NCR Healthcare Redesign

Tri-Service Symposium

13 July 06

Objectives Driving MJCSG Planning

• Reduce excess capacity• Relocate medical care into facilities and

installations of higher military value and capacity

• Provide greater opportunity for medics to maintain medical currency

• Enhance Jointness

BRAC Scenarios