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Using force structure analysis to drive transformation.

The Army's greatest resource is its people. Within the Army Nurse Corps vision--Embrace the Past, Engage the Present, and Envision the Future--a critical process is to ensure that the personnel force structure (the people) of the Army Nurse (AN) Corps must be transformed to support the complex healthcare missions of the 21st century. This incorporates our lessons learned, both from the garrison (home station) daily healthcare missions and the healthcare support in multiple combat theaters of operation. This article discusses the analytical and business applications used to project future AN Corps officer force structure requirements and associated Army Medical Department Center and School (AMEDDC&S) training strategies. Additionally, the article provides examples of the synchronization of force structure and training strategies to execute the Corps Chief's vision of optimizing human capital in support of the Army Medical Department (AMEDD) and Army missions.

In the autumn of 2009, the Chief, Army Nurse Corps reestablished a separate functional staff position of the Army Nurse Corps, the Corps Specific Branch Proponency Officer (AN CSBPO), previously a "dual-hatted" position under the AN Deputy Corps Chief. Serving as the coordinator for developing and maintaining the Corps' strategic plan and its integration into the AMEDD's strategic vision, the AN CSBPO serves as a special staff officer to the AN Corps Chief and Deputy Corps Chief. (1) As such, the AN CSBPO primarily serves as the integrator between the Corps Chief's vision and senior AN Corps leaders, including the Chief Nurses of the Army Medical Command (MEDCOM), Army Forces Command, Army Human Resources Command, Army Recruiting Command, and Reserve Officer Training Corps (ROTC) respectively. Each of these senior AN Corps leaders oversee components of personnel management within the Corps. Each senior AN Corps leader has a different view of the force that provides the AN CSBPO essential information required for the projection of future requirements. Failure to maintain a robust dialogue among these key leaders can contribute to gaps in vital information necessary to make cogent, strategic, corporate decisions. The AN CSBPO position also serves as the linchpin between future force structure modeling executed by the AMEDD Personnel Proponent Directorate (APPD), and associated training strategies executed by the Department of Nursing Science, AMEDDC&S.

The APPD serves as The Surgeon General's personnel analysis activity. It partners with the Medical Capabilities Integration Center and Office of The Surgeon General (OTSG) Program Analysis and Evaluation to perform operating force and generating force structure analysis. The APPD provides input to life cycle management of all AMEDD areas of concentration (AOC), military occupational specialties, and civilian occupational series. The Personnel Proponent Officers of the APPD Officer Personnel Proponent Division (OPPD) are responsible for personnel force structure projections and analyses. The Division performs analysis and develops AMEDD officer personnel policy recommendations and strategic initiatives to assist The Surgeon General; the Commanding General, AMEDDC&S; and the AMEDD Corps Chiefs in support of their roles within the AMEDD in accordance with Army Regulation 600-3 (2) and Army Regulation 5-22. (3) As the AMEDD officer personnel proponent integration activity, the OPPD recommends personnel management policies to the OTSG Human Resources Directorate for AMEDD officer and warrant officer personnel, using the Army personnel life-cycle management functions (Figure 1).

The Army National Guard and the Army Reserve work in collaboration with the Active Army AN Corps on specific proponent issues. The Army Reserve OPPD Personnel Proponent Officers are not Corps-specific and are responsible for overarching Army Reserve proponent issues and collaboration on policies and plans for Army Reserve AMEDD officers. The budgeted end strength for the Army Reserve is generated by the Chief, Army Reserve. Army Reserve Personnel Proponent Officers develop, coordinate, and integrate lifecycle issues with the appropriate entities including The Surgeon General; Office of the Chief, Army Reserve; National Guard Bureau; Assistant Secretary of the Army, Manpower and Reserve Affairs; MEDCOM; Army Recruiting Command; Army Reserve Command; and the Commanding General, AMEDDC&S. Collaboratively, the APPD staff officers responsible for personnel force structure and lifecycle projections use a suite of tools to support this work.

[FIGURE 1 OMITTED]

The OTSG Human Resources Directorate provides APPD with the budgeted end strength for the Active Army officer corps. The APPD Army Nurse Personnel Proponent Officer is responsible for developing the Objective Force Model (OFM) for the Army Nurse Corps. The model must be developed within the constraints of the Corps' budgeted end strength. The AN Personnel Proponent Officer, in conjunction with APPD's operations research analyst, uses the budgeted end strength of the Army Nurse Corps, which includes the documented authorizations in both the tables of distribution and allowances * and tables of organization and equipment, ([dagger]) the allocated nonavailable force (not available for distribution, such as transients, holdees, and students), and the allocated AMEDD branch immaterial structure ([double dagger]) to determine the number of personnel by specialty AOC and grade that are required to sustain lifecycles for the respective AOCs.

