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Equipping the combat support hospital: a case study.

The U.S. Army Medical Materiel Agency (USAMMA) at Fort Detrick, Maryland, is subordinate to the Army Medical Research and Materiel Command and serves as the Army's life-cycle management command for class VIII (medical materiel). The mission of USAMMA is to plan, synchronize, and provide medical logistics for health service support to forces conducting joint and full-spectrum operations by managing medical materiel life-cycle projects, equipping and sustaining the medical force, managing medical strategic centralized programs, and advancing performance excellence.

USAMMA performs its mission with the Army Materiel Command (AMC) in areas such as Army pre-positioned stocks (APS), left-behind equipment (LBE), and reset. As the life-cycle management command for class VIII, USAMMA is responsible for equipping and sustaining medical units, which must be done using the Army Force Generation (ARFORGEN) model. The Army Medical Research and Materiel Command and USAMMA make up the medical generating force as it relates to equipping units under the AFRORGEN model for medical units.

To accomplish this task, USAMMA has developed the Medical Materiel Readiness Program (MMRP) to support the Army's most complex medical unit, the combat support hospital (CSH). The MMRP solution for addressing ARFORGEN CSH equipping issues focuses on three tenets:

* Define a CSH baseline equipment set to be maintained at home station.

* Equip the generating force medical training base.

* Control equipment not at home station through a well-defined, centralized medical equipment management program maintained by USAMMA by applying many of the concepts associated with the APS program.

This article will discuss managing medical materiel in a CSH and the MMRP solution to assist in addressing medical materiel readiness issues in ARFORGEN.

Equipping Challenges

On any given day, USAMMA must balance the equipping requirements of deploying unit, reset, LBE, modernization of equipment and sets, kits, and outfits (SKO), and theater demands. The resources required to meet these equipping demands are overwhelming at best, but the Army's Title 10 responsibilities must be met. If they cannot be met, steps must be taken to mitigate the risks associated with unit materiel requirements not being fully satisfied.

During the early days of Operation Iraqi Freedom, USAMMA and Headquarters, Department of the Army (HQDA), realized that the mandate to equip all units to 100 percent was no longer viable unless millions of dollars were poured into the equipping and sustainment accounts. Not only would funding have to increase, so would the forces maintenance and sustainment programs, as demonstrated by the LBE program initiated in fiscal year 2008.


As USAMMA joined hands with AMC to assist with the LBE program, both organizations found that the forces' equipment was not being maintained properly. In fact, USAMMA learned over a period of more than 2 years (2008 to 2010) that in 6 Active component 248-bed CSHs, approximately 50 percent of the medical equipment was not mission capable. This validated already perceived anecdotal evidence and came as no great surprise to USAMMA. It provided the facts USAMMA needed to move forward with its MMRP initiative.

Reducing Unit Equipment

Over the years, the Army Medical Department has found that attaining unit readiness upon mobilization creates many challenges. During the early days of Operation Desert Storm, medical prophylaxes medications such as the MARK I (nerve agent antidote) kit were found to be expired or missing. Similarly, medical expendable items with a shelf life and expiration date were found to be expired or not on hand upon mobilization. The Office of The Surgeon General (OTSG), along with USAMMA, made the case to HQDA in the mid-1990s to centralize the storage and maintenance of MARK I kits and expendable medical items. Generally, units were no longer required to maintain these items at home station; USAMMA would take on this responsibility.


During the early days of Operations Enduring Freedom and Iraqi Freedom, those decisions proved to be invaluable. Not only did USAMMA deliver to the deploying units, these centralized programs saved tens of millions of dollars and allowed for rapid unit deployment. Most impressive, many of the problems that were identified from medical unit deployments for Operation Desert Shield were not repeated. Simply stated, medical centralized storage programs are efficient and effective.

