Navy Medicine Navy Enterprise Enabler prepared for Surgeon General’s Symposium January 2007

1. Navy Medicine Navy Enterprise Enablerprepared forSurgeon General’s SymposiumJanuary 2007 IntroBaselineOverview - People - Dollars - “Stuff”Maximizing Value Metrics Moving Forward

2. FRE HSS: Fleet Health Domain Membership CFFC CPF BUMED NWDC AIRFOR SURFOR SUBFOR NECC MSC NSW NNFE MARFOR TMO N931 Navy SG (Healthcare Enabler) CFFC (FRE) CFFC Surgeon (FHD BOD) (BUMED CEB) Navy Medicine – Enterprise EnablerFramework to Optimize Readiness at Cost WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN USMC NAE SWE USE NNFE NECC MPT&E X AT&L X Installations X Moving forward to a Naval Enterprise Health Care X X X X X X X FYDP NEXTNEXT FYDP NEXTNEXT S&T CURRENT……FUTURE READINESS X Other X=People, Dollars, Stuff, Services X OAG Managing the Navy Enterprise Intersections Sailors and Marines Medically Ready for Tasking as measured by Individual Medical Readiness (IMR)

3. Output (Input to Enterprise) Governance People Work Value • Sailors/Marines Medically Ready for Tasking • Ready Medical Force • Healthcare Services for Family Readiness Dollars Stuff Effects Based Metrics - Lean Six Sigma Provide Quality Care Efficiently Provide Prepared Forces Individual Medical Readiness (IMR) – Single Fleet Metric • No Deployment Limiting Conditions • Immunizations • Health Assessments • Medical Readiness Labs • Dental Class 1 or 2 • Individual Medical Equipment Navy Medicine’s Value Chain Value Output Input • Input • Naval • Requirements • Operations Concept • DoD • Funding • Policy • Congress • Appropriations • Policy • Healthcare Industry • Policy • Practice Standards

4. In Dialogue Navy Medicine – Enterprise EnablerIntegration at the Intersections WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN USMC NAE SWE USE NNFE NECC MPT&E X AT&L X Installations X Health Care X X X X X X X FYDP NEXTNEXT CURRENT……FUTURE READINESS S&T X Other X • Enterprise Directly • Influences • Sailor and Family Utilization • Healthy Lifestyles • Safety • Compliance In Dialogue Achieving Visibility of the Full Cost of Readiness

5. To Ensure the Right Capabilities • Navy Medicine VISION within Navy Enterprise • Provide medically ready forces and healthcare services for family readiness. • Deliver quality, economical health care emphasizing prevention. • Focus research and development efforts on warfighter performance, protection, and survival. • Provide a ready medical force prepared for the full spectrum of combat service support requirements. • Shape tomorrow’s force to meet future needs in Joint environments. Current Environment Future Environment SSTR/Humanitarian Operations Scalable/Modular Agile Capabilities • QDR – Medical Roadmap • Transform the Force • Transform the Infrastructure • Transform the Business • Sustain the Benefit Combat Casualty Care GWOT Injuries GWOT-driven Health Services (Rehab, PTSD, TBI) DoD Medical Service Joint Oriented CSS for Joint Warfighter Constrained Infrastructure/finances Cost Predictability Shifting Demographics Optimize Return on Investment Medical Inflation/Shifting healthcare environment Sustainable Benefit/Cost

6. CFFC CPF BUMED N931 Navy SG (Healthcare Enabler) CFFC (FRE) CFFC Surgeon (FHD BOD) (BUMED CEB) The Healthcare Domain is linked to the FRE by the relationship of the CFFC Surgeon within the Navy Enterprise framework to both the Commander, U.S. Fleet Forces Command and to the Navy Surgeon General. Fleet Health Domain and Linkage Desired Effect: Cross-functional team that collaboratively delivers health and medical services across the range of likely military operations. Fleet Health • CHARTER • Develop / integrate requirements • Provide enabling resources needed to meet requirements • Fund integrated requirements • Execute requirements (with $ and enabling resources from providers) Board of Directors C2F C3F C5F C6F C7F NWDC AIRFORSURFOR SUBFOR NECC MSC NSW NNFE MARFOR TMO FOH CONOPS December 2006

7. FRE Demand SignalFuture Capability from Fleet Health Domain • Aggregated Operations: • Sea-based HSS for MCO • First Responders: Organic Fleet HSS assets • Forward Resuscitative Care: Surface Combatants (ERSS) Carrier Strike Group Casualty Receiving and Treatment Ships (LHD/LHA/LPD-17) • Level III care in Theater (T-AH) • Designated EnRoute Care (clears casualties from Sea Base) • Aggregated Operations: • Humanitarian Assistance /Disaster Relief • Sentinel event generates demand signal for US Forces to provide disaster relief from the sea. • JFMCC provides initial capabilities for sea-based HA/DR using CSG, CRTS, ERSS, T-AH. • Joint, interagency, coalition, host nation, and IGO/NGO resources transition from sea-based to shore-based HA/DR. • Disaggregated Operations: • EMIO in GWOT • JFMCC Commander alerted to High Value Target in AOR. • EMIO planned with high risk of trauma. • ERSS team deployed to interdiction vessel. • US casualties sustained during EMIO. • On site damage control surgery saves US personnel.