The OFM variables include the number of accessions by AOC and grade, the promotion rates to major, lieutenant colonel, and colonel, and the yearly transition percentage from feeder AOCs into other AOCs (eg, 66H, Medical-Surgical Nurse to 66G, Obstetric and Gynecologic Nurse) as applicable. The OFM also considers due course officers (those officers who enter the Corps at the grade of 2nd lieutenant) and non-due course officers (those officers that enter the Corps with constructive credit and possibly advanced grades based on education and/or experience). Using well-proven computer-based modeling, the total budgeted end strength for that year is distributed across all AN Corps AOCs to ensure that each AOC reflects a balanced rank structure and optimal inventory at each year of service. This is essential to ensure compliance with recommended Defense Officer Personnel Management Act (DOPMA) (Pub L No. 96-513 (1980)) promotion rates for every grade and AOC. The AN Personnel Proponent Officer presents the OFM to the AN CSBPO and Deputy Corps Chief, who then obtain the AN Corps Chief's approval. The AN Corps Chief is the approval authority for the Corps' OFM. Once approved, the OFMs are used to support force management decisions, including promotions, accessions, training requirements, and AOC transitions. Additionally, the OFMs prescribe the optimal inventory target at each year of service (Figure 2).

For the Reserve Component, the Reserve Officer Personnel Management Act (ROPMA) (Pub L No. 103-337 (1996)) serves the same purpose as the Active Army's DOPMA. The act synchronizes the Reserve Component promotion system with that of the Active

Army. The fact that ROPMA replaced the fully qualified system with best-qualified is of significant importance for career advancement because it allows the Army Reserve to mirror the Active Army for promotion purposes. The Army Reserve OFMs present a snapshot in time for the force structure by grade, year group, and AOC. These models are developed for 3 Reserve Component segments: Army Reserve Selected Reserve (Troop Personnel Unit, Individual Mobilization Augmentee); Army Reserve Individual Ready Reserve; and Active Guard Reserve officers.

[FIGURE 2 OMITTED]

The Active Guard Reserve officers are currently in a separate competitive category and have separate OFM histograms for the personnel structure by year group. The Army National Guard has one set of models and histograms depicting inventory, but unlike the Army Reserve, it does not have separate categories of officers. The goal is to have a close relationship between the OFM line and the number of officers in a respective AOC by promotion year group (Figures 3 and 4). Like the Active Army, the Reserve Component OFMs and histograms are the foundation for many of the Army Reserve APPD recommendations and the basis for present and future force structure, promotion rates, incentives, training, school seats, recruiting goals, and sustainment of the force. All models--Active Army, Army Reserve, and Army National Guard--are dynamic in that they change and evolve as changes occur within the Army.

The APPD plays a key role in supporting the decision-making process regarding training requirements for each specialty area, for graduate and doctoral education, and for the leader development programs to include the Basic Officer Leadership Course, Captains Career Course, and Army Intermediate Level Education Course. Using the OFM projections and historical utilization data, APPD coordinates with the training arm of the AMEDDC&S and recommends the appropriate number of training seats to ensure that the correct numbers of AN assets, by specialty, are available to meet mission requirements. This coordination supports the AMEDDC&S Pre-Structure Manning Decision Review process and informs the Army's Structure Manning Decision Review that validates training requirements, compares training requirements with resource capabilities, and reconciles differences into an affordable, acceptable, and executable training program to meet readiness objectives. (4)