The fiscal years 2008 to 2013 Program Objective Memorandum (POM), which was developed in 2006, applied lessons learned and mitigated the issues associated with unit maintenance, with the goal of equipping units to 100 percent of their modification tables of organization and equipment (MTOEs). This developed a radical paradigm shift in equipping medical units. Specifically, USAMMA focused on its most complex organization, the CSH, which includes over 1,700 medical equipment items. An Active component CSH includes an 84-bed company at the unit's location and a 164-bed company located at Sierra Army Depot, California. This paradigm included a concept to deliberately reduce unit-owned equipment while increasing use of the unit-leased concept through proven business processes, such as APS.

Along with reducing unit-owned equipment, USAMMA's concept included improving the generating force's training base locations and centrally managed medical equipping programs. This concept would become one of USAMMA's key initiatives in their strategic plan--the MMRP. For many reasons, USAMMA was not permitted to include the MMRP initiative in its 2006 POM, but it was asked to further develop the concept with the Army Forces Command (FORSCOM), HQDA, OTSG, and other stakeholders.

Refining MMRP Tenets

In fiscal year 2006, USAMMA participated in a study with the Army Program Management Office Study Program Coordination Committee Working Group to further develop its MMRP initiative. This study served as the catalyst for the funding that allowed USAMMA, in concert with OTSG, to program some of USAMMA's MMRP initiative into the equipping POMs for fiscal years 2010 to 2015 and 2012 to 2017. The 2010 POM recognized the three MMRP tenets.

In 2007 and 2008, USAMMA met with a number of stakeholders to develop the MMRP concept and quickly realized the difficulty of defining the first MMRP tenet: What should be maintained at home station, and what is the purpose of this equipment (training only or training and mission support)?

Another major challenge was to establish the second tenet: What are the organizations in the medical training base, and what equipment is needed to appropriately meet the training requirements? For example, for hospitalization, USAMMA is mandated to support the Army Reserve generating force regional training sites-medical (RTSs-MED) locations at Fort Gordon, Georgia; Fort McCoy, Wisconsin; and Camp Parks, California, along with the U.S. Army Medical Command's (USAMEDCOM's) hospital training site located at Camp Bullis, Texas. Additional undocumented requirements were noted, with the largest one being the First Army, which needed equipment for validating units before mobilization. Unfortunately, for many reasons, USAMMA could not gain any traction on developing a holistic multicomponent medical training base.

Modernizing CSHs

As a bridging strategy to equip the third MMRP tenet, the Army provided approximately $30 million for equipment and overhead costs to modernize four CSHs under OTSG's and USAMMA's control to support U.S. Army Reserve Command (USARC) hospitals. These four CSHs belong to the USARC Reserve Component Hospital Decrement (RCHD) program located at Sierra Army Depot. Essentially, USAMMA modernized 4 antiquated 248-bed CSHs within the RCHD program to the latest MTOE authorization and SKO available for any deploying CSH, regardless of component. USAMMA also partnered with Sierra Army Depot to update a large warehouse to facilitate the maintenance, storage, and sustainment operations of these hospitals, which replicates their APS facilities and processes around the world.

The decision in 2007 to modernize four hospitals in the USARC RCHD program as the introduction to the third MMRP tenet managed by USAMMA proved invaluable because a CONUS-based CSH was directed to deploy to Afghanistan in October 2009. The deploying CSH's equipment was less than adequate from a modernization and sustainment perspective. At the unit's request, OTSG supported the use of a MMRP CSH from the medical centralized storage program for the CSH's deployment to Afghanistan. Had the MMRP CSH not been available, the deploying CSH would have required months of preparations, including inventories, maintenance services, equipment purchases, modernizations, and upgrades, before deploying to Afghanistan. Having to do this would have put the CSH's arrival date in jeopardy. This is not an indictment of the unit but an indication of the equipping model currently established for CSHs.

