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The US Army public health command initiative: transforming public health services for the Army.

INTRODUCTION

The United States is at a healthcare crossroads. We spend more on healthcare than any other nation on the planet (in excess of $2 trillion ([10.sup.12]) per year, or about 16% of gross domestic product) and yet our population's health is, at best, only average by most measures (life expectancy, chronic disease rates, access to healthcare, infant mortality, etc). (1) This problem is projected to worsen as the US population ages. The Army follows the overall US trends. Army medical beneficiaries (Active Duty, military retirees, their Families, and Army civilian employees) are as healthy or unhealthy as their civilian counterparts. Army beneficiaries suffer the same chronic disease rates, use tobacco and alcohol at equal or higher rates, and are as overweight and/or obese as their civilian counterparts, with 2 important exceptions: our Soldiers are fitter than their civilian counterparts due to mandatory physical fitness training and weight limits but suffer more injuries due to the physical nature of their duties, and our beneficiaries have universal access to quality medical care. (2,3)

Recognizing that more must be done, the Army Medical Command (MEDCOM) has begun to place an increased emphasis on improving beneficiary health by using a public health-centric approach to its overall strategy. (4) This approach uses such initiatives as:
   Creating incentives for Army medical treatment
   facilities (MTFs) to improve their beneficiaries'
   health via enhanced preventive health screenings
   measured by the Healthcare Effectiveness Data
   and Information Set (HEDIS *) metrics (5) and
   outcome based care measured with ORYX ([dagger])
   metrics (6) The MEDCOM has established an
   enterprise goal that Army MTFs will exceed 90%
   for 8 different preventive health screening HEDIS
   measures and 4 additional ORYX measures.

   Reducing the rates of workplace injuries in Army
   MTFs by providing MTF commanders with data
   about the rates and types of injuries suffered by
   their employees, and testing various safe patient-handling
   practices to identify which techniques
   best reduce workplace injuries.

   Decreasing the rate of overweight and obese
   Family members and retirees by adopting the
   Healthy Population 2010 (7) goals for overweight
   and obesity and implementing a standardized
   weight management program developed by the
   Department of Veterans Affairs. (8)


A key component of this increased emphasis on public health is the creation of an Army Public Health Command as part of the overall MEDCOM reorganization. This article describes the Army Public Health Command (APHC), its objectives, and current status.

BACKGROUND

In July 2008, the MEDCOM Chief of Staff formed an APHC Workgroup to conduct a staff analysis and provide recommendations to the Commander, MEDCOM on the feasibility of a command focused on public health. The Workgroup members consisted of representatives from the Army Center for Health Promotion and Preventive Medicine (CHPPM), the Army Veterinary Command, the Proponency Office for Preventive Medicine, the Department of Defense (DoD) Veterinary Service Activity, and the 6 MEDCOM regional medical commands. John Resta [coauthor], was chosen to lead this effort and served as the chair of the Workgroup.

The APHC Workgroup followed a military decisionmaking process: conducting a mission analysis, developing courses of action (COAs), analyzing and comparing the COAs, and ultimately recommending a COA for approval. (9) The workgroup completed an Enterprise Risk Assessment of the final COAs to ensure that the final decisions were fully informed. (10) Enterprise Risk Assessments are designed to identify and assess risks across 7 dimensions: scope, people, strategy, technology, contracting, process, and external factors. (11) Typically, the risk assessments are done to support major acquisition efforts but have been used to support organizational studies in the private sector. As a direct result of the efforts and analyses conducted by the Workgroup, in July 2009, the Commander, MEDCOM directed the establishment of the APHC, comprised of missions and resources from the CHPPM and the Army Veterinary Command. The Commander, CHPPM was tasked to lead the reorganization effort.

