NCR Healthcare Redesign

1. NCR Healthcare Redesign Tri-Service Symposium 13 July 06

2. Objectives Driving MJCSG Planning • Reduce excess capacity • Relocate medical care into facilities and installations of higher military value and capacity • Provide greater opportunity for medics to maintain medical currency • Enhance Jointness

3. BRAC Scenarios for NCR MTFs • Closure of WRAMC and placement of consolidated medical facilities and functions at Bethesda (North) and Fort Belvoir (South). • No loss of capability and continue to serve as a world class center for casualty care • Based on actual workload, no purchased care recapture • 1.3M new SF in the NCR • 300 bed tertiary care MEDCEN in the north – 300K SF • 165 bed community hospital in south - 1M SF • $781M capital investment • 1376 manpower eliminations from closure of WRAMC installation • Downsize Malcolm Grow Medical Center to an outpatient facility with ambulatory surgery capability.

4. NCR MHS BRAC Intent “Let me describe what this new Walter Reed National Military Medical Center would look like.  It will be the centerpiece of military health care, clinical practice, education, and research.  It will rival Mayo Clinic, Johns Hopkins, and the other great medical institutions of the world, and it will be jointly staffed. ” LtGen Peach Taylor, Medical Joint Cross Service Group, 13 May 05 “Whatever it costs, we need to incur that cost to provide that world-class care to an extraordinary group of men and women in harm’s way.” Anthony Principi, Chairman, 2005 BRAC Commission “In Washington, the new Walter Reed National Military Medical Center will be a joint medical facility, and the – not a – but the world leader in military medicine – in quality, in research, in technology, and in training…” Dr. William Winkenwerder, Jr., Assistant Secretary of Defense for Health Affairs, 30 Jan 06

5. WRAMC Migration Diagram Chemical Biological Defense RDA COE Aberdeen Proving Ground, MD Not moving Old location New location PDA PEB Medical Biological Defense Research COE Ft Detrick RIID WRAIR Bio NMRC Bio 5 Dec 05 ICD WRAIR Chem. Ft. Belvoir Non-Tertiary Care Forest Glen Annex, MD Bldg 509/510 Bldg 503 Bethesda, MD MEDCEN NMRC Inf Dis Walter Reed National Military Medical Center Non-Tertiary Care WRAIR Chem. Tertiary Care (AFIP) ACTUR Tissue Repository Borden Institute WRAIR Bio WRAIR Inf Dis NARDC PDA/PEB MSMO CID NARCO NARMC NARVC 2290TH AMSA WRAMC MAIN POST NMRC Bio WRAIR CCC Dept of Retrovirology NMRC CCC AFIP Dover AFB, DE Infectious Disease Research COE Medical Museum Legal Med Ctr for Clin Lab DoD Pt Safety Program Mgmt Off Enlisted Histology DoD Vet Path Medical Examiner Ft. Sam Houston, TX Medical Examiner DNA Repository Accident Invest (AMEDDC&S) Borden Inst Enlisted Histology DNA Repository Forest Glen, MD NMRC CCC Dept of Retrovirology Accident Investigation WRAIR CCC Rockville, MD

6. NCR MHS Missions • Force Health Protection • Deploying a medically ready force • Deploying a ready medical force • Maintaining clinical competence • Support to other MTFs • GME and Non-GME training • Mobilization/De-mobilization mission • Active Duty and Beneficiary Care • Tertiary Care • Casualty Care • World-wide referral • Executive Medicine • Research • Force Health Protection Related • Health Professions Education Related • Collaborative Research with other Federal Agencies

7. NCR BRAC Planning Principles NCR BRAC Planning: • Is Workload based • Does not go beyond intended throughput • Approaches planning from a Market perspective • Considers BRAC actions at individual facilities to be indivisibly linked • Seeks to maximize seamless beneficiary care between the North and South, and throughout the NCR

8. North and South Markets Methodology Used for Joint Service NCR BRAC Planning • Divided NCR into North and South based on distance/drive time to Bethesda and Fort Belvoir • Pulled data (visits, admits, RVUs/RWPs) for NNMC, WRAMC, and Fort Belvoir based on geographic distribution (patients home zip code) • Redistributed South “tertiary care” workload to the North based on a combination of qualitative and quantitative clinical service data and input • Approximately 20% of South-generated inpatient activity (and 13% Ambulatory care) is expected to migrate to the North

9. Workload Distribution Based on Market-Based Analysis • The FY04 Inpatient (ADPL & RWPs) and Outpatient (RVU) projections used in planning facilities for the NCR (in response to BRAC) are below MJCSG COBRA estimates.

