.” [Ref. 17] 

3; Readiness Reengineering Plan (RRP) 

As previously discussed, the Navy’s initial response to the debate 
concerning the ‘correct’ size of Navy medicine was the creation of the Total 
Health Care Support Readiness Requirement (THCSRR) model. In order to 
implement THCSRR, as well as address other requirements, Navy medicine 
created the Readiness Reengineering Plan (RRP). The RRP is a comprehensive 
strategic plan to improve Navy medicine’s preparedness for its Defense Planning 
Guidance assigned readiness missions. One definition of readiness is the ability of 
forces, units, weapon systems, or equipment to deliver outputs for which designed. 
“Additionally, JCS doctrine states that readiness requires (1) the right people, (2) 
with the right training (unit and individual), (3) with the right equipment, (4) in the 
right place at the right time.” [Ref. 18] 

To address the personnel a. the implementation and continued refining 
of the THCSRR model will quantify the number of “the right people,” and initiate 
actions required for readiness realignment. As force structure issues are being 


resolved, and firm implementation plans established, Navy medicine is moving to 


21 


realign 1ts billet structure to put THCSRR at the core of every Medical and Dental 
Treatment Facility. 

The Navy’s response to “the right training” issue is the Readiness 
Realignment Plan. Often referred to as the “Galactic Radiator,” this plan was 
developed to align major casualty care platforms with specific naval hospitals. See 
Figure 2. “Its premise is the THCSRR, the need to improve Navy medical 
readiness to account for lessons learned from Desert Shield/Desert Storm and to 
address certain changes in the post Cold War security environment.” [Ref. 6] This 
alignment also clarified the requirement for actual readiness training facilities in 


peacetime, and those required for casualty care in wartime. 


P w tee ii aoa = aa 
[Hh EG = = Sea 
E FleéuFMF Ä Fe — em 


‚Augment 
a 4 j 











See pr napa. a 


Core Military Functions 


Fleet/Fleet Marine Force Augmenting Personnel 


> _.... OCONUS MTF Augmenting Personnel | 
Rotation Base Medical and Dental Staff (Non-augm 


ra ei 0 m AA een a en re 


sm san he 


wy 
es > 
RT se 





i 
v 


SPECIALTY TEAMS - PNDL 
SPECIALTY TEAMS - PCLA 


* 
A 
Dash: 


SPECIALTY TEAMS -LEJ 


a 


e...) 
E 
. 
ES, 
> 





Figure 2. Readiness Re-Alignment Plan: Unit Training 


22 


One of the more heated topics in Navy medicine has revolved around the 
number of Medical Treatment Facilities required to meet the readiness mission. 
The Navy’s response to this “right equipment” issue was the development of the 
CONUS Healthcare Readiness Infrastructure Sizing Model (CHRISM), as shown 
in Figure 3. This model looks at the individual readiness requirements for CONUS 
Medical Treatment Facilities: (1) care of wartime casualties, (2) unit readiness 
training, (3) rotation base for overseas and deployed personnel, and (4) THCSRR 
medical skills training. It then creates a union of the four requirements to 
determine the “minimum need for inpatient Medical Treatment Facilities.” [Ref. 


18] 


TAIL 2 CRTS, 
FMF, OCONUS 


É C. Lejeune | C. Lejeune | 
Leleo (Cherry Pr) Ea == = 


i 
C. Pe: santos €. Pendicton 
ema | 
í == 





Figure 3. CONUS Healthcare Readiness Infrastructure Sizing Model 
(CHRISM) 


Navy medicine is forward deployed throughout the world on a continuous 
basis. “Approximately 30 percent of Navy medical personnel are supporting 
forward-deployed operational and overseas units.” [Ref. 18] It is with these 
statistics that the Navy responds to “the right time and place” issue. 

a. Readiness Reengineering Oversight Council (RROC) 

These pieces to the medical readiness puzzle -- THCSRR, Readiness 
Realignment Plan, and CHRISM -- go a long way toward defining Navy 
medicine’s plan. The Readiness Reengineering Oversight Council (RROC) is one 
key to putting the pieces together. 

The RROC was chartered in 1997 by then Navy Surgeon General 
Vice Admiral Harold M. Koenig. It provides flag officer level oversight of Navy 
medicine’s readiness reengineering efforts. 

The RROC is currently chaired by Navy Deputy Surgeon General 

Rear Admiral S. Todd Fisher and includes all of the Assistant Chiefs 

at the Bureau of Medicine and Surgery (BUMED MED-01 through 

MED-08, inclusive); the Director of Medical Resources, Plans and 

Policy on the Chief of Naval Operations staff (OPNAV N931); the 

Commander-in-Chief, Atlantic Fleet Surgeon; the Commander-in- 


Chief, Pacific Fleet Surgeon; and the Medical Officer of the Marine 
Corps. Rei. 19] 


The RROC exists to develop new doctrine, strategies and 
management systems to successfully meet the challenges of a new operational 


environment. 


(1) Readiness Reengineering Task Force (RRTF). While the 
RROC provides oversight, three subordinate groups tackle the readiness reengineering 
initiatives. The first of these is the Readiness Reengineering Task Force (RRTF). The 
RRTF is an action officer level matrix organization composed of six functional teams. 
These six teams are Education and Training; Evaluation; Finance; Fit and Healthy Force; 
Marketing; and Operations. Currently, four of the six teams have constructed specific 
goals to assist them in achieving the RRTF’s overall mission. 


The mission of the Task Force is to guide the Program Objective 
Memorandum (POM) process with the goal of supporting Navy 
medicine’s operational platforms with (1) the right personnel, (2) the 
right training, and (3) the right equipment. [Ref. 20] 


(2) Naval Health Services Doctrine Working Group 
(NHSDWG). The second group under the RROC is the Naval Health Services 
Doctrine Working Group (NHSDWG). This group facilitates Navy medicine’s 
input into the health service support doctrine development process. 
The mission of the NHSDWG its to work in conjunction with the 
Naval Doctrine Command (NDC) and the Marine Corps Combat 
Development Command (MCCDC) on development of doctrine and 
selected tactics, techniques, and procedures for the establishment, 


deployment, and employment of health service support platforms in 
support of naval forces. [Ref. 21] 


The NHSDWG will focus the scope of its work on 
augmentation medical forces for operational units including Marine Forces, large 


deck amphibious ships, and other units identified in the Navy Capabilities and 


Mobilization Plan (NCMP). To date, the NHSDWG has completed updates, both 
revised and new, for the health service Naval Warfare Publication (NWP) series 
issued in April 1998. 

(3) Deployable Medical Platforms Advisory Council 
(DMPAC). The third group under the RROC is the Deployable Medical Platforms 
Advisory Council (DMPAC). The DMPAC provides expertise on issues involving 
Casualty Receiving and Treatment Ships, Fleet Hospitals, Hospital Ships and other 
deployable medical platforms. “The purpose of the DMPAC is to serve as a forum 
to link reengineering and doctrinal efforts with platform considerations.” [Ref. 22] 
Additionally, under the DMPAC, the Consolidated Integrated Logistics Support 
Working Group (CILSWG) exists to provide expert advice on medical logistics 
issues and facilitate a continuous process of improvement and interoperability 
across the deployable medical platforms. 

All of these pieces of the RROC organization meet at a 
minimum of semi-annually, with most meeting more frequently, in an effort to 
implement THCSRR and keep the readiness reengineering efforts on course for the 


future of Navy medicine. 


C. SUMMARY 
Navy medicine has responded positively to a myriad of changes that have 


impacted the Military Health System. In order to meet evolving readiness 


26 


missions, the Navy developed a model that calculated the personnel needed, both 
active and reserve, to support both wartime and day-to-day requirements of Navy 
medicine. That model is known as the Total Health Care Support Readiness 
Requirement (THCSRR) model. To assist in the implementation of THCSRR and 
to address other changing requirements, the Navy developed the Readiness 
Reengineering Plan (RRP). These are the key components to Navy medicine’s 
readiness reengineering efforts intended to address issues associated with 


rightsizing the MHS.after the Cold War. 








IM. MILITARY PLANNING AND THE NAVY CAPABILITIES 

AND MOBILIZATION PLAN 
This chapter will address some of the planning systems utilized by the ' 
Department of Defense in formulating strategic plans. It will also provide an 
introduction to the central focus of this thesis, a Navy-unique planning document 
called the Navy Capabilities and Mobilization Plan (NCMP). Finally, this chapter 
will provide a comparison of the old Health Services Support annex to the NCMP, 


Annex P, to that of the proposed new one, Annex Q. 