8. Federal Health Partners USA USAF USCG VA HHS HLS T R I C A R E Operating Across the Enterprises Framework to achieve Sailors and Marines Medically Ready for Tasking WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN WARFARE DOMAIN USMC NAE SWE USE NNFE NECC Provide Quality Care Efficiently MPT&E Provide Prepared Forces X AT&L X Installations X Moving forward to a Naval Enterprise Health Care X X X X X X X FYDP NEXTNEXT CURRENT……FUTURE READINESS S&T X Other X DEEP DIVE: Individual Medical Readiness (IMR) DEEP DIVE: Pharmacy

9. Military EssentialityFuture Capabilities Require New Thinking Unique to military • What’s the right curve for non-traditional, evolving missions? • Assessment examines: • Mission capability required • Costs • Skill type • Labor type CONPLAN 7500 Capability Required Military Non-Military NGO, CIVPERS Available In marketplace Initial deployment speed Fast Slow • QDR: Transform the People • Interoperability and Agility of Operational Medicine Capabilities • Homeland Defense and Medical Civ-Mil Operations

10. Current projection of active authorization DON Military Medical / BSO 18 Federal Civilian Workforce history and projection Active 31,384 (PDM: -2,340) 30,483 (PDM: -900) Total Medical Force decreased 9.5% from FY99 – FY13 18,454 (DON: +2,340) Civilian Reserve PDM: 2,340 Conversions Can be achieved with limited personnel and facility consequences Significant consequences: civilianization of entire facilities, closure of training programs, increased PERSTEMPO, decreased MTF services PDM: 901 eliminations

11. DT- 8707 FMF HM-8404 FMF HM-8404 FMF HM-8445 OCULAR HM-8646 ENT HM-8483 SURGERY DT-8783 SURG HM-8483 SURGERY HM-8479 B/BMET HM-8478 A/BMET DT-8732 DEN REPAIR HM-8478 A/BMET HM-8451 B/XRAY HM 8452 A/X-RAY HM-8452 A/XRAY DT-8752 B/PROS DT-8753 A/PROS HM-8753 A/PROS HM-8486 UROLOGY HM-8416 NUCMED HM-8434 DIALYSIS HM-8495 DERM CONVERTING TO CIVILIAN POSITIONS Matching Supply and DemandSea Warrior Implementation Hybrid HM Outcomes • Increased skill inventory • Positive impact on PERSTEMPO Phase I: HM-DT Merger • Increased skill inventory • Positive impact on PERSTEMPO • Decreased joint training infrastructure • Phase II: NEC Management • 46 total HM/DT NECs • 13 NECs consolidated to 5 • 4 NECs deleted due to • Mil-to-Civ conversion • Standardized skill set from 3 to 1 • Meets industry standard • Standardized skill set from 2 to 1 • Will decrease Joint training infrastructure • Freed up inventory for critical operational skill sets Phase III: Continue review of remaining NECs Desired Effects: Assignment flexibility, streamlined training, decreased training infrastructure. Impact on Advancement Exams: One advancement cycle complete to date.

12. Workforce Diversity Labor Force by Gender Leadership Opportunities Labor Force by Race/Ethnicity Widened aperture in FY06 GS-13 Military and Civilian Medical Community is more diverse in gender, race, and ethnicity than Navy.

13. Budget History and ProjectionNavy Medicine TOA (FY01-FY13) Today Short Falls OP & RDTE,DHP OP, RDTE, O&M,N Medical Purchased Services DHP & Navy Pharmaceuticals O&M,DHP: Facilities, IT, HQ, Purchased Care, Education & Training Civilian Salaries Mil/Civ Conversions Military Personnel Navy Navy Navy Medicine is approximately 27% of OSD Health Affairs Budget *Based on MRR of 2340

14. Major Projects (DHP MILCON) FY05/FY06 NACC Charleston - Joint venture with VA FY07/FY08 North Chicago Federal Healthcare (Great Lakes) - Joint venture with VA NH Okinawa FY09 - FY12 NH Guam Major BRAC MILCON Walter Reed National Military Medical Center Medical Enlisted Training Campus Fort Sam Houston Joint Centers of Excellence for Chemical, Biological and Medical Research, Development & Acquisition Fort Sam Houston, Fort Detrick, and Wright Patterson AFB Brooks City Base/Directed Energy Laboratory Matching Facilities to DemandFixed Facilities Transforming Investment Decision Making Process • Capital Investment Decision Model (CIDM) • Effect: Create logical, timely, and transparent decision making tool that is responsive to change – current with market and mission requirements. • Ties capital asset investment decisions to MHS Business and Strategic Plans. • Eliminates inconsistent manner by which Services determine project priority. • CIDM to be implemented for FY09 DHP MILCON program. OMB mandated.