The APPD uses the OFM in conjunction with the Corps' strategic vision to support analysis of the AMEDD's Long-Term Health Education and Training programs. The AN CSBPO and AN Personnel Proponent Officer are the AN Corps' representatives at the AMEDDC&S for implementation of the graduate Long-Term Health Education and Training Policy established in 2009. This policy established a multi-phased process for determination of each Corps' graduate training requirements based upon current and projected inventory, authorized positions, postgraduate utilization assignments, and financial resources. In the first year of implementation, the policy has driven comprehensive analyses of personnel authorization documents to validate actual graduate and doctoral civilian education level training requirements. This includes collaboration with AN consultants to The Surgeon General and the AN Branch, Army Human Resources Command, to project future utilization tours based on personnel authorization documents. Additionally, collaboration is done with the AN representative, AMEDDC&S Department of Health Education and Training, to project the fiscal costs of graduate education. The APPD's AN Personnel Proponent Officer also uses AOC-specific school seat models to validate prospective programmed graduate education starts, AOC and skill identifier training requirements, and to evaluate the need for civilian education level coded authorizations. Additionally, Corps Personnel Proponent Officers conduct analyses to determine the status of, and need for, training seats for the Basic Officer Leadership Course, Captains Career Course, and Army Intermediate Level Education courses.

[FIGURE 3 OMITTED]

The APPD provides recommendations annually for the development of the AMEDD Recruitment Strategy Memorandum for the Army's Accessions Command. The memorandum provides the guidance for direct accession requirements, including advanced practice nurse (eg, certified registered nurse anesthetists and family nurse practitioners) direct accession recruitment, and fully qualified AOC or skill identifier-specific (eg, critical care, perioperative, medical surgical) direct accession recruitment. The basis of the memorandum is the OFM; current AN inventory; projected ROTC AN commissions; and candidates in the Army Nurse Commissioning Program, the AMEDD Enlisted Commissioning Program (AECP), and the Funded Nurse Education Program (FNEP). In collaboration with AN senior leaders, the AN CSBPO, Accessions Command, and the AN Personnel Proponent Officer, a "precision recruitment" strategy is formulated to balance the accession of newly licensed nursing graduates without clinical experience coming from ROTC, AECP, or FNEP with the direct accession of registered nurses with clinical experience and/or advanced degrees. Precision recruitment also balances the direct accession of officers with clinical experience but without military experience with officers who have some past military experiences through ROTC, AECP, or FNEP, but limited clinical experience. The goal for future accession strategies is to proportionally balance recruitment through the available accession portals to maintain the inventory within the defined AN Corps budgeted end strength, while ensuring accession of personnel with needed capabilities.

Another collaborative initiative between the AN CSBPO, AN Personnel Proponent Officer, MEDCOM Chief Nurse, Regional Nurse Executives, and the AMEDDC&S Department of Nursing Science has been the examination of the authorized AN generating force structure by AOC and grade to determine if the current force structure meets the mission requirements of today and tomorrow. The first key area examined was the current allocation of AN colonels by location and AOC to determine if the grade and AOC were appropriate for the location and the mission. The initial review indicated that numerous positions were identified as AOC-specific, primarily 66H (Medical-Surgical), when the actual duty responsibilities were administrative in nature and could feasibly be assigned to qualified AN officers within other AN specialty nursing practice areas. By recoding these positions from 66H to 66N (Operational Nursing), the best qualified officer leader from any AN AOC could be assigned to the position. From a career life-cycle perspective, conversion of senior level positions to 66N opens advanced leadership opportunities to AN officers who may have felt constrained by the limited number of senior positions identified within their respective specialty areas. Positions requiring specific clinical capabilities are not affected by this initiative. This same collaborative process will be used to examine the other office grades and AOCs within each facility defined by a table of distribution and allowances (TDA). Additionally, through a work group led by the MEDCOM Decision Support Cell, the nursing requirements for several inpatient units within TDA facilities were examined to ensure optimization of nursing personnel resources based upon workload and changes in AMEDD missions. This optimization study provided recommendations to the senior AMEDD leadership for reallocation of nursing assets to best support the corporate AMEDD mission and clinical skills needed by AN officers when supporting Army missions. The findings of the recent optimization study have been incorporated in the decision-making processes of the 2011 Human Capital Distribution Conference.

[FIGURE 4 OMITTED]

While the AN Personnel Proponent Officer and AN CSBPO are primarily focused on future structure and training requirements, the roles also intersect with the MEDCOM Manpower Division as they examine current manpower requirements and authorizations. Recently, the AN CSBPO joined the Manpower Division in an examination of nursing administrative staffing models for clinical inquiry cells, research nurses, nurse methods analysts, and clinical nurse specialists. While currently not approved for implementation, the initiative would establish the nursing requirements to support the AN Corps Chief s implementation of the Patient CaringTouch System--the Army Nursing model for standardization of nursing practice--which dovetails with The Surgeon General's "Culture of Trust" imperative.