A. DEFENSE PLANNING 

The purpose of the Department of Defense Planning, Programming, and 
Budgeting System (PPBS) is to produce a plan, a program, and a two-year budget 
for the Department of Defense, with the ultimate objective of furnishing the 
combatant commanders with the best mix of forces, equipment, and support 
attainable within fiscal constraints. The PPBS is a cyclic process containing three 
distinct, but interrelated phases, 1.e., Planning, Programming and Budgeting. The 
Chairman of the Joint Chiefs of Staff (CJCS) provides the Secretary of Defense 
with specific programming recommendations through the Joint Strategic Planning 


Process (JSES). [Rei 25 


29 


E Joint Strategic Planning System (JSPS) 

The JSPS provides the strategic foundation for all Department of Defense 
planning. It is the 

[flormal means by which the CJCS, in consultation with the other 

members of the Joint Chiefs of Staff (JCS) and the combatant 

commanders, discharges his responsibility to give strategic plans and 


direction to the Armed Forces of the United States and to interact 
with other Department of Defense systems. [Ref. 24] 


The JSPS establishes the formal process for review of the national security 
strategy and all functions necessary to achieve national security objectives. There 
are numerous documents associated with the JSPS. Many of these documents, 
such as the Defense Planning Guidance (DPG) and the Contingency Planning 
Guidance (CPG), provide input or feedback to the JSPS. 

The DPG fulfills the Secretary of Defense's responsibility to provide the 
services with policy guidance for the preparation of their program 
recommendations and budget proposals. While the DPG's primary purpose is 
establishing the Secretary's programming guidance to the military departments for 
the development of their Program Objective Memorandums (POMs), it also 
provides the defense strategy and the planning guidance to support that strategy. 
[Ref. 23] The DPG includes 


[m]ajor planning issues and decisions, strategy and policy, strategic 
elements, the Secretary’s program planning objectives, the Defense 


t 


Planning Estimate, the Illustrative Planning Scenarios, and a series 
of studies. [Ref. 24] 


The DPG is the key link between the JSPS and the PPBS. 

The CPG is the means by which the Secretary of Defense, in consultation 
with the CJCS, fulfills the annual requirement to provide written policy guidance 
to the CJCS for the preparation and review of contingency plans. [Ref. 23] The 
President must approve the finalized CPG. The CPG directly affects the 
formulation of the Joint Strategic Capabilities Plan (JSCP). The JSCP, and the 
National Military Strategy (NMS), are just two of the numerous products of the 
SBS. 

a. National Military Strategy (NMS) 
The NMS furnishes to the 

President, the National Security Council, and the Secretary of 

Defense the advice of the CJCS, in consultation with other members 

of JCS and the combatant commanders, as to the recommended 

national military strategy and fiscally constrained force structure 

required to support attainment of national security objectives. [Ref. 

24] 

The NMS assists the Secretary of Defense in preparing the DPG and 
provides strategic direction for the development of the JSCP. 
b. Joint Strategic Capabilities Plan (JSCP) 


The JSCP contains guidance to the Commanders in Chiefs (CINCs) 


and Service Chiefs for accomplishing military tasks and missions based on current 


a 


31 


military capabilities. These assignments take into account the capabilities of 
intelligence information, available forces, and guidance issued by the Secretary of 
Defense. The JSCP directs the development of contingency plans to support 
national security objectives by assigning planning tasks and apportioning major 
combat forces and strategic lift capability to the combatant commander. Tt 
constructs a coherent framework for giving capabilities-based military advice to 
the National Command Authority (NCA). It is designed to be reviewed biennially 
and is the principle document that assigns tasks to the combatant commanders to 
develop operations plans, Concept Plans with or without Time-Phased Force and 
Deployment Data (TPFDD), and functional plans using deliberate planning 


procedures. 


B. PLANNING 

i Joint Operational Planning and Execution System (JOPES) 

The process of joint operational planning is defined as “a coordinated joint 
staff procedure used by a commander to determine the best method of 
accomplishing assigned tasks and to direct the action necessary to accomplish the 
mission.” [Ref. 24] The staff of a combatant command must consider many 
factors in its planning in order to select the best means of conducting a military 


mission. 


Lo 
ho 


The Joint Operational Planning and Execution System (JOPES) details an 
established, orderly way of translating the contingency planning task assignments 
into plans or orders. JOPES is directed by the Department of Defense to be used 
as the process for joint planning. The particular procedures used in joint planning 
depend upon the time available to accomplish them. The amount of time available 
to the staff significantly influences the planning process. JOPES uses two 
different methods of planning. 

a. Deliberate or Peacetime Planning 

The first method of planning utilized in JOPES is known as the 
Deliberate or Peacetime Planning method. It 1s the process used when time is not a 
critical factor and permits the total participation of the commanders and staffs of 
the joint community. Development of the plan, coordination among supporting 
commanders and agencies, the services, reviews by the Joint Staff, and 
conferences can take many months to develop. The plan is based on predicted 
conditions that will be countered with resources available during the planning 
cycle. The product of Deliberate Planning is called an operations plan that can be 
either an OPLAN, CONPLAN, or Functional Plan, depending on the level of detail 


that is included. 


Ur 
u) 


b. Time-Sensitive or Crisis Action Planning (CAP) 

The second method of planning utilized in JOPES is known as Time- 
Sensitive or Crisis Action Planning (CAP) method. CAP is conducted in response 
to crises where U.S. interests are threatened and a military response is being 
considered. While deliberate planning is conducted in anticipation of future 
hypothetical contingencies, CAP is carried out in response to specific situations as 
they occur and that often develop very quickly. The time available for planning is 
short and the near-term result is expected to be an actual deployment and/or 
employment of military forces. The overall process of CAP parallels that of 
Deliberate Planning, but is much more flexible to accommodate requirements to 
changing events a NCA requirements. The product of CAP is called a 


Campaign Plan or an OPORD, depending on the level of detail that 1s included. 


al BASIS FOR MILITARY PLANNING 

The process of planning a joint operation produces a contingency plan for 
military action. It begins with a national strategy stated by the President, 
supported with the funding resources by Congress, and is defined by the task 
assignments published by the CJCS. The players in the planning process include 
the NCA (President and Secretary of Defense); their advisors, supporting 
executive-level agencies and a group collectively called the Joint Planning and 


Execution Community (JPEC). [Ref. 24] The civilian leadership decides the 


preliminary direction of contingency operations and approves the final plans. The 
JPEC publish the task-assigning documents, review the products and approve the 
final version of peacetime plans. JOPES translates the assignments into plans or 
orders based upon time available. 

The military service chiefs have developed a series of documents that 
Support, direct, and guide component commanders based upon strategic guidance 
in CJCS taskings and program and budget guidance. Each service has unique 
documents that are used in the planning system and have specific application in the 
development of joint plans in support of the JSCP. The JSCP identifies major 
combat forces and each component command develops its own total force list 
composed of combat, combat support, and combat service support forces using the 
service unique planning documents. The Air Force uses the Air Force War and 
Mobilization Plan (WMP), the Army uses the Army Mobilization me 
Planning and Execution System (AMOPES), the Marine Corps uses the Marine 
Capabilities Plan (MCP), and the Navy uses the a Capabilities and 
Mobilization Plan (NCMP). [Ref. 24] The JSCP also furnishes planning guidance 
that prioritizes and deconflicts planned employment of forces that are apportioned 


to more than one CINC. 


u) 
N 


D. NAVY CAPABILITIES AND MOBILIZATION PLAN (NCMP) 

Service documents provide specific service planning guidance in support of 
the JSCP. The supporting Navy document is the Navy Capabilities and 
Mobilization Plan (NCMP). Both the JSCP and the NCMP are instrumental in the 
development of CINC OPLANs. The JSCP provides information on 
“apportionment of above the line or combat forces while the NCMP provides data 
on apportionment and sourcing of below the line or combat support forces.” [Ref. 
5] The NCMP provides Navy planners with overall mobilization policy and 
procedures as well as mission-specific mobilization direction and capabilities. It 
identifies, for planning purposes, availability of Navy combat support forces for 
use by Navy Component Commanders (e.g., Fleet Commanders in Chief 
(FLTCINCs)) in support of the Unified Commanders. The discussion that follows 
with regard to the NCMP and Annex P is based upon the most current published 
version of this document, 2 April 1993, and may not reflect current requirements 
or capabilities. Discussion of Annex Q reflects the most recent policies and 
capabilities that are proposed for mi revised draft NCMP due out in FY 99. 

The NCMP provides specific guidance and information on: 


- Mobilizing naval forces for prompt and sustained combat 


- Apportionment and sourcing of active and reserve support forces to 
the FLTCINCs for planning purposes 


- Employment and administration of the U.S. Coast Guard when 
operating as a service to the U.S. Navy 


- The mobilization process for Reserve Forces, with step-by-step 
procedures from call up through demobilization 


- Development of Manpower Mobilization and Support Plans 
(MMSPs) by Echelon 2 Navy Commanders in support of the 
PLECINGs 


- “Participation in the development and evaluation of Joint Operation 
Plans (OPLANSs) by commanders of naval component commands 


- Naval functional capabilities. [Ref. 5:p. 1-1] 

The NCMP is composed of a series of annexes with each annex focused on 
a particular naval function or mission area. [See Appendix B] References are 
included in each annex to facilitate further research and more detailed study, as 
required. Particular emphasis has been placed on the areas of mobilization of 
personnel and logistics, and the apportionment and sourcing of noncombatant 


Naval Forces. 


