Army force health protection: past, present, and future.
Following the 1990-1991 Persian Gulf War, many service members reported health problems and believed these problems were associated with their military service in the Persian Gulf. A paucity of health and deployment data severely limited the ability to investigate the nature and causes of these illnesses. The National Defense Authorization Act for Fiscal Year 1998, (1) enacted in November 1997, directed the Department of Defense (DoD) to establish a system to assess the medical condition of service members before and after deployments. In 2002, the Government Accounting Office (GAO) was asked to determine if the military services met DoD's force health protection and surveillance requirements for service members deploying in support of Operation Enduring Freedom in central Asia and Operation Joint Guardian in Kosovo, and if DoD had corrected problems related to the accuracy and completeness of databases reflecting which service members were deployed to certain locations.
The findings of this GAO study were published in September 2003. (2) The GAO found that the Army and the Air Force did not comply with the DoD's force health protection and surveillance policies for many active duty service members, including the requirement that they be assessed before and after deploying overseas, that they receive certain immunizations, and that health-related documentation be maintained in a centralized location. The GAO's review of 1,071 service members' medical records from a universe of 8,742 at selected Army and Air Force installations participating in overseas operations disclosed that:
* From 38% to 98% were missing one or both of their health assessments.
* From 14% to 46% were missing at least one of the required immunizations.
The study (2) also found that the DoD did not maintain a complete, centralized database of service members' medical assessments and immunizations. Health-related documentation missing from the centralized database ranged from 0% to 63% for predeployment assessments, 11% to 75% for postdeployment assessments, and 8% to 93% for immunizations. Additionally, there was no effective quality assurance program at the Office of the Assistant Secretary of Defense for Health Affairs or at the Army or Air Force that helped to ensure compliance with policies. The GAO believed that the lack of such a program was a major cause of the high rate of noncompliance. The GAO was concerned that continued noncompliance with these policies might result in the deployment of service members with health problems, or delays in obtaining care when they return.
Based on these findings, the GAO recommended that the Secretary of Defense direct the Assistant Secretary of Defense for Health Affairs to establish an effective quality assurance program that would help ensure that the military services comply with the force health protection and surveillance requirements for all service members. The DoD concurred with this recommendation.
In November 2003, The Surgeon General of the Army tasked the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) with the development of a quality assurance program for deployment health. The Army Deployment Health Quality Assurance (DHQA) Program was designed to provide a capacity for on-site record reviews as well as a system for accountability (compliance with standards and public law), quality assurance, and reporting.
Late in 2003, USACHPPM sent 2 teams to conduct the first Army deployment health quality assurance site visits at Fort Stewart, Fort Drum, Fort Lewis, Fort Hood, and Fort McCoy. The visits consisted of reviews of outpatient records, discussions with medical staff and medical support staff, and visits to deployment processing centers. During these first visits, the teams found a general lack of knowledge among medical staff and medical support staff regarding deployment health policies and requirements for deploying Soldiers. At that time, the deployment health assessment forms were completed by hand, in triplicate, and the copies were forwarded to the Army Medical Surveillance Activity (AMSA). Once received, the forms were scanned into a centralized electronic database.
In January 2004, The Assistant Secretary of Defense for Health Affairs issued HA Policy 04-001, (3) which outlined specific guidance for the DoD Deployment Health Quality Assurance Program. The major requirements of this policy included
* Reports on centralized pre- and post-deployment health assessments
* Reports on service-specific deployment health quality assurance programs
* Visits to military installations to assess deployment health compliance and effectiveness
* Major findings and recommendations summarized in an annual report and coordinated through the Force Health Protection Council
PROGRESS SINCE 2003
Chapter 7 of The Department of the Army Personnel Policy Guidance (PPG) (4) and Department of Defense Instruction 6490.03 (5) serve as references for compliance standards, metrics, and reporting requirements for Army DHQA activities. The PPG is updated frequently and is reviewed routinely for the latest guidance.
Current requirements of the Army DHQA program include, but are not limited to
* Deployment health assessments
* A predeployment health assessment (DD Form 2795) must be completed for all Soldiers and Department of the Army (DA) civilians before a major deployment, as prescribed by DoD and DA policy, and archived electronically at the Armed Forces Health Surveillance Center (AFHSC) (formerly AMSA). The required method for completing and forwarding deployment health forms is the Army Medical Department Medical Protection System (MEDPROS).
* A postdeployment health assessment (DD Form 2796) must be completed for all Soldiers and DA civilians upon redeployment as prescribed by DoD and DA policy, and archived electronically at AFHSC.
* A postdeployment health reassessment (DD Form 2900) must be completed for all Soldiers and DA civilians upon redeployment as prescribed by DoD and DA policy and archived electronically at AFHSC.
* Deployment serum specimens. A predeployment serum specimen must be drawn for all Soldiers and DA civilians as prescribed by DoD and DA policy and forwarded to AFHSC for storage in the DoD Serum Repository (DoDSR). Similarly, a postdeployment serum specimen must be drawn for all Soldiers and DA civilians as prescribed by DoD and DA policy and forwarded to AFHSC for storage in the DoDSR.
* Immunizations. A record of each immunization required for deployment will be documented using MEDPROS. Immunization requirements vary by deployment destination (for specific guidance, see Army Regulation 40-562 6 and the PPG4).