Merging Hospital Assets

Although it was successful in modernizing the four CSHs and the infrastructure at Sierra Army Depot, USAMMA still needed a decision on reducing unit-assigned equipment at home station--MMRP's first tenet, the CSH baseline equipment set. USAMMA's recommendation on reducing unit-assigned equipment included reexamining what was at home station and what belonged to the unit but was stored at Sierra Army Depot in the FORSCOM Hospital Optimization Standardization Program (HOSP). The HOSP was designed to take the 164-bed CSHs at FORSCOM locations and centralize them at Sierra Army Depot, using a memorandum of agreement with AMC. The memorandum of agreement between FORSCOM and AMC provided for the storage and maintenance of the units' 164-bed CSHs on a reimbursable basis, while the units maintained their 84-bed CSHs at home station.

Specifically, USAMMA recommended that the USARC RCHD and the FORSCOM HOSP assets at Sierra Army Depot be merged into one program managed by USAMMA to create efficiencies and reduce the maintenance burden on owning units. Ultimately, many felt this bridging strategy to merge the two disparate programs would provide a more responsive hospital set to deploying forces, both at home and abroad. In fact, the commander of the 18th Medical Command (MEDCOM) and the 121st CSH in Korea requested that USAMMA maintain its CSH based on USAMMA's success with similar units within the APS program located at Camp Carroll, Korea. USAMMA accepted this request, and the readiness of the 121st CSH has improved immensely. The 121st CSHs maintenance services are now on track, dozens of equipment items have been replaced, and the unit was fully modernized in fiscal year 2010.

Addressing MMRP Concerns

During a FORSCOM CSH commanders' meeting in 2008, USAMMA briefed on the three tenets of MMRP, the merging of HOSP and RCHD, and its partnership with the 18th MEDCOM and the 121st CSH in Korea. This briefing received mixed reviews by those in attendance; however, everyone agreed that the discussion topics had to be addressed. FORSCOM leaders at the conference were opposed to reducing unit-owned assets at home station, while USARC applauded the concept. FORSCOM leaders were concerned that if they did not have adequate equipment on hand at home station, their training would suffer and their ability to respond to a local need would be challenged.

To address these issues, OTSG and USAMMA asked the RAND Corporation to study the tenets of the MMRP concept. In this study, RAND explored many of FORSCOM's concerns and USAMMA's recommendations in great detail with the stakeholders. In 2009, USAMMA and RAND representatives attended another FORSCOM CSH conference and provided an updated MMRP concept brief that was commended by most of the conference attendees. Although the details on the CSH baseline equipment set were not fully solved, the FORSCOM G--3 organization integrator and G--4 medical logistics planner agreed to explore the concept in detail. The CSH commanders unanimously agreed to merge RCHD and HOSP, but this concept still required the approval of the USAMEDCOM and FORSCOM commanders. The commanders of USAMEDCOM and the Army Medical Research and Materiel Command gave their staffs and USAMMA approval to work closely with FORSCOM to fully develop the MMRP initiative.

The Army Equipping Strategy

In September 2009, the Deputy Chief of Staff, G--8, Department of the Army, published a white paper titled "The Army Equipping Strategy," which described how the Army plans to achieve equipping balance by the end of 2011. This strategy seeks an end state in which Soldiers have the right amount and type of modernized equipment to meet their mission requirements, whether in combat, training at home station, or supporting the homeland.

Like USAMMA's MMRP initiative, the white paper states that units will be equipped to accomplish the mission. Given the realities of funding and the complexities of the CSH, USAMMA's concept to develop a standard medical baseline equipment set is critical. Units going into the ARFORGEN reset phase will be equipped to a percentage of their MTOE based on basic individual and limited collective training requirements so they will be prepared to enter their train/ready phase.

The MMRP concept works in parallel with the Army ARFORGEN "ways model" discussed in the white paper. Once a unit receives its mission in the ARFORGEN train/ready phase, the CSH will receive the equipment required for its mission. The medical equipment for the deploying CSH could be sourced from various stockpiles, to include USAMMA's suggested medical centralized management equipment program at Sierra Army Depot (which would ultimately combine the USARC and FORSCOM CSH sets) or other sourcing programs (such as theater-provided equipment and APS). Using the "ways" to equip CSHs is very challenging but generally follows the spirit of the model discussed in the G--8 white paper.