E. ANNEX P TO NCMP, HEALTH SERVICES SUPPORT ANNEX 
Annex P, Health Services Support discusses medical and dental support. It 
provides direction and guidance for Mission and Authority, Mobilization and 
Support Concepts, Mobilization Plans and Resources, Medical Planning Factors, 
Medical Logistics Support (i.e., medical materiel apportionment), and Mission 


Taskings. [Ref. 5:p. P-1] Annex P focuses initially on policy guidance for 


planners with respect to the mission, role, authority, medical support, and research, 
development, test and evaluation (RDT&E) that will be provided by the Navy 
Medical Department. 

The first issue discussed in Annex P deals with the mission of Navy 
medicine as it relates to the NCMP. The mission of Navy medicine is to conserve 
manpower by returning personnel to full duty as soon as possible, preventing 
disease and injury, restoring functional health and well being, and minimizing 
disability. The peacetime role of Navy medicine is to provide effective health care 
services and to maintain a readiness to rapidly support the operating forces with a 
highly trained and operationally oriented force capable of treating casualties in an 
integrated Chemical, Biological, and Radiological (CBR) and conventional 
environment. [Ref. 5:p. P-1] 

The Bureau of Medicine and Surgery (BUMED) is responsible for the 
provision of medical and dental care to the Fleet, Fleet Marine Force (FMF), and 
the shore establishment. During contingency/wartime, BUMED provides medical 
department personnel to meet the augmentation requirements of both the Fleet and 
FMF. Additionally, BUMED OCONUS Commands transfer to their respective 
FLTCINCs when directed to provide the command and control and staff necessary 
to direct medical support provided by expanded fixed Medical Treatment Facilities 


(MTES). 


le Capabilities 

a. Casualty Receiving and Treatment Ships (CRTS) 

Annex P also lists the capabilities that exist for planning purposes to 
provide medical care to casualties generated during a conflict. The first of these 
capabilities is the Casualty Receiving and Treatment Ships (CRTS). These are the 
ships designated within the Amphibious Task Force (ATF) that will provide initial 
resuscitative care (Echelon 2) [See Appendix C] and medical and dental support to 
the Landing Force (LF) until the mission is completed or until the ships are tasked 
with a follow-on mission. In order to achieve full casualty handling capability, 
these ships require augmentation by large numbers of medical department 
personnel. ATF ships suitable for use as CRTSs are the Amphibious Assault Ship 
(Multipurpose) (LHD), the Amphibious Assault Ship (General Purpose) (LHA), 
and the Amphibious Assault Ship (Helicopter) (LPH). [Ref. 5:p. P-3] Only these 
three ship types are designated for medical personnel augmentation. 

(1) Amphibious Assault Ship (LHD). The LHD (Multipurpose) 1s 
the newest, largest, and most versatile amphibious assault ship. It also has the largest 
medical capability of any amphibious ship currently in use. The medical spaces include 
SIX Operating rooms and 604 beds, of which 528 are designated as overflow beds. LHDs 
require augmentation by 343 medical department personnel (73-Officer and 270-Enlisted) 


to achieve full casualty treatment capability. Additionally, Class VIII Materiel (medical 


material) is prepositioned for the LHD in Authorized Medical Allowance List (AMAL) 
blocks, with each AMAL block providing a predetermined amount of supplies, 
equipment or resupply. The LHD Class VIII Materiel quantity consists of four AMAL 
blocks, two Surgical, one Surgical Resupply and one Surgical Support. [Ref. 5:p. P-4] 

(2) Amphibious Assault Ship (LHA). The LHA (General- 
Purpose) ship has a smaller medical capability then the LHD. Its medical spaces 
include four operating rooms and 367 beds, of which 300 are designated as 
overflow beds. LHAs require augmentation by 170 medical department personnel 
(44-Officer and 126-Enlisted) to achieve full casualty treatment capability. It 
contains the same size Class VIII Materiel support as the LHD, 1.e., four AMAL 
blocks of supplies. [Ref. 5:p. P-5 | 

(3) Amphibious Assault Ship (LPH). The LPH (Helicopter) 
ship is the smallest of the three ships designated as a CRTS. Its medical spaces 
include two operating rooms and 220 beds, of which 200 are designated as 
overflow beds. The LPH requires augmentation by 115 medical department 
personnel (41-Officer and 74-Enlisted) to achieve full casualty treatment 
capability. The LPH requires only three AMAL blocks of Class VIII Materiel 


support, two Surgical and one Surgical Resupply. [Ref. 5:p. P-6] 


40 


b. Other ATF Ships 

Annex P also lists other ATF ships, but not as suitable CRTS 
platforms. They are mentioned only to inform the Commander Amphibious Task ' 
Force (CATF) of potential overflow capabilities to treat and transport combat 
patients, 1f required. All required medical personnel augmentation should be from 
within the ATF. No medical augmentation is planned for those ships. 
Additionally, no Class VIII Materiel is prepositioned for these ships. These ships 
are the Amphibious Transport Dock (LPD), the Dock Landing Ship (LSD), 
Amphibious Cargo Ship (LKA), Tank Landing Ship (LST), and the Amphibious 
Command Ship (LCC). [Ref. 5:p. P-7] 

Other capabilities that exist within the Navy medicine continuum 
that are covered under Annex P are Overseas Medical Facilities, CONUS Medical 
Activities, Mobile Medical Augmentation Readiness Teams (MMARTs), Blood 
Product Support in Emergency, Dental Facilities, and Medical Department 
Deployable Systems Capabilities. 

E: Overseas Medical Facilities 

Overseas Medical Facilities are fixed MTFs generally capable of 
providing medical/dental (Echelon 4) [See Appendix C] care for a specified 
number of operating beds based upon staffing criteria. Overseas medical facilities 


are “located along Sea Lines of Communication (SLOC) and in the 


41 


Communication Zone(s) (COMMZ) of potential theaters of combat operations in 
order to support deployed Navy/Marine Corps forces as well as Joint Operations.” 
[Ref. 5:p. P-7] 

d. CONUS Medical Activities 

CONUS Medical Activities provide medical/dental care (Echelon 5) 
[See Appendix C] to naval forces and other eligible beneficiaries, and represent the 
contingency mobilization base for the readiness training and professional 
development of personnel. These facilities also serve to care for returning 
casualties. [Ref. 5:p. P-7] 

e. Mobile Medical Augmentation Readiness Teams 

MMARTSs are a system of specialty teams and medical supply blocks 
capable of rapid response to various peacetime contingencies. These teams are 
maintained in an alert status at all times to facilitate rapid response. [Ref. 5:p. P-7] 

J: Blood Product Support in Emergency 

The Blood Product Support in DERS is part of the Navy Blood 
Program (NBP). This capability can be expanded in response to an emergency 
within the Navy or in concert with the blood programs of other military 


departments. [Ref. 5:p. P-8] 


42 


g. Dental Facilities 

Dental Facilities are the shore-based dental facilities that provide 
service to Navy and Marine Corps personnel. [Ref. 5:p. P-8] 

h. Medical Department Deployable Systems Capabilities 

The Medical Department Deployable Systems Capabilities consist of 
the Rapidly Deployable Medical Facility (RDMF), Fleet Hospitals and Hospital 
Ships (T-AH). The RDME is a highly mobile, erectable, and relocatable shore- 
based medical system (Echelon 3) [See Appendix C]. It 1s staffed and equipped to 
render resuscitative care to casualties resulting primarily from an amphibious 
operation. 

The Fleet Hospital is a 500 bed shore-based, iii intensive 
facility capable of providing care in the Combat Zone (CBTZ) (Echelon 3) and 
COMMZ (Echelon 4) [See Appendix C]. Fleet Hospitals are preconfigured and 
propositioned to meet medical support requirements. There are 12 Fleet Hospital 
packages, with manpower provided by active and reserve Fleet Hospitals. [Ref. 
5:p. P-9] 

The Hospital Ship is an afloat, surgically intensive, acute care 
hospital (Echelon 3) [See Appendix C]. The Navy operates two Hospital Ships, 
the USNS MERCY (T-AH 19) and the USNS COMFORT (T-AH 20). The 


MERCY is based out of San Diego, California and the COMFORT is based out of 


Baltimore, Maryland. Both are maintained in Reduced Operating Status-5 (ROS- 
5) and can get underway within 5 days with all required medical and nonmedical 
staffing and 30 days of supply. [Ref. 5:p. P-10] 

28 Mobilization Planning Direction 

Annex P also covers Mobilization Planning Direction covered under 
Department of Defense policy guidance for wartime. It covers definitions for this 
planning as well as guidelines for the mobilization plan, to include descriptions of 
actions required to support each phase of naval mobilization. 