STRUCTURED APPROACH TO TRANSFORMATION

A structured approach was developed to engage the challenge of establishing the APHC. On August 28, 2009, the Commander, CHPPM signed a charter to form an APHC Transition Team consisting of an executive board, steering committee, and a core team to serve as an advisory team and conduct the necessary staff analyses to fully establish the APHC. John Resta and COL Gary Vroegindewey, Assistant Chief, Army Veterinary Corps, serve as cochairs in leading this effort. The Transition Team adopted the "A3 Thinking" methodology to employ a systematic, structured means of analyzing the various complexities involved in the APHC transition and identifying solutions.

A3 Thinking is a Toyota-developed, "lean" method of problem solving or performance improvement. (12) There are 9 steps in the method:

1. Reason for action

2. Initial state

3. Target state

4. Gap analysis

5. Solution approach

6. Rapid experiments

7. Completion plan

8. Confirmed state

9. Insights

All 9 steps can be represented in a 9 box format on an 11 in by 17 in (international standard A3) sheet of paper.

A3 working groups have been established to review, revise, and republish all policies, regulations, and procedures needed to govern the operations of the APHC; develop the appropriate procedures and agreements to conduct enterprise oversight of installation level public health services; and, in conjunction with the regional medical commands, consolidate installation public health assets under the command and control of the medical treatment facility commander. These working groups are being led by senior personnel from throughout CHPPM and the Army Veterinary Command.

MISSION

The mission of the APHC is to promote health and prevent disease, injury, and disability to Soldiers and military retirees, their Families, and Army civilian employees; and assure effective execution of full spectrum veterinary services for Army and DoD Veterinary missions (Figure 1). This mission is significantly broadened because it commits the Army Medical Department to providing public health services to military Family members, military retirees and their Families, as well as to Soldiers and Army civilian employees. Previously, Army public health programs were focused on Soldiers and Army civilian employees. The APHC will sustain the Veterinary Command's unique mission as the sole provider of veterinary services to the Department of Defense and all military services. Those missions include medical care for government-owned animals; zoonotic disease surveillance and control; food safety and quality assurance; food defense; and medical care for beneficiary-owned pets.

COMMAND COMPOSITION

The APHC is being formed by integrating missions and personnel from CHPPM and the Veterinary Command. Its headquarters will be organized as a distinct headquarters element with command and control, policy development, and oversight responsibilities. The headquarters will be located at Fort Sam Houston, Texas.

[FIGURE 1 OMITTED]

Five public health command regions (Figure 2) will report to the headquarters. These regional commands will initially be at the current locations of CHPPM or Veterinary Command regional subordinate commands. They will be responsible for monitoring the public health programs of MTFs and providing technical consultation and support to public health programs at MTFs, installations, and operational units. A primary goal of the APHC transformation is to collocate these regions with the corresponding regional medical command headquarters to encourage collaboration. Fourteen public health command districts (Figure 2) will report to the various regional public health commands.

What was formerly known as CHPPM-Main at Aberdeen Proving Ground, Maryland, will become the US Army Institute of Public Health, reporting directly to the APHC headquarters. The institute will deliver unique, low-density public health services to MTFs, installations, and operational units; provide consultative assistance to public health regions and districts; develop Armywide public health programs; and oversee public health program process improvement and quality assurance.

The DoD Military Working Dog Center at Lackland Air Force Base, Texas, will remain as is, and report directly to the APHC headquarters.

Installation-level public health teams will be created by combining installation veterinary services missions and personnel from the Veterinary Command with preventive medicine missions and personnel from the installation MTFs. These installation public health teams will be under the command and control of the MTF commander/director of health services. However, installation veterinary services delivered overseas will remain within the APHC under the command and control of the overseas (Europe, Pacific) APHC regions. This organizational structure is depicted in Figure 3.

The relationship between the APHC and the 6 regional medical commands (North Atlantic, Southeast, Great Plains, Western, Pacific, Europe) will change significantly. To ensure that public health programs across the Army are optimized and properly synchronized, the APHC will have enterprise oversight of all Army public health activities in accordance with Army Core Enterprise governance guidance. The Army's Core Enterprise initiative is an emerging Department of the Army business transformation effort that provides multiple stakeholders with the ability to synchronize efforts in a specific area while maintaining separate command and control structures. (18) This new approach to management will require preparation and revision of MEDCOM regulations and policies, as well as creation of management controls to ensure that public health activities throughout the Army are synchronized and achieving the program goals.