10. COBRA Omissions

11. Inadequate Scope at NNMC

12. NCR MTF Realignment Recap Pre-BRAC COBRA DD1391 After 14 Nov 05 Renovations = 167K SF Renovations = 260K SF Bethesda 196 Beds 113 ADPL 839K RVUs 10.5K RWPs 1.4M GSF WRNMMC 300 Beds 240 ADPL (80%) 1,184K RVUs 18K RWPs 1.9M GSF WRNMMC 346 Beds 276 ADPL 1,143K RVUs 19K RWPs 2.1M GSF WRNMMC 345 Beds 262 ADPL 1,143K RVUs 17.2K RWPS 1.76M GSF Reduce 77.5K SF clinical 337K SF total Shift subspecialty inpatient North WRAMC 294 Beds 189 ADPL 1,148K RVUs 16.5K RWPs 2.8M GSF Shutdown 2.8M SF clinical 7.8M SF total Ft Belvoir 120 Beds 92 ADPL 706K RVUS 10.8K RWPS 872K GSF Ft Belvoir 147 Beds 109 ADPL 706K RVUs 12K RWPs 977K GSF Ft Belvoir 165 Beds 116 ADPL (70%) 1,372K RVUs 13K RWPs 1.05M GSF Reduce 105K SF clinical Ft Belvoir 45 Beds 20 ADPL 568K RVUs 1.9K RWPs 377K SF Shutdown 377K SF clinical Net Shutdown 1.8M SF clinical 6.8M SF total Net Shutdown 1.6M SF clinical 6.6M SF total Net Shutdown 1.8M SF clinical 6.7M SF total MGMC 60 Beds 33 ADPL 314K RVUs 2.7K RWPs MGMC 0 Beds 0 ADPL 300k+/- RVUs 0 RWPs MGMC 0 Beds 0 ADPL 300k+/- RVUs 0 RWPs Inpatient workload to the Network. No change in SF 595 Beds 322 ADPL 60% Occupancy 465 Beds 356 APPL 76% Occupancy 465 Beds 354 ADPL 76% Occupancy

13. NCR Market Solution • Use existing market assets to decrease capital construction investment and still be fully mission capable. • Optimizes direct care system • Does this comply with BRAC Law? Yes • Does this exceed COBRA Model? Yes • Includes omissions, inadequate scope due to test-fit, and community support services, but further decreases 14 Nov 05 construction requirements by using existing market spaces and other alternatives minimize MILCON requirements. *PA and PD cost only. Does not include Initial Outfitting & Transition, or CAT E & F Equipment

14. Risks included in the NCR MHS BRAC Business Plan • Reducing the Supporting Facility cost factor from 20% to 13% • Reducing the Army’s Corps of Engineers and the Navy’s Facilities Engineering Command Supervision, Inspection & Overhead (SIOH) rate from 5.7% to 3%. • $80M reduction in Initial Outfitting and Transition in FY11 • Unit cost escalation fixed at 2.45% • Business Plan is tightly constrained and assumes vigorous control of costs and full realization of savings.

15. Initial Outfitting and TransitionReductions • Reduced planning factors: • Initial Outfitting from 30/25% to 18% • Transition from 5% (10% for renovations) to 4% (8%) • Risk = $80M • Risk mitigation: • Maximize reuse and relocation of existing equipment • Standard planning factors not scaled for extremely large projects.

16. BRAC Facility Planning Process • COBRA Analysis – Spring 2005 • NCR BRAC Planning – Summer 2005 • Solicit NCR User Group input in developing Program for Design (PFD) requirements – Fall 2005 • NCR MHS BRAC Business Planning – Winter 2006 • Complete the Program for Design – Summer 2006 • NNMC Master Plan – Summer/Fall 2006 • Design Authority – Summer 2006 • Engage architects to design facilities – Fall 2006

17. NCR MHS BRAC and Integration • Inherent in MHS BRAC 2005 actions is the integration of MTFs such that they begin to function as an Integrated Delivery System. • MEDCENS, Inpatient facilities, and Ambulatory commands in the NCR are proceeding with Integration as we plan and execute BRAC.