In order to build an Army Nurse Corps that can support both the garrison healthcare missions and wartime healthcare requirements in theaters of operation, the AN CSBPO role includes assessment of theater lessons learned to revise force structure and training strategies as indicated. An example of the role of the AN CSBPO and AN Personnel Proponent Officer in deployment related issues is drawn from Corps experiences in 2009. During a Corps update brief to the Chief, Army Nurse Corps, the Emergency Nurse Consultant to The Surgeon General identified significant shortfalls in the distributable inventory of qualified 66HM5 (Emergency Nursing) officers. This shortfall was exacerbated by the significant deployment requirements in support of both Operation Iraqi Freedom and Operation Enduring Freedom, which presented the potential for 66HM5 officers to be redeployed earlier than the allocated "dwell time" between theater deployments. The Consultant's concerns led to an intensive analysis of 66HM5 and 66H8A (Critical Care Nursing) inventory, annual training requirements, and retention issues. Key problem areas were identified, including "masked losses" of these 2 specialty areas to other AOCs, specifically 66F (Nurse Anesthetist) and 66P (Family Nurse Practitioner), and a proportionally greater loss of 66HM5 and 66H8A from the Army Nurse Corps at the end of initial service obligations. The analysis also revealed a need for additional annual training seats, especially within the 66HM5 Emergency Nursing Course. In addition, the staff of the Human Resource Command AN Branch identified a substantial waiting list of applicants for the 66HM5 Emergency Nursing Course. The AN CSBPO and AN Personnel Proponent Officer expanded the personnel force structure analyses to determine inventory shortfalls for both 66H8A and 66HM5 personnel. While past models examined AOC inventory, in this case, for the total 66H Medical Surgical Nurse population, the skill identifier-specific model (coined "school seat models" by APPD) scrutinized losses of the skill identifiers 66H8A and 66HM5 populations. The AN Personnel Proponent Officer also added an additional consideration in the model which examined the previously unaccounted losses of these 2 skill identifier specialty populations as they transitioned into other AOCs.

With the information derived from the analytical modeling and the identified inventory shortfalls, the AN CSBPO and AN Personnel Proponent Officer coordinated with the AMEDDC&S Department of Nursing Science (DNS) to examine current training strategies and training seats for the 2 specialty courses. The DNS identified a training capacity constraint within the 66HM5 Emergency Nursing Course which was conducted only at the Brooke Army Medical Center.

Based on this assessment, DNS prepared a business case analysis in coordination with nursing leadership at Madigan Army Medical Center to open a second Emergency Nursing Course. The AMEDDC&S approved the initial pilot funding, and the first 66HM5 course began at Madigan in the fall of 2010. A second business case analysis for sustained funding of the Madigan 66HM5 course received funding approval in November 2010. This initiative doubles the number of 66HM5 graduates per year, thus expanding the available inventory of 66HM5 nursing personnel for garrison military treatment facilities as well as deployed combat support hospitals and forward surgical teams.

The above initiative was implemented to resolve the current shortfalls in distributable inventory, while the AN CSBPO, AN Personnel Proponent Officer, and DNS work to develop a long term strategy for both the 66H8A and 66HM5 programs. One of the proposals considered by the AN Corps Chief is the creation of an AOC that combines the 66H8A and 66HM5 authorizations, thereby removing them from the 66H Medical Surgical Nurse AOC. The Critical Care Consultant to The Surgeon General, the Emergency Nursing Consultant to The Surgeon General, AN CSBPO, and DNS are examining core competency requirements and revisions of the current 66H8A and 66HM5 specialty courses to ensure future applicability to all AMEDD and Army missions. The focus is on the ability of both specialty categories to provide expert patient care, whether in the emergency care or critical care environment. Based on theater lessons learned, a need for additional curriculum related to the patient movement/enroute care of critical care/trauma patients has been identified. This includes curriculum related to basic patient movement concepts for in-hospital transports (eg, to radiology for special procedures) or transports to other treatment facilities, and for ground or air transports within theaters of operation. This requirement is not intended to replace current enlisted Health Care Specialist (military occupational specialty 68W) personnel. It is intended to ensure that hospitalized, stabilized, critically ill trauma patients (whether in a combat support hospital or forward surgical team facility) receive the same level of critical care when transported between military treatment facilities intratheater, or to Air Force strategic staging areas for air evacuation from the theater of operation.