15. IM/IT Consolidation Strategy Effects required • Establish baseline • 25% reduction in Navy Medicine owned IT assets by CY07 • Increase use/growth of tri-service owned IT Status • IT application, server and network counts increased in FY06 despite consolidation efforts Drivers • Lack of baseline ~ continued discovery • Multi-level governance structures not yet well coordinated Actions • Hire Navy Medicine CIO – completed Sep 2006 (former Logistics FAM lead) • Establish final baseline for DADMS reporting in January-February 2007 • Put Navy Medicine IT governance processes in place • Interfaces to DoD & Navy • Include Legacy review • Set targets to coincide with Navy targets • Information Assurance visits to identify and shut down unreported legacy IT assets Consolidation and Standardization Tri-Service Medical IT Managed by ASD (Health Affairs) Hospital IT Managed by NAVMED Support Command Funded by ASD (HA) Hospital IT Managed by Local Medical Facilities Funded by ASD (HA) Consolidation and Standardization Efforts Underway

16. Tri-Service Board* Navy Medicine’s Innovation Framework Improving Business and Productivity for the Enterprise Productivity (RVU) Business Process MHS Plan Venture Capital MHSSI, IIP, JIF Monitoring Against National Benchmarks Warfighter Readiness Quality and Safety Navy/Marine Combat Trauma Registry

17. Negotiate with Industry Participate with DoD PEC & PTC Collaborate with VA DEEP DIVE: Formulary Management Structured action for standardization, savings and safety • Formulary Cost Reduction Initiatives • DoD/Tri-Service/VA Collaboration • Federal Supply Schedule • Prime Vendor • Use of generic medication • Tiered Co-Pay • Total Cost Avoidance >$500M over 5 years One example: Blood pressure medication Savings of >$280K/month Federal Supply Schedule Costs Prime Vendor Costs Most clinically effective – most cost efficient medication provided to the beneficiary

18. IMR Improvement Initiatives Partnership with N1 MRRS NMPS Sites for IAs Operational Dental Readiness (ODR) Goals Reserve AT Requirement: Medical Class 1 or 2 Link PHA to PRT SECNAVINST on IMR DEEP DIVE: Individual Medical Readiness Active Duty Readiness Lean Six Sigma Focus Area Constraints and Barriers • IT Interoperability • Process variability in data collection • Policy Gap 4th Quarter 2006 data Reserve Readiness Sailors and Marines Medically Ready for Tasking as measured by Individual Medical Readiness (IMR)

19. DEEP DIVE: Individual Medical Readiness Lean Six Sigma Focus Area - IMR

20. AHLTA DOD Electronic Medical Record The 6 Elements of IMR DEEP DIVE: Individual Medical ReadinessMRRS - Single Authoritative Source for IMR MRRS • MRRS Web Site • Direct Data Entry for • Reservist • USMC • Active Duty (Non SAMS) Clinical Data Repository for all DoD Medical Records Montgomery, AL CDR daily 1/07 NMO 3/07 Data Broker Dental - Dental - Immunizations - Labs (G6PD, Blood Type, DNA) - Deployment Limiting Conditions - Periodic Health Assessment (PHA) - Equipment: Eyeglasses, Gas Mask Inserts SAMS Operational Active Duty IMR Tool

21. Tier II Supporting Goals Tier II Supporting Goals Tier II Supporting Goals Tier II Supporting Goals Tier II Supporting Goals Tier II Supporting Goals Regional Commander NCA Regional Commander West Regional Commander East Chief of Staff Regional Commander NMSC N931 CIO Comptroller MEDIG Measuring Performance….Changing Behavior Provide Quality Care Efficiently Provide Prepared Forces Desired Effect Ends • Deployment Readiness • Agile Forces • Effective Force Health Protection • Quality of Care • Delivery of Care (production) • Cost Management Major Metrics Performance Accountability Monthly Review Tier II Goal Owners (52 Supporting Metrics) Responsibilities Means Strategic Planning Drives Execution Performance Navy Performance Excellence Guidebook (NPEG)

22. Measuring Desired EffectsWhat Does Success Look Like? As of 17 January 2007

23. Measuring Desired EffectsWhat Does Success Look Like? As of 17 January 2007

24. Moving ForwardNavy Medicine Challenges 1 – Stress on the Force - Combat Operational Stress Control - Care of the Caregiver 2 – Force Structure - Military-Civilian Conversions (PBD 712/POM 06, POM 08) - PDM-IV divestitures - Capabilities - USMC force growth 3 – POM-08 - Efficiency Wedge 4 – BRAC - Multi-Service Markets – National Capital Area - Education and Training – San Antonio, TX - Research and Development