* Screening tests. A record of predeployment testing for tuberculosis infection and human immunodeficiency virus infection, performed as prescribed by DoD and DA policy, will be recorded using MEDPROS. A record of testing for deployment-related tuberculosis infection, as prescribed by DoD and DA policy, will also be recorded using MEDPROS.
* Deployment health care. Health care provided during deployment must be documented either electronically, where available, or on appropriate forms (eg, DD Form 2766 and SF600).
* Other metrics as required
Key elements of the Army DHQA program:
* Periodic status reports on centralized data and serum specimens. AFHSC provides reports as required on deployment health assessment data to the Force Health Protection Quality Assurance coordinator at the Office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness (DASD/FHP&R).
* Site assistance visits to assess deployment health programs.
* Onsite assistance visits complement the corporate-level periodic reports. Site visits also provide the opportunity to obtain an operational perspective on the deployment health program, identify the most efficient and effective practices, and highlight quality assurance and process improvement activities.
* The timing, site selection, and scope of the site visits are determined by need and current issues. Visits are designed to maximize utilization of staff resources while minimizing interruption of installation activities.
Since 2003, a team from USACHPPM has visited approximately one Army installation per quarter, including one visit per year with a team from DASD/ FHP&R. These visits focus primarily on force projection sites and have included, among others, Fort Bragg and Fort Bliss, as well as return visits to Fort Drum, Fort McCoy, and Fort Lewis. USACHPPM also visited the US Army Corp of Engineers Headquarters in Winchester, VA, at their request, to provide guidance and recommendations for deploying DA civilian engineers.
USACHPPM, with assistance from AFHSC, provides all required reports to DASD/FHP&R on the Army's deployment health quality assurance program. Over time, there has been remarkable improvement noted in deployment health metrics and practices. Electronic completion and capture of deployment related health forms, archiving deployment health related forms and data in the centralized database at AFHSC, and the use of systems like MEDPROS to document and monitor deployment health related requirements have all improved dramatically.
MEDPROS was developed by the Army Medical Department to track all immunizations, medical readiness, and deployment data for all active duty and reserve component Soldiers of the Army, as well as DA civilians. It is a powerful tool allowing the chain of command to determine the medical and dental readiness of individuals, units, and task forces. Commanders and leaders at various levels are responsible for the use and implementation of MEDPROS to monitor their units and/or individual readiness status.
Comprehensive medical readiness data in MEDPROS includes all medical and dental readiness requirements. Included are immunizations, permanent physical profiles, eyeglasses, blood type, medical warning tags, medications, pregnancy screening, DNA, HIV, and dental status. Deployment health assessment forms can now be completed electronically using the MEDPROS link in the "My Medical" tab on the Army Knowledge Online website. These forms are automatically forwarded electronically to AFHSC to be archived in the central database.
Department of Defense Instruction 6200.05 (7) implements policy, assigns responsibilities, and prescribes procedures for establishing a comprehensive DoD Force Health Protection Quality Assurance (FHPQA) Program; and expands deployment health quality assurance activities by applying FHPQA to key elements throughout the entire period of an individual's military service. The DoD FHPQA Program is designed to ensure that the health of service members, as well as applicable DoD civilian and contractor personnel, is effectively monitored, protected, sustained, and improved across the full range of military activities and operations.
FHPQA is focused on:
* The promotion and sustainment of a healthy and fit force.
* The prevention of illness and injuries, and protection of the force from health threats.
* The provision of medical and rehabilitative care to the sick and injured.
The Army remains committed to providing quality health care and maximum protection to its Soldiers, regardless of geographic location and circumstances. The new Force Health Protection Quality Assurance Program is a force multiplier, designed to provide not only a system for accountability (compliance with standards), but also a system to assure quality and continuous improvement in the care provided to our Soldiers and DA civilians throughout their careers.
(1.) Pub L. No. 105-85, 111 Stat 1629.
(2.) US General Accounting Office. Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance. Washington, DC: US General Accounting Office; September 19, 2003, Report GAO 03-1041. Available at: http://www.gao. gov/new.items/d031041.pdf. Accessed April 27, 2009.
(3.) HA Policy 04-001: Policy for Department of Defense Deployment Health Quality Assurance Program. Washington, DC; Assistant Secretary of Defense for Health Affairs: January 9, 2004. Available at: http:// fhp.osd.mil/pdfs/ha_memo_dep_health_quality _assure_prog.pdf. Accessed April 27, 2009.
(4.) Department of the Army Personnel Policy Guidance for Contingency Operations in Support of GWOT. Washington, DC. US Dept of the Army; February 13, 2008. [updated April 13, 2009] Available at: http:// www.armyg1.army.mil/militarypersonnel/PPG/PPG. Accessed November 1, 2008.
(5.) Department of Defense Instruction 6490.03: Deployment Health. Washington, DC: US Dept of Defense; August 11, 2006.
(6.) Army Regulation 40-562: Immunizations and Chemoprophylaxis. Washington, DC: US Dept of the Army; September 26, 2006.
(7.) Department of Defense Instruction 6200.05: Force Health Protection Quality Assurance Program. Washington, DC: US Dept of Defense; February 16, 2007.
E. Wayne Combs, PhD, RN
Dr Combs is a Community Health Nurse at the US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Grounds, Maryland.