3: Navy Casualty Rates 

Annex P is concluded with an appendix, Appendix P-I, Navy Casualty 
Rates (NCR). The discussion here will be limited, as this appendix is classified. 
NCR had been developed by the David Taylor Research Casita for shipboard 
personnel and by Naval Health Research Center (NAVHLTHRSHCEN) for both 
Navy personnel ashore and Naval DNBI. The Navy Casualty Rates Ashore were 
developed by NAVHLTHRSCEN for the following categories: Forces Organic to 
USMC, Mobile Forces, and Personnel Stationed at Fixed Sites. These rates were 
derived from data gathered in Vietnam (Light Combat), Korea (Moderate 
Combat), Okinawa (Heavy Combat), and Iwo Jima (Intense Combat). As was 
previously noted in Chapter II, casualty rate estimates are vital to determining 


wartime medical requirements. [Ref. 6] 


44 


F. ANNEX Q, PROPOSED CHANGES 

As is the case with many military planning documents, they are designated 
as “works in progress.” That is, they take into account the constantly changing 
environment within which the Department of Defense operates. The NCMP, as a 
planning document, is no different in this regard. It has been updated numerous 
times since its inception and continues to be reviewed as required. The most 
recently published version of the NCMP, dated 2 April 1993, is in the process of 
being updated by the Chief of Naval Operations (CNO). As expected, Annex P, 
Health Services Support, had some changes to be incorporated into the update. 

The first of these changes is readily apparent; the annex will be designated 
as Annex Q vice Annex P. This was done in order to reflect nomenclature 
consistent with FLTCINC literature and to align the medical portion of all 
orders/plans. 

1. Planning Guidance 

The remaining changes are not quite as obvious but play an important part 
in understanding the changes in Navy medicine and the progress of Navy 
medicine’s readiness reengineering efforts. One of the first changes is noted under 
Planning Guidance, as Navy planners have addressed the issue of Augmentation. 

Not previously alluded to in Annex P, augmentation deals with the staffing 


of platforms to their maximum extent possible. Augmentation deals with manning 


45 


priorities based on the warfighting CINCs” time phased requirements for medical 
support. These are listed in order of general priority: 1) CRTS, 2) USMC 
Forces/Division/Wing/Force Service Support Group (FSSG), 3) Hospital Ships (T- 
AH), 4) Fleet Hospitals, OCONUS, and 5) CONUS MTFs and Staff Headquarters. 
IReft 25] 

This prioritization is important because it addresses the medical personnel 
augmentation “systems” problems identified in Operation Desert Shield/Desert 
Storm and follow-on peacekeeping and humanitarian operations. 

2. Capabilities 

a. Casualty Receiving and Treatment Ships 

The né change addressed in the draft Annex Q is in the area of 
Medical Department Capabilities. The capabilities of Casualty Receiving and 
Treatment Ships (CRTS) have been adjusted to reflect recent review changes. Of 
note, the Navy decommissioned all remaining LPH Amphibious Assault Ship 
(Helicopter) platforms, thus eliminating that capability from Annex P. Therefore 
the medical department personnel augmentation of 115 (41-Officer and 74- 
Enlisted), as well as the Class VIII Materiel support was eliminated in Annex Q. 
Changes were also made to the two remaining CRTSs (LHD and LHA) with 
regard to their respective medical capabilities/spaces, medical department 


personnel augment, and Class VIII Materiel support. [Ref. 25] 


46 


(1) Amphibious Assault Ship (LHD). The LHD now lists its 
medical spaces to include four operating rooms and 60 beds. This is a decrease of 
two Operating rooms and 544 total bed spaces. This decrease eliminates all 
overflow bed spaces (528) listed in Annex P capabilities. Logically, with a 
reduced medical capability, it would follow that the personnel and equipment 
needed to support this reduced capability should be reduced as well. In order to 
achieve full treatment capability, the LHDs now require a total HSS augment of 
100 personnel (42-Officer and 58-Enlisted). This denotes a reduction of 243 total 
personnel (31-Officer and 212-Enlisted) required from Annex P. The Class VIII 
Materiel supply prepositioned onboard each ship in this class is now two AMAL 
blocks, one Surgical Resupply and one Orthopedic Surgical Resupply. This is a 
reduction of two AMAL blocks of supply required from Annex P. [Ref. 25] 

(2) Amphibious Assault Ship (LHA). The other CRTS, the 
LHA also lists its medical spaces to include four operating rooms and 60 beds. 
This 1s a decrease in bed spaces only, a total of 307. Again this decrease 
eliminates all overflow bed spaces (300) listed in Annex P capabilities. To achieve 
full casualty treatment capability the LHAs now require a total HSS augment 
identical to the LHDs, 1.e., 100 personnel (42-Officer and 58-Enlisted). This is a 
reduction of 70 total personnel (2-Officer and 68-Enlisted). The Class VIII 


Materiel supply prepositioned on each ship in this class is again identical to that of 


47 


the LHD, that is, two AMAL blocks, which also denotes a reduction of two blocks 
of supply required from Annex P. [Ref. 25] 

b. Other ATF Ships 

For planning purposes, under the category of Other ATF Ships, the 
Amphibious Cargo Ship (LKA) and Tank Landing Ship (LST) were deleted from 
Annex P due to the decommissioning of these classes of ship. 

©: Overseas Medical Facilities 

With regard to Overseas Medical Facilities, no changes were made 
to the generic capabilities of these MTFs, but Annex Q updates information for 
OCONUS MTFs that will receive additional medical augmentation personnel. 
These facilities are U.S. Navy Hospitals (USNAVHOSPs) Guam, Okinawa, and 
Yokosuka. Annex Q lists a breakdown of their Active/Inactive and Expanded bed 
capabilities. [Ref. 25] This information will help planners for mobilization of 
personnel and movement of casualties. 

d. CONUS Medical Activities 

Annex Q also provides previously unpublished information for 
planners regarding CONUS Medical Activities. It lists facilities that provide direct 
support to the care of returning casualties (CORC) mission of the United States 
Atlantic Command’s (USACOM) Integrated CONUS Mobilization Plan ICMOP). 


(Ref. 25] The list details the Active/Inactive and Expanded bed capabilities of the 


48 


following facilities: NNMC Bethesda, NMC Portsmouth, NH San Diego, NH 
Bremerton, NH Camp Pendleton, NH Jacksonville, NH Pensacola, NH Great 
Lakes, and NH Camp Lejeune. 

e. Fleet Surgical Team (EST) 

A new capability within both the HSS and Annex Q is the Fleet 
Surgical Team (FST). The FST concept has augmented the old MMARTs concept 
used in Annex P. FSTs are 16-man medical augmentation teams permanently 
assigned to the FLTCINCs. They consist of trained HSS personnel to meet the 
CINCs’ routine and amphibious deployment medical requirements and to provide 
Echelon 2 [See Appendix C] medical support to the operating forces, Fleet and 
Marine Forces (MARFOR) exercises and scheduled deployments of Amphibious 
Ready Groups (ARG). [Ref. 25] FSTs are normally deployed as a unit on a CRTS 
of the ARG and are part of the personnel augmentation package to LHA/LHD 
deploying platforms. 

f Medical Department Deployable Systems Capabilities 

Another change in Annex Q addresses the capabilities listed under 
Medical Department Deployable Systems Capabilities. The Rapidly Deployable 
Medical Facility (RDMF) listed in Annex P has been eliminated and replaced by 
the concept of the Naval — Medical Support System (NEMSS) Fleet 


Hospital (FH) Package. This system is capable of providing modular subsets of a 


49 


FH with all equipment, materials, supplies, and manpower to come from existing 
FH manpower requirements, equipment and supply lists. [See Figure 4] It is 
capable of providing limited austere medical care in Smaller Scale Contingencies 
(SSCs), Operations Other Than War (OOTW), or disaster/humanitarian relief 
operations. [Ref. 25] Its medical core functional areas include casualty receiving, 
operating room preparation and hold, and surgical suites. Those areas are 


provisionally staffed to meet a limited combat mission. 


RECONFIGURATION 
‘Naval Expeditionary Medical Support System” 












2 OR Tables 
. 10 ICU Beds 
0 - 90 Acute Beds 


6 OR Tables 


Prepositioned 
wee: 80 ICU Beds 
420 Acute Beds 


Figure 4. Naval Expeditionary Medical Support System (NEMSS) 
Fleet Hospital (FH) Package 


50 


2. U.S. Marine Corps Health Services Support Operations 

While the Navy and Marine Corps are two distinct organizations 
within the same military department, their combat missions require coordinated 
medical planning for support of joint and amphibious operations. Coordinated 
Navy and Marine Corps medical and logistics planning at all organizational levels 
is necessary for employment of medical department assets to ensure the most 
effective medical support. 

