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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
Downloaded from NPS Archive: Calhoun
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KNOX appointed — and published — scholarly author.
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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
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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
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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
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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,
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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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