18. NCR Portfolio Integration Planning BRAC Health Care Planning/PFD Integration Planning Mission Population Forecasting Workload Forecasting Staffing/Manpower Rqmts Direct vs. Purchased Care Demand Analysis 2 MEDCENs to 1 Market Inpatient Integration Market Direct Care Integration Network Integration Functional Integration Capital Asset Inventory Market Assessment Defining Characteristics Supply Management Maximize use of Capital Assets Increase Beneficiary Access Recapture Purchased Care Lower Operating Costs Provider Requirements Volume Thresholds/ Optimization Functional Alignment Consolidation Planning Scenarios Space Requirements Forecast Space Program Functional Options Optimize Capital Assets Facility Planning Scenarios Functional & Facilities Analysis Alternative Architectural Solutions Project Identification Facility Planning & Development Establish Program Management Office tied to NCR Market Governance, Office of Integration and MSMO Documentation

19. Revolutionary Change Evolutionary Change “Business as usual” MEDCEN #1 MEDCEN #1 “VISION” “VISION” ONE MEDCEN MEDCEN #2 ONE MEDCEN MEDCEN #2 TIME TIME Disadvantages: too many last minute details – won’t get it right; appears disorganized; will disenfranchise patients and staff; probably take longer to get where you want to be. Advantages: less traumatic; people know where they are going; less degradation of MEDCEN assets; earlier you start the easier it will be. BRAC, Integration, and Change

20. Priority of efforts: Build an Integrated Delivery System (IDS) in the NCR Include MGMC BRAC actions in the NCR integration plans Develop a seamless continuum of care between the North/South Functionally integrate WRAMC and NNMC NNMC #4 WRAMC #1 #3 Other NCR MG #2 Ft. Belvoir National Capital Area (NCR) Military Health System (MHS) MSMO Focus The circle diagram describes a single NCR-wide integrated entity with WRAMC and NNMC integration of specialized, tertiary-level care and support functions at the center. Through this Northern merger of people, processes, and structure, North/South functional integration, and along with other NCR component facilities, health services are aligned.

21. Priority of efforts: Functionally integrate WRAMC and NNMC Develop a seamless continuum of care between the North/South Include MGMC BRAC actions in the NCR integration plans Build an IDS in the NCR NNMC #1 WRAMC #4 #2 Other NCR MG #3 Ft. Belvoir National Capital Area (NCR) Military Health System (MHS) Integration Office • Focus - Clinical Care, Healthcare Care Ops, & GME/Research

22. NCR Integration • The NCR is approaching Integration from both a MEDCEN perspective and a Market perspective • The Office of Integration focuses on functionally merging the MEDCENS and functionally integrating the MEDCENS with the community hospital at Fort Belvoir • The MSMO focuses on developing the NCR Market as an integrated health care delivery system. • Building Blocks • MEDCEN = WRAMC + NNMC + USUHS • Inpatient/Specialty care = MEDCEN + DeWitt + MGMC • Direct Care = Inpatient & Specialty Care + Primary Care ambulatory commands

23. NCR Integration Org Chart IMPLEMENTATION IMPLEMENTATION

24. Areas of Intense Focus • Office of Integration • Health Care Operations • Administrative Services • Information Systems • Communications and Marketing • Nursing • Clinical Services • Health Professions Education • Research • MSMO • Manpower • Healthcare Operations • Logistics • Resource Management

25. Questions?

26. Shared Vision for Integration18 Aug 05 In concert with the medical provisions of BRAC 2005, we envision one unified NCR military health care system. Jointly staffed inpatient campuses at the Walter Reed National Military Medical Center at Bethesda (North) and Fort Belvoir (South), and other NCR MTFs - also jointly staffed - will provide high quality, efficient and convenient care for our beneficiaries. The WRNMMC will serve as a world class academic medical center focused on highest quality tertiary care, graduate medical education, and clinical research while serving as a worldwide military referral center. The Ft. Belvoir community hospital will be the major satellite teaching hospital. Both campuses will be sized to provide health care at the closest facility to the beneficiary whenever clinically appropriate.

27. NCR BRAC Planning Assumptions • BRAC plans based on NCR MSMO analysis • NCR MSMO BRAC plans workload based, used FY04, vice COBRA (more accurate plan based current workload) 3. Eligible Population will remain stable at 450,000 4. Enrolled population will remain stable: 5. Worldwide referral capability is an enduring mission and the volume of patients will remain stable in the near and mid-term • MHS Workload in the NCR will remain relatively stable • GME programs will remain relatively stable • Current MTF-based research missions in the NCR will remain stable

28. NCR BRAC Planning Assumptions • In regards to Manpower, planning will achieve at least 1,376 fewer people in Federal employment as a result of BRAC Scenario 169 A & B. • The 543 AF staff moving into the NCR will allow additional Manpower savings above the 1,376 positions identified through the COBRA model. • There will be ongoing Forest Glen/Glen Haven BASEOPS requirement after Walter Reed compound closure • BRAC transition plans will include moving some service to WRAMC during Bethesda renovations. • Walter Reed compound will not close until construction at Bethesda and Belvoir completed.