With this idea in pin, Annex Q now lists U.S. Marine Corps Health 
Services Support Operations under the heading of Capabilities in Annex Q. This 
includes HSS to Marine Expeditionary Forces (MEF), Medical Battalion and 
Dental Battalion. Within the Medical Battalion, the Marine Corps has restructured 
its organization to update the new capabilities of the Surgical Company and the 
Shock Trauma Platoon, both of which have been designed to deliver a more 
mobile, responsive capability to the casualty. [Ref. 26] 

h. Other Health Service Support 

The final proposed change to Annex Q is another addition to both 
HSS and Annex Q Capabilities. Listed under Other Health Service Support, the 
Forward Deployed Laboratory (FDL) represents a new capability. The primary 
mission of the FDL is to provide public health support within the task force by 


rapidly diagnosing militarily relevant infectious diseases and biological threat 


51 


agents during deployments. The FDL provides the Task Force Commander with 
“a rapidly deployable, portable, state-of-art, diagnostic capability to meet 
specialized needs of evolving contingencies.” [Ref. 25] 

3. Navy Casualty Rates 

One area that has not been updated, but is critical to determining wartime 
medical requirements, is the Casualty Rates. The David Taylor Research Center 
has not been tasked to update the data it used to generate the rates for Annex P. 
There has been much discussion as to which Navy functional area has the 
responsibility to develop these rates and, to date, none has been developed for 
inclusion into the draft of the NCMP. [Ref. 8] 

The casualty rate estimate is the most significant planning factor in 
determining what network of medical assets will be needed to support a combatant 
commander. The casualty rate estimate is one of the key inputs for medical 
requirements planning models used to identify wartime medical manpower 
requirements. Since the late 1970's, the military has used the Medical Planning 
Module (MPM) to assist the medical planner in predicting and evaluating medical 
requirements in support of OPLAN development. However, the MPM has been 
criticized and labeled as “outdated and inaccurate” by many agencies familiar with 


medical planning. [Ref. 27] 


52 


The model developed to replace the MPM is the Medical Analysis Tool 
(MAT). The MAT has been in use since 1997, providing medical planners with a 
“highly accurate and sufficiently flexible model that as changes occur in planning 
factors and technology, the MAT can change with them.” [Ref. 27] This new 
model, along with updated casualty estimate rate inputs from the NCMP, will 
provide a much more accurate prediction of wartime requirements to support 


planning. 


G. SUMMARY 

The Department of Defense, in the course of its operations, attempts to use 
standardized systems in its planning process in an effort to increase efficiency. 
The outcomes of these planning systems are numerous reviews, guidance, 
strategies and plans. One of these plans is the. Joint Strategic Capabilities Plan 
(JSCP). Service documents provide specific service planning guidance in support 
of the JSCP. The supporting Navy document is the Navy Capabilities and 
Mobilization Plan (NCMP). 

The NCMP is a guide for CINCs that lists the capabilities of forces 
available for augmentation purposes. Navy Health Services Support is addressed 
in an annex to the NCMP. This annex discusses the medical and dental support 


capabilities available to the commander. Many proposed HSS changes have been 


recommended for the current update of the NCMP, based upon technology 


improvements and changes in medical readiness doctrine. 


54 


IV. UPDATE OF THE NAVY CAPABILITIES AND 
MOBILIZATION PLAN (NCMP) 
This chapter will examine the revision of the Navy Capabilities and 
Mobilization Plan (NCMP), with a focus on the update to the Health Services 
Support annex, Annex Q. It will also look at the responsibilities, process and 


drivers behind the update of this planning document. 


A. RESPONSIBILITY FOR NCMP 

As discussed previously, the NCMP is the Navy-unique document that 
supports the JCS Joint Strategic Capabilities Plan (JSCP). It provides Navy 
planners with overall mobilization policy, in fulfillment of requirements 
established by Annex N (Mobilization) to the J SCP. and procedures, as well hi 
mission-specific mobilization direction and capabilities. [Ref. 5] The NCMP 
describes Navy capabilities and sets forth required force levels for planning under 
various regional contingencies. 

The NCMP is composed of a series of annexes, with each annex focusing 
on a particular naval function or mission area. Annex responsibility is parceled out 
to the specific OPNAV office (N code) coordinating that particular subject matter. 
[See Appendix B] The NCMP is prepared by the Chief of Naval Operations, with 
the Director of Strategy, Plans, Policy and Operations Division (N3/N5) ultimately 


responsible for its publication. It 1s considered to be continuously effective for 


55 


planning purposes and should be updated biennially in conjunction with the 
publication of the JSCP. [Ref. 28] 

With the 2 April 1993 version of the NCMP being its most recent, the Navy : 
has fallen well short in its biennial obligation to update the document. A 
memorandum from then OP-06 (now N3/N5) initiated the required review and 
update of the NCMP for FY 95 as per the JSCP. [Ref. 29] The revision was 
initiated and staffed, but for reasons unknown was never signed off and therefore 
never implemented. Some latitude could be given in that the JSCP was not 
updated during the 1993-1996 time period either. However, until recently, the 
latest JSCP available to planners was the 1996 publication (the JCS released a 
1998 update in October of this year). There are a number of reasons given as to 
why no revision for the NCMP was conducted until this year. | 

We begin with a brief look at the time period involved, the early to mid 
1990’s, recognizing that this was a tumultuous time for the entire Department of 
Defense structure, including the Navy. As all the services looked to meet 
personnel end strength cuts mandated by Congress, no area escaped “chopping 
block” scrutiny. In 1992, the Navy reorganized its OPNAV offices in an attempt 
to meet Congressional mandates. This reorganization served two purposes, first, it 


was part of the Navy required active duty strength reduction, and second, this 


56 


aligned “the structure and functions of OPNAV offices” with their Joint Staff 
counterparts. [Ref. 30] 

This OPNAV reorganization was in addition to the normal personnel 
assignment rotation that generally produces a state of flux in many offices. Prior 
to this reorganization, a single individual within the then OP-06 division was 
responsible for the NCMP. It was this individual”s sole job to track and make 
appropriate changes to the document. [Ref. 29] As a result of the reorganization 
effort, this ana was transferred to another OPNAV office. While the 
responsibility for the NCMP remained within the now N3/N5 division, no one was 
assigned that requirement until February 1998. The result was obvious, no 
revision could be completed until someone was assigned the responsibility to do 


SO. 


B. PROCESS TO UPDATE NCMP 

In February 1998, the N3/N5 section initiated the required review and 
update of the NCMP for FY 99 in congruence with the expected release of the 
JSCP. Since the NCMP greatly impacts the reserve component, plans went into 
effect with the idea that the reserve units would take the lead effort and work 
closely with the OPNAV office responsible for each annex. Additionally, N3/N5 


placed a request for a select reservist (SELRES) to act as the overall coordinator 


> 


for this project. This individual would be placed on active duty for six months at a 
time or longer to supervise the revision. 

In March 1998, an organizational meeting was held with all the cognizant 
OPNAV offices to develop a timeline for the NCMP revision. A June 1998 due 
date was established with a plan for the final draft to be reviewed at the Navy 
Planners Conference (NPC), scheduled to convene in August 1998. Although 
timeline activities were pushed back a bit, the basic work of the revision was 
updated and compiled as planned. The date of release of the JSCP was pushed 
back, as was the date for the NPC. In October 1998, the NPC met with a goal to 
review each of the revised annexes of the NCMP and get the FLTCINC planners’ 
input. That goal wer met and the final revisions and — were due in 
November 1998. As of this date, a majority of the final revisions have been 
submitted to the N3/N5 division and it is still striving for a compilation/ 


distribution date of late January 1999. [Ref. 29] 


C. DRIVERS BEHIND UPDATE OF NCMP 

The prime reason behind the need to revise or update a product is change. 
Change generally leads to some form of obsolescence. The same could be said for 
the NCMP. Prior to the end of the Cold War, our nation’s military strategy was 
one of global conflict. The main enemy was clear, i.e., the former Soviet Union 


and its Warsaw Pact partners. The Cold War strategy was built around mass and 


58 


power, depending upon large numbers of forward-deployed assets. Scenarios were 
based on a slow buildup of assets that would give us overwhelming combat power 
and that would eventually participate in a protracted, direct combat type of war. 