TIMELINE

The APHC will be established in 2 phases over a 2-year period (Figure 4). In the first phase (October 1, 2009 through September 30, 2010), the MEDCOM established an APHC (Provisional) to integrate the capabilities of CHPPM and the Veterinary Command, and continue the delivery of public health and veterinary medical services during the transition. This phase includes the development of a concept plan describing the APHC mission, roles, and responsibilities; policies that define an integrated Army public health program; and the assignment of enterprise oversight, monitoring, and execution responsibilities to the various MEDCOM organizations.

In the second phase, scheduled to begin October 1, 2010, the APHC (Provisional) will achieve an initial operational capability. This phase actually begins with the Department of the Army approval of the APHC concept plan, and ends when all tasks outlined in the concept plan have been completed, to include activation of the APHC and inactivation of CHPPM and the Army Veterinary Command.
Figure 2. The planned designations and locations of the 5
APHC regions and the 14 districts as of October 1, 2011.

APHC Region--Europe (Landstuhl, Germany)
APHC District--North Europe (Kaiserslautern, Germany)
APHC District--South Europe (Vicenza, Italy)

APHC Region--Pacific (Tripler, HI)
APHC District--Central Pacific (Fort Shafter, HI)
APHC District--West Pacific (Apra Harbor, Guam)
APHC District--Korea (Yongsan)
APHC District--Japan (Camp Zama)

APHC Region--North (Fort Belvoir, VA)
APHC District--Fort Knox (KY)
APHC District--Fort Belvoir (VA)
APHC District--Fort Eustis/Fort Bragg (Fort Bragg, NC)

APHC Region--South (Fort Sam Houston, TX)
APHC District--Fort Hood (TX)
APHC District--Fort Gordon (GA)

APHC Region--West (Joint Base Lewis-McChord, WA)
APHC District--Joint Base Lewis-McChord (WA)
APHC District--San Diego (CA)
APHC District--Fort Carson (CO)


CONCLUSION

The decision to create the APHC marks a distinct change in both the strategic and practical approaches in the Army Medical Department's delivery of services to those in its care. In the words of The Army Surgeon General,
   The establishment of the USAPHC (Provisional) is the
   most visible step in Army medicine's efforts to
   transform the nation's sick-care paradigm to a
   healthcare paradigm where disease and injury
   prevention become the foundation for American and
   military healthcare. (19)


While it will continue to deliver excellence in clinical and rehabilitative care, the Army Medical Department's shift to a public health-centric approach better serves its beneficiaries by sustaining and improving individual health and unit readiness through prevention, promoting health behaviors and personal responsibility for health, and making necessary care more available through sound stewardship of our human and fiscal resources.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

ACKNOWLEDGEMENT

We thank Lyn Kukral for her assistance in editing and review of this article.

REFERENCES

(1.) US Dept of Health & Human Services, Centers for Medicare and Medicaid Services. National healthcare expenditures 2008 highlights. Available at: http:// www.cms.gov/NationaLHealthExpendData/downloads/ highlights.pdf. Accessed May 4, 2010.

(2.) TRICARE Management Activity. Health care survey of DoD beneficiaries: 2008 adult annual beneficiary report. Available at: http://www.tricare.mil/survey/ hcsurvey/annual-report.cfm. Accessed May 4, 2010.

(3.) Military Health System. 2008 DoD Survey of Health Related Behaviors Among Active Duty Military Personnel. Washington, DC: US Dept of Defense; December 2009. Available at: http://www.tricare.mil /2008HealthBehaviors.pdf. Accessed May 3, 2010.

(4.) AMEDD Balanced Scorecard resources page. US Army Medical Department Center & School Web site. Available at: https://ke2.army.mil/bsc/ [restricted access]. Accessed May 5, 2010.