Ultimately, the G--8 white paper discusses "friction" points in the Army's process for equipping units. "Friction" in this context refers to inadequate equipment inventories available to equip to the full Acquisition Authority Objective (AAO). In the case of a CSH, the continuous and unfunded requirements of rapid technology turnover and inadequate time to maintain hundreds of equipment items make equipping individual CSHs to the full AAO wasteful and ultimately burdensome to CSH leaders, users, and maintainers. Units rarely deploy with all of their equipment. They do not need it or have the capability to maintain it. USAMMA and RAND suggest a model that equips units initially to what is minimally needed to train and, if they have received the mission to support quick, local threats (homeland defense requirements), they would be trained accordingly.

Improving Equipment for Training

As units move through the ARFORGEN phases, the MMRP concept suggests that additional equipping be provided from various inventories as discussed earlier. To mitigate the training risks associated with less than full AAO equipping, USAMMA would increase the priority placed on equipping the generating force medical training sites, such as the RTSs-MED managed by the USARC but available to both Active and USARC units. These locations would receive adequate modernized materiel and SKOs to meet large-scale collective training requirements not available at home station. This model works very well with USARC CSHs because they train at the RTSs-MED during their annual training and only maintain a small amount of equipment at home station.

In many cases, Active component CSHs train at the RTSs-MED as well, based on the expertise and capabilities of the RTSs-MED staffs. Other efficiencies the USAMMA CSH equipping model provides are transparency and asset visibility of centrally managed medical equipment sets, based on the day-to-day control and management USAMMA would provide, similar to the APS program USAMMA manages along with AMC.


The LBE process that USAMMA conducts with AMC has revealed that 50 percent of medical equipment in CSHs was not fully mission capable. The equipping white paper insists that units must find ways to foster more effective stewardship of unit-owned equipment. USAMMA fully supports this with one caveat: Realistically, the volumes of CSH medical equipment (this includes over 1,700 medical equipment items and thousands of supplies and pharmaceutical items) and technologies are overwhelming. Granted, the CSHs could improve their sustainment programs, but without additional training to address the complexities of the equipment assigned to a CSH and more medical equipment repairers assigned to a CSH, unit readiness will always be less than acceptable.

USAMMA suggests that the basis-of-issue plans be reduced early in the ARFORGEN process and prudent equipment decisions be made as a CSH receives its mission in the ARFORGEN train/ready pool. Under the MMRP model, unit leaders would have more time to focus on actual training and not the burdensome maintenance tasks associated with the large quantities of medical equipment items.

The suggestions of the MMRP concept and its tenets as they relate to equipping CSHs are an obvious paradigm shift and require the reexamination of decades-old equipping programs and policies. Leaders must open themselves to the "Army owned, unit leased" equipping concept. The Army must also reconsider how basis-of-issue plans are applied and how units report readiness as part of their monthly unit status reports. Many would argue that USAMMA's suggested equipping strategy for a CSH involves many risks; however, a better argument would suggest that failure to explore USAMMA's MMRP equipment strategy is even riskier. With the lessons learned by the LBE program and the decision to deploy a CSH to Afghanistan, the MMRP concept fosters a more available, less costly, and less burdensome equipping solution for our units.

The Army should consider the suggested USAMMA MMRP equipping strategy for CSHs because the current ways of equipping the Army's CSHs are struggling. CSHs deserve smaller onhand equipment inventories. They need only the technologies and equipment items minimally required for training, with the understanding that the medical generating force training locations will be equipped to mitigate any risks from reduced equipment at home station. Finally, as the CSH receives a mission, USAMMA must have medical SKOs available to meet unit mission requirements as they progress through the ARFORGEN phases. Once the USAMMA MMRP model is vetted and demonstrates its value to a CSH's readiness, it could be applied to other medical units and beyond.



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Author:Strite, Charles H., Jr.
Publication:Army Sustainment
Article Type:Case study
Geographic Code:1USA
Date:Sep 1, 2010
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