As the Soviet Union and the Warsaw Pact deteriorated, our nation’s military 
strategy changed as well, from one of global conflict to that of a two Major 
Regional Conflict (MRC) strategy. The strategy is based upon the concepts of 
forward presence and power projection. Scenarios are now based on a rapid 
deployment of assets that would eventually participate in a short war. Instead of 
the goal of overwhelming combat power, it now focuses on decisive combat power 
with the use of technologically improved smart or standoff weapon systems. [Ref. 
31] 

However, a wider access to this advanced technology along with modern 
weaponry, including weapons of mass destruction (WMD), will increase the 
number of actors with sufficient military potential to upset existing regional 
balances of power. This modern weaponry is sufficiently powerful that smaller 
numbers can dramatically alter threats facing today's military forces. A number of 
potential adversaries may acquire the military hardware to make themselves 


distinctly more dangerous. 


39 


In sum, today's military must prepare to face a wider range of threats, 
emerging unpredictability, employing varying combinations of technology, and 
providing a challenge at varying levels of intensity. 

These threats have been the driving factor behind the changes in our 
supporting military doctrine. This is important to understanding the incentives 
behind the revision of the NCMP. To emphasize the importance of the military 
doctrinal changes that have occurred over the past decade, it is worth taking a brief 
look at those Ae eal publications that have impacted the current revision of the 
NCMP. 

The following doctrinal publications were referenced in the revision of the 
NCMP: Concept of Operations/Strategy: A National Security Strategy for a New 
Century, May 1997; National Military Strategy of the United States of America, 
1997; Joint Vision 2010; Defense Contingency Planning Guidance (no date); From 
the Sea, 1992; Forward from the Sea, 1994; and Operating Forward from the Sea, 
1997. [Ref. 29] All of these doctrinal publications address the changing threat 
environment and have impacted heavily upon the revision of the NCMP, including 


Annex Q. 


D. RESPONSIBILITY FOR ANNEX Q 
Annex Q, the Health Services Support annex, is one of the 26 separate 


annexes that make up the NCMP. The update and revision of each annex is tasked 


60 


to a specific OPNAV office. The OPNAV office, or N code, responsible for 
Annex Q is N931, the Medical Resources, Plans and Policy Division. As the 
responsible OPNAV office, N931 went through a process similar to that used by 


N3/N5 to update Annex Q. 


E. PROCESS TO UPDATE ANNEX Q 

Just as the NCMP is considered to be continuously effective for planning 
purposes until revised, so is Annex Q. N931, along with the other NCMP 
responsible OPNAV offices, received the N3/N5 NCMP revision memorandum in 
February 1998. However, through both excellent planning and early initiative, 
N931 had started the process of updating Annex Q prior to the receipt of the 
memorandum. 

Recognizing that the mission and the structure of the Navy and the Marine 
Corps was changing, N931, in concert with Navy medicine's Readiness 
Reengineering efforts, took an in depth look at the impact that these changes 
would have on Annex Q. These strategic changes, when combined with advances 
in the practice of medicine, created a change in many of the capabilities addressed 
in the medical annex. It was with these changes in mind that N931 developed a 
“Truth in Advertising” campaign and took these changes to the medical service 


community in November/December 1997. [Ref. 32] 


61 


The main focus of this campaign was the attempt to identify the real 
medical capabilities of the Casualty Receiving and Treatment Ships (CRTS) and 
the LHA and LHD class ship. Previously overstated capabilities were replaced 
with more realistic and reasonable ones. N931 had observed the medical portion 
of the Kernel Blitz '96 exercise that utilized the CRTS during the course of the 
evolution. The medical facilities of the CRTS, when tested using different 
scenarios, were stretched beyond their limits. Further observation revealed that 
when attempting to incorporate the medical personnel augment necessary to reach 
this overstated capability, there was insufficient berthing space available for the 
augment. N931, utilizing lessons learned from this evolution, previous exercises 
and recent real world operations, then went about revising the capabilities of the 
CRTS to meet more realistic standards. The result was the “Truth in Advertising” 
campaign which reduced dramatically the stated medical capabilities of the CRTS. 
[Ref. 32] 

This did not, initially, meet with approval from jie Marine Corps Health 
Services personnel. [Ref. 32] These planners, a mix of Navy and Marine Corps 
personnel, vehemently argued that this reduction in capability would greatly affect 
Marine Corps warfighting efforts. However, over the course of the November 
1997-January 1998 time period, N931 was able to convince the Marine Corps that 


these capabilities had previously been overstated and that the new capabilities 


62 


advertised were more realistic. [Ref. 32] N931 was also able to convey that these 
changes were brought about by the change in military strategy, as well as 
improvements to medical service that resulted from the strategic changes, 
highlighted in the reorganization of Marine Corps Health Service Support. [Ref. 
26] 

Upon receipt of the N3/N5 memorandum, N931 was able to continue its 
campaign and put out draft updates to OPNAVINST 3105.J, Required Operational 
Capabilities (ROC) and prarected Operational Environment (POE) for deploying 
platforms to the Atlantic Fleet (LANTFLT) and Pacific Fleet (PACFLT) medical 
personnel for input. N931 did this without incorporating the detailed numbers 
(personnel and equipment) they had developed. This was done in an effort to have 
LANTFLT and PACFLT medical departments provide uncensored data feedback 
based on their expertise. [Ref. 32] The feedback from both medical departments 
was returned by May 1998. This input was then matched against the numbers 
developed by N931 and incorporated into the “final” draft. The data returned was 
quite close to the numbers developed by N931. A finalized version was quickly 
sent back out to the fleet medical departments for any additional input. [Ref. 8] 

With relatively few changes, N931 was able to quickly incorporate this 
CRTS capability into the Annex Q revision, along with other changes, and thus 


have it ready for review at the NCP in October 1998. 


ie THE ROLE OF MEDICAL DOCTRINE IN THE UPDATE 
OF ANNEX Q 


Clearly, as threats and planning scenarios change, medical requirements to 
support the missions will change as well. Future planning scenarios are likely to 
be based on smaller populations at risk, lower casualty rates, different assumptions 
about which casualties are treated in theater and in the United States, and which of 
the patients evacuated to the United States are to be treated in military and civilian 
hospitals. 

One doctrinal publication that has had tremendous impact on the revision of 
Annex Q is the Marine Corps' concept of Operational Maneuver from the Sea 
(OMFTS). Briefly, this concept reinforces our National Security Strategy of being 
globally involved to help reid the tenets of democracy and to assist countries 
and regions to stabilize and become productive economic participants in the world 
marketplace. The missions range from disaster assistance to peacekeeping to 
peacemaking to conflict and war. OMFTS will assist in carrying out those 
missions by rapidly projecting the appropriate force to the area of need. In most 
instances, this will be a highly mobile, flexible, technologically expert, tailored 


force package prepared to deploy anywhere in the world. [Ref. 33] 


64 


This change in warfighting concept involves creating a smaller forward 
footprint. Navy medicine, as a supporting service to the Fleet Marine Forces, must 
also be organized as flexible, agile and technologically adept. 

It was with this concept in mind that the Naval Doctrine Command, in 
conjunction with the Marine Corps Combat Development Command (MCCDC), 
developed an activity model for providing combat casualty care in support of 
OMFTS. The model recommended a number of changes for Navy medicine. The 
first of these was to shift the primary focus of combat medicine from return-to- 
duty care (which requires a large HSS footprint) to preventive care. Second, 
Trauma care capability inherent in the maneuver forces would be increased based 
upon technological advances providing great future potential. Third, the Navy 
would develop task-based HSS in the form of rapidly assembled Medical 
Capabilities Packages (MCP) to support the dynamics presented by ¡ON 
naval operations (wartime, contingency and peacetime). Finally, future shore- 
based hospitals would be structured as modular units capable of “rapid 
deployment, employment and re-deployment.” [Ref. 34] 

These recommendations are evident in the updates made to Annex Q. The 
revision of the CRTS medical capability is based on the smaller fighting force 
envisioned in OMFTS. As fallout of this smaller force, a reduction in the expected 
casualty rate and bed space 1s incorporated into this capability. Also, the medical 


personnel augmentation package to support this capability has been greatly 


65 


reduced as well. Additionally, the Class VIII Materiel supply support (AMAL 
blocks) has been reconfigured, resulting in a sizable decrease in Weight and cargo 
space requirements. 

New capabilities addressed in Annex Q are the Fleet Surgical Teams (FST), 
Forward Deployed Laboratories (FDL) and the Navy Expeditionary Medical 
Support System (NEMSS) dimension of the Fleet Hospital. All of these provide 
greater prevention or care at the point of injury while simultaneously keeping pace 
with the maneuver element. 

The doctrine behind the update of Annex Q is centered on the changes in 
military strategy, Navy medicine's efforts to support these changes in a more 


efficient manner and the advances of technology in medical practices. 