(5.) National Committee for Quality Assurance. What is HEDIS?. NCQA Web site. Available at: http:// www.ncqa.org/tabid/187/Default.aspx. Accessed May 3, 2010.

(6.) ORYX facts page. The Joint Commission Web site. Available at: http://www.jointcommission.org/ AccreditationPrograms/Hospitals/ORYX/ oryx_facts.htm. Accessed May 4, 2010.

(7.) Office of Disease Prevention and Health Promotion. Healthy people. US Dept of Health and Human Services. Available at: http://www.healthypeople. gov/. Accessed May 6, 2010.

(8.) VA National Center for Health Promotion and Disease Prevention. MOVE! weight management program. US Dept of Veterans Affairs. Available at: http://www.move.va.gov/. Accessed May 6, 2010.

(9.) Field Manual 5-0: The Operations Process. Washington DC: US Dept of the Army; March 26, 2010:B1-B39.

(10.) Business Transformation Agency. Enterprise risk assessment methodology. US Dept of Defense. Available at: http://www.bta.mil/products/eram.html. Accessed May 4, 2010.

(11.) Defense Business Transformation Agency. Enterprise risk assessment methodology. US Dept of Defense. Available at: http://www.bta.mil/products/eram.html. Accessed May 6, 2010.

(12.) Sobek DK, Smalley A. Understanding A3 Thinking: A Critical Component of Toyota's PDCA Management System. New York, NY: Taylor & Francis Group, LLC; 2008.

(13.) Army Regulation 40-3: Medical, Dental, and Veterinary Care. Washington, DC: US Dept of the Army; February 22, 2008. [Revision 3, March 12, 2010]

(14.) Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; May 25, 2007.

(15.) Army Regulation 40-656: Veterinary Surveillance Inspection of Subsistence. Washington, DC: US Dept of the Army; August 28, 2006.

(16.) Army Regulation 40-657: Veterinary/Medical Food Safety, Quality Assurance, and Laboratory Service. Washington, DC: US Dept of the Army; January 21, 2005.

(17.) Army Regulation 40-905: Veterinary Health Services. Washington, DC: US Dept of the Army; August 29, 2006.

(18.) 2010 United States Army Report to Congress, Office of Business Transformation. Washington, DC: Office of the Under Secretary of the Army, US Dept of the Army; March 1, 2010. Available at: http:// www.armyobt.army.mil/downloads/2010_congressional_report.pdf. Accessed May 4, 2010.

(19.) The Surgeon General's Blog. National public health week: comprehensive soldier fitness. Army Medicine Web site; April 8, 2010. Available at: https:// blog.amedd.army.mil/tsg/?Page=PostViewMulti &displayMonthlyArchives=April%26nbsp%3B2010 &month=4&year=2010. Accessed May 4, 2010.

Rosemarie M. Ugalde, BSPH

John J. Resta, PE

* HEDIS is a tool used by more than 90% of America's health plans to measure performance on important dimensions of care and service. HEDIS was developed and implemented by The National Committee for Quality Assurance, a private sector, US-based, not-for-profit organization offering accreditation to health plans throughout the United States and Puerto Rico.

([dagger]) ORYX is the performance measurement and improvement initiative of the Joint Commission (One Renaissance Blvd, Oakbrook Terrace, Illinois 60181), a private sector, US-based, not-for- profit organization founded in 1951. The Joint Commission operates accreditation programs for a fee to subscriber hospitals and other healthcare organizations.

Ms Ugalde is the Executive Officer of the Army Public Health Command Transition Team, US Army Public Health Command (Provisional), Aberdeen Proving Ground, Maryland.

Mr Resta is the Scientific Advisor to the Commander, US Army Public Health Command (Provisional), and is co-leader of the Army Public Health Command (Provisional) Transition Team, Aberdeen Proving Ground, Maryland.
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Author:Ugalde, Rosemarie M.; Resta, John J.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Apr 1, 2010
Words:2589
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