After consideration of the advantages of combining the 66H8A and 66HM5 skill identifiers, the AN Corps Chief approved the proposal to integrate the critical care and emergency nursing specialties. That change process is now underway. The 2 specialties will be combined into an AOC titled "Trauma Nursing."

The DNS at AMEDDC&S is conducting a similar bottom-up review of all AN AOC, skill identifier, and professional leadership development courses within its purview. The objective is to ensure that the curriculum and training strategies for each program will support current and future healthcare mission requirements, thereby Envisioning The Future.

Simultaneously, the Army Nurse Corps examined other AOC and skill identifier categories to determine the optimal alignment of specialty care nurses for future missions. Similar to the analyses conducted for the 66H8A and 66HM5 populations, the AN Personnel Proponent Officer reviewed the current 66G (Obstetric-Gynecologic Nurse), 66G8D (Nurse Midwife), 66C (Psychiatric Mental Health Nurse), and 66CM8 (Psychiatric Nurse Practitioner) populations to determine if delineation of the advanced practice nurses (midwives and psychiatric nurse practitioners) as separate AOCs is a feasible course of action. The examination and analysis demonstrated that the establishment of separate AOCs for those advanced practitioners is warranted. As with the critical care and emergency care nursing populations, the actual distributable inventories of obstetrical/gynecological nurses and psychiatric mental health nurses are masked when a portion of the population is attending graduate training for advanced practice nursing roles. By separating the groups into distinct AOCs, the actual distributable inventory can be more easily tracked, while the required annual specialty training requirements can be adjusted to compensate for actual losses as nurses transition to advanced practice or other roles. Initial analysis indicates that the creation of separate AOCs retains promotion rates for each group within DOPMA guidelines. Additionally, monitoring of the actual distributable inventory would be enhanced to better support current and future missions. The Chief, Army Nurse Corps has approved the strategy to create these new AOCs, and APPD has prepared the required documentation. As this article is written, staffing of that documentation to all stakeholders is in progress.

The Army Nurse Corps transformation includes development of personnel and training strategies congruent with future mission requirements. Through the analyses of personnel and operational data from multiple sources, and with the guidance of the AN Corps Chief and Deputy Corps Chief, the AN CSBPO and the AN Personnel Proponent Officer have established and codified administrative processes to ensure continuity, both now and beyond the transition of current staff officers from these positions. For the AN CSBPO and AN Personnel Proponent Officer, Envision The Future served as the mantra for transformation of the AN personnel force structure and training requirements in support of current and future healthcare missions in concert with the AN Corps Chief s strategic vision.

ACKNOWLEDGEMENTS

We thank LTC Gabriella Miller, Army Reserve Personnel Proponent Officer, and LTC Patricia Steinocher, Army National Guard Personnel Proponent Officer, for their input concerning the Reserve Component and the Army National Guard respectively. We also thank COL Kaylene Curtis and Mr Keith Parker for their reviews and recommendations in preparation of this article.

References

(1.) MEDCOM Regulation 10-2/OTSG Regulation 10-32: Organization and Functions, Headquarters, United States Army Medical Command. Fort Sam Houston, Texas: Headquarters, United States Army Medical Command; September 29, 2010.

(2.) Army Regulation 600-3: The Army Personnel Development System. Washington, DC: US Dept of the Army; February 28, 2009.

(3.) Army Regulation 5-22: The Army Force Modernization Proponent System. Washington, DC: US Dept of the Army; February 6, 2009.

(4.) Army Regulation 350-1: Army Training and Leader Development. Washington, DC: US Dept of the Army; December 18, 2009:10.

* Table of Distribution and Allowances: Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to perform a specific mission for which there is no appropriate table of organization and equipment.

([dagger]) Table of Organization and Equipment: Defines the structure and equipment for a military organization or unit.

([double dagger]) Immaterial structure positions can be filled by any AMEDD Corps, rather than a specific Corps and AOC.

COL Carol J. Pierce, AN, USA

COL Janice F. Nickie-Green, AN, USA

When this article was written, COL Pierce was the Army Nurse Corps Specific Branch Proponency Officer, AMEDDC&S, Fort Sam Houston, Texas.

COL Nickie-Green is the Army Nurse Corps Personnel Proponent Officer, AMEDD Personnel Proponent Directorate, AMEDDC&S, Fort Sam Houston, Texas.
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Author:Pierce, Carol J.; Nickie-Green, Janice F.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Oct 1, 2011
Words:3824
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