G. SUMMARY 

This chapter examined the revision of the NCMP and its Health Services 
Support annex, Annex Q. It identified the organizations responsible for the 
revision, the N3/N5 division’s responsibility for the overall NCMP update and the 
N931 division’s role in the update of Annex Q. The chapter also covered the 
process used by each of these divisions ın the revision of their respective areas and 
the factors influencing the process. Lastly, the chapter described the medical 
doctrine changes behind this revision of the NCMP, most of which stems from the 
turmoil created in the post Cold War decade and the strategic changes that 


occurred from that fallout. 


66 


V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 
FOR FUTURE STUDY 


A. SUMMARY 

The lessons learned from operations conducted in this past decade, from 
Desert Shield/Desert Storm up to the current peacekeeping and humanitarian 
operations, have been plentiful for all areas of the Department of Defense. The 
focus of this thesis has been in the area of health service support. These lessons 
learned, in conjunction with the strategic implications of the end of the Cold War 
and the downsizing of the Department of Defense, have widely impacted medical 
end strength and medical readiness policies. Appendix A identifies the significant 
events associated with these lessons learned. 

Navy medicine has responded positively to these developments. The initial 
response was the development of a model that calculated the personnel needed, 
both active and reserve, to support both wartime and day-to-day requirements of 
Navy medicine. That model is known as the Total Health Care Support Readiness 
Requirement (THCSRR) model. 

To assist in the implementation of THCSRR and to address other changing 
requirements, the Navy developed the Readiness Reengineering Plan (RRP). 
These are the key components to Navy medicine’s readiness reengineering efforts 


intended to address issues associated with rightsizing the Military Health System 


67 


(MHS) after the Cold War. One of the tools with which the Navy will address 
these changing requirements is a document used in support of operational 
planning, the Navy Capabilities and Mobilization Plan (NCMP). 

The Department of Defense, in an effort to increase efficiency, utilizes 
standardized systems for operational planning. The Joint Strategic Capabilities 
Plan (JSCP) is just one of the many plans, reviews and strategies that is generated 
by this planning system. The JSCP contains guidance to Commanders In Chiefs 
(CINCs) and Service Chiefs for accomplishing military tasks and missions based 
on current military capabilities. Service documents, such as those described in 
Chapter III, provide specific service planning guidance in support of the JSCP. 
The supporting Navy document is the NCMP. 

The NCMP is a guide for CINCs that lists the capabilities of forces 
available for augmentation purposes. Navy Health Services Support is addressed 
in one of the 26 annexes to the NCMP. This annex details the medical and dental 
Support capabilities available to the commander. As a result of the numerous 
changes in medical readiness doctrine and technological improvements, many 
changes have been proposed for the current update of the NCMP. 

The NCMP is currently in its final stages of revision and is projected to be 
published in late January 1999. The Director of Strategy, Plans, Policy and 


Operations Division, N3/N5, is ultimately responsible for the publication of the 


68 


NCMP. The Medical Resources, Plans and Policy Division, N931, is the 
responsible OPNAV office, or N code, for the Health Services Support annex, 
Annex Q. The process used by both of these divisions in the revision of their 
respective areas and the factors influencing the process were detailed here. 

This thesis also reviewed the medical doctrine changes behind this revision 
of the NCMP and Annex Q. Most of these stem from the turmoil created in the 


post-Cold War decade and the strategic changes that occurred from that fallout. 


B. CONCLUSIONS 

The update of the medical annex, Annex Q, of the NCMP has impacted 
both resources and medical end strength within the Navy. The ultimate goal of 
this revision is to update and list those capabilities avain to the commander. 

As a result of the revision process, one resource, the Class VIII Materiel 
supply support (AMAL blocks) has been reconfigured. This reconfiguration has 
resulted in a sizable decrease in weight and cargo space requirements for the 
AMAL blocks. This resource savings is passed on to the Marines on board the 
Casualty Receiving and Treatment Ships (CRTS). This reduction has created 
additional cargo space, which can be turned back over to the Combat Cargo 
Marines and used for other activities. This cargo space equates to three additional 
High Mobility Multi-Wheeled Vehicles (HMMWV) that can be placed aboard 
ship. [Ref. 8] 


69 


The resource savings from the revision of Annex Q can be viewed in fiscal 
terms as well. The AMAL block reconfiguration leads to approximate savings of 
$20,000 per CRTS (LHA or LHD). [Ref. 8] With 11 total CRTS, the initial ' 
reconfiguration, when completed, will result in a total savings of $220,000. 
Eventually, over the life cycle of these classes of ships, the cost to replace or 
restock the AMAL blocks will be reduced as well, but by how much is unknown at 
this time. 

Another area impacted by the update of the medical annex is medical end 
strength within the Navy. As a result of N931’s “Truth in Advertising” campaign, 
the medical capabilities of the CRTS have been dramatically altered. This 
alteration is based on a smaller fighting force envisioned in many strategic 
documents, thus reducing expected casualties and bed space oni needed in 
the CRTS. For the LHD class ship, the revision of Annex Q resulted in a reduction 
of 544 total bed spaces, including all 528 overflow bed spaces. The LHA class 
ship experiences a reduction of 307 total bed spaces, including all 300 overflow 
bed spaces. 

The medical personnel augmentation package to support this capability has 
been reduced as well. For the LHD class ship, the revision of Annex Q resulted in 
a reduction of 243 medical personnel (31-Officer and 212-Enlisted). For the LHA 


class ship, it has resulted in a reduction of 70 medical personnel (2-Officer and 68- 


70 


Enlisted). The Navy currently has six LHD class ships and five LHA class ships in 
operation. This would suggest an overall medical personnel savings of 1,458 (186- 
Officer and 1,272-Enlisted) for the LHDs and 350 (10-Officer and 340-Enlisted) 
for the LHAs: 

This, however, would be an incorrect calculation. The actual savings would 
be situational because not all 11 ships are underway at any given time. It should 
also be pointed out that this personnel augmentation is an on-call capability, not a 
required one. 

A second common error encountered when calculating the resource savings 
from the Annex Q revision deals with the possible monetary savings involved with 
the decreased augment package. Although the medical personnel augment 
package savings appear obvious, it is actually a very difficult and confusing 
process to define any fiscal savings in this area. The Defense Health Program in 
support of the CINCs pays for the augment packages. Any savings that come from 
this augment reduction do not necessarily go to the Navy. didi for that matter, can 
they be viewed as a dollar for dollar savings for the Defense Health Program. 

The augment personnel are removed from a Medical Treatment Facility 
(MTE) and eventually replaced by medical reservists to carry out the requirements 
at that particular MTF. Essentially, any medical end strength savings would be 


reduced by the purchase of that productive capability left open by the augment. 


a 


[Ref. 35] That could be done either by the method described above or through 
outsourcing to private facilities. This must be done because the MTF from which 
the augment was pulled retains a peacetime mission to provide care. Thus, a 
“make versus buy” decision must be determined in order to evaluate any real fiscal 


savings as a result of the NCMP revision. [Ref. 35] 


E: RECOMMENDATIONS FOR FUTURE STUDY 

The process of condena the research for this thesis has led to several 
recommendations for future study in this area. 

The first of these is in the area of changes to the NCMP. The Navy’s 
failure to meet the biennial revision obligation imposed by the JSCP exposed some 
problems in the update process. This process used to update the NCMP could be 
more efficient if it mirrored the JCS approach and was updated during annual 
Service planning conferences. Quarterly or even semi-annual updates would 
ensure the NCMP revision process is always moving forward, rather than waiting 
for the biennial revision process. 

Finally, access to the NCMP on a Navy secure computer would improve the 
overall process of putting together a revision. Due to the significant importance of 
these planning documents, this area warrants future study. 

A second recommendation for future study is in the area of casualty rate 


estimation. The casualty rate estimate is probably the most significant factor in 


E 


determining wartime medical requirements. Unfortunately it is one of the 
requirements that 1s currently incomplete and could create delays in the publishing 
of the NCMP. Because of its significant impact on requirements generation, this 
area warrants future study. 

A final recommendation for future study is in the area of medical end 
strength. As noted in the thesis, the revision of Annex Q has led to an obvious 
reduction in the medical personnel augment package for the CRTS. Because of the 
void created by the augment package, a cost versus benefit analysis of the “make 
versus buy” decisions to fill that void must be conducted. The impacts on the 
force structure of Navy medicine and the potential for saving money in an ever- 


decreasing budget are significant enough to warrant future study in this area. 








APPENDIX A. MAJOR DOCTRINAL AND POLICY DEVELOPMENTS 


1988 


1990-91 


1991 


1992 


19953 


1994-95 


1994 


1995 


1995 


1997 


1928 


AFFECTING MEDICAL READINESS 1988-1999 


Medical Readiness Strategic Plan I published 
Operation Desert Storm 


Congress directs 733 study 


DoD adopts Base Force 
Joint Strategic Capabilities Plan (FY 93) published 
Navy Capabilities and Mobilization Plan (FY 93) published 


Services begin reengineering deployable hospitals and reorganizing 
other medical readiness functions 


DoD conducts Bottom Up Review 
DoD completes 733 study 
Medical Readiness Strategic Plan II published 


Joint Pub 4-02, Doctrine for Health Services Support in Joint 
Operations published 


Joint Strategic Capabilities Plan (FY 97) published 
JHSS Vision 2010 initiated by JCS 

DoD conducts Quadrennial Defense Review 
Medical Readiness Strategic Plan III published 
Joint Pub 4-02 revised 


Force Medical Protection initiated by JCS, replacing JHSS Vision 
2010 


75 


Joint Strategic Capabilities Plan (FY 99) published 


999 Navy Capabilities and Mobilization Plan (FY 99) published? 


76 


ANNEX 


A MU > 


DN AAA 


as, 


OPNAV CODE 


N2 

N402 
N514 
N512 


N512 


N85 


N096 
N421 
N512 
N312 
N644 
NIR 

N511 
N932 
N643 


N41 


N866 


N865 


77 


APPENDIX B. NCMP ANNEX P RESPONSIBILITY 


TELE 


Intelligence 

Logistics 

Theater Nuclear Force Policy 
Special Warfare 


CW, CBR Defense, and Use of Riot 
Control Agents and Herbicides 


Command, Control and 
Communication (C3) 


Oceanography Program 
Mobility 

Composite Matters 

U.S. Coast Guard 
Electronic Warfare 
Manpower Mobilization 
Forces 

Health Services Support 
Space Program 


Advanced Base Functional 
Component (ABFC) 


Amphibious Warfare 


Antisubmarine Warfare 


N86 
N866 
N3T/NST 
N445 
N865 
N87 
N312 

N3 

NO9C 
N161 


N413 


78 


Inshore Undersea Warfare 

Mine Warfare 

Naval Control of Shipping 

Naval Construction Force 
Strike/Antisurface Warfare 
Submarine Warfare 

Continuity of Operations Plan 
Security Groups 

Public Affairs 

Automatic Data Processing (ADP) 


Navy Cargo Handling Force 


APPENDIX C. MILITARY HEALTH SYSTEM 
FIVE ECHELONS OF CARE 

P Echelon I 

Care is rendered at the unit level and includes self and buddy aid, 
examination, and emergency lifesaving measures. 
2. Echelon Il 

Care is rendered at a MHS organization by a team of physicians or 
physician assistants, supported by appropriate medical, technical, or nursing staff. 
At this level, care includes basic resuscitation and stabilization and may include 
surgical capability, basic laboratory, limited x-ray, pharmacy, and temporary 
holding facilities. 
3. Echelon Ill 

Care administered at this level requires clinical capability normally found in 
a medical treatment facility (MTF) that is typically located in a lower level enemy 
threat environment. The MIF is staffed and equipped to provide resuscitation, 
initial wound surgery, post operative treatment, and care that may include the first 
steps toward restoration of functional health. 
4. Echelon IV 

This echelon of care will provide not only a surgical capability but also 


further definitive therapy for patients in the recovery phase. 


7) 


5: Echelon V 
Care is convalescent, restorative, and rehabilitative and is normally 
provided by military, Department of Veteran Affairs, or civilian hospitals in 


CONUS. 


80 


10. 


ER 


LIST OF REFERENCES 


Medical Readiness: Progress in Stating Manpower Needs, General 
Accounting Office, (GAO/NSIAD 87-126), April 1987. 


National Defense Authorization Act, Fiscal Year 1986, House Report 99- 
235, February 1985. 


National Defense Authorization Act, Fiscal Year 1992-1993, Section 733, 
House Report 2100, Public Law 102-190, March-April 1985. 


Wartime Medical Care: Aligning Sound Requirements With New Combat 
Care Approaches Is Key to Restructuring Force, General Accounting 
Office, (GAO/T-NSIAD 95-129), March 1995. 


United States Navy, Navy Capabilities and Mobilization Plan (NCMP), 
OPNAVINST S3061.1D, 2 April 1993. 


Doyle, Richard. Medical Readiness. Executive Management Education 
Module, Naval Postgraduate School, Monterey, - CA, 1998, 


http://www.laurasian.org/MR/MR HomeText.htm. 


DoN Total Health Care Support Readiness Requirement Model: A financial 
management perspective, [sic] LT Kimberly A. Copenhaver, USN, Navy 
Comptroller, October 1995. 


Chustz, Vincent, Senior Chief, HMCS, USN, Medical Plans and Policy 
Branch, N931D, Washington, D.C., Interview(s), 18, 20, and 25 September 
1998. 


The THCSRR Model: Determining Navy Medicine’s Readiness Manpower 
Requirements, LT Timothy H. Weber, MSC, USN, Navy Medicine, 
September-October 1994. 


Statement by Edward D. Martin, M.D., Acting Assistant Secretary of 
Defense for Health Affairs Before the Subcommittee on Military Personnel 
House National Security Committee, 26 February 1998. 


Operation Desert Storm: Problems with Air Force Medical Readiness, 
General Accounting Office, (GAO/NSIAD-94-58), December 1993. 


81 


12: 


La 


14. 


jo: 


16. 


17. 


18. 


19: 


20, 


Zale 


DD: 


23, 


24. 


Operation Desert Storm: Improvements Required in the Navy’s Wartime 
Medical Program, General Accounting Office, (GAO/NSIAD-93-189), July 
1993. 


Operation Desert Storm: Full Army Medical Capability Not Achieved,. 
General Accounting Office, (GAO/NSIAD-92-175), August 1992. 


Department of Defense, Medical Readiness Strategic Plan 1998-2004, 
DOD5136.1-P, Assistant Secretary of Defense For Health Affairs, March 
1998. 


Force Medical Protection Brief, CDR Rick Cocrane, MSC, USN, Medical 
Readiness Division, Joint Staff, Washington, D.C., N.D. 


Concept of Naval Force Health Protection for the 21S! Century, Navy 
Warfare Development Command and Marine Corps Combat Development 
Command, In Progress Working Draft, 22 June 1998. 


Wartime Medical Care: DOD IS Addressing Capability Shortfalls, but 
Challenges Remain, General Accounting Office, (GAO/NSIAD-96-224), 
September 1996. 


Navy Medicine Readiness Reengineering Journey, CDR Dan Snyder, MSC, 
USN, Navy Medicine, March-April 1998. 


Readiness Reengineering Oversight Council web = site, http://nmic 
bumed web.med.navv.mil/rroc/. 


Readiness Reengineering Task Force web site,  http://nmic 
bumed_web.med.navy.mil/mtf/default.htm. 





Naval Health Services Doctrine Working Group web site, http://nmic 
bumed web.med.navy.mil/nhsdwg/default.htm. 


Deployable Medical Platforms Advisory Council web site, http://www- 
dmpac.med.navy.mil/dmpac/charter.htm. 


The United States Naval War College, An Executive Level Text ın 
Resource Allocation, Volume I, The Formal Process, March 1998. 


National Defense University, Armed Forces Staff College, Publication 1, 
The Joint Staff Officers Guide 1997. 


82 


28. 


29. 


20. 


Ble 


P2. 


23. 


34. 


DD. 


United States Navy, Navy Capabilities and Mobilization Plan (NCMP), 
OPNAVINST S3061, (draft), N.D. 


Fuhrer, T.J., Implementing the Shock Trauma Platoon in the Reorganization 


of the Marine Corps Medical Battalions: Resource and Tactical 
Implications, Thesis, Naval Postgraduate School, Monterey, CA, December 


199% 


Jeffs, S.M., The Evolution of Military Health Services System Wartime 


Manpower Requirements Generation: From the Medical Planning Module 
to the Medical Analysis Tool, Thesis, Naval Postgraduate School, 


Monterey, CA, March 1997. 


Chairman, Joint Chiefs of Staff Instruction, Joint Strategic Capabilities Plan 
(JSCP), CJCSI 3110.01C, October 1998. 


Lewis-Cooper, J.. CDR, USN, Strategy, Plans, Policy and Operations 
Division, N3/N5, Washington, D.C., Interview, 2 November 1998. 


Gillen, D.J., Surface Combatant Planning Since the End of the Cold War, 
Thesis, Naval Postgraduate School, Monterey, CA, December 1998. 


Joint Chiefs of Staff, National Military Strategy of the United States of 
America, 1997. 


Smith, S., LCDR, MSC, USN, J-4, Medical Readiness Division, 
Washington, D.C., Interview, 23 September 1998. 


United States Marine Corps, Operational Maneuver From the Sea, 1993. 


Doctrine Notes, Vol I No. 2, Naval Doctrine Command, Norfolk, VA, 
September 1996. 


Houser, K.J., LT, MSC, USN, Manpower Analyst, N931, Washington, 
D.C., Interview, 30 October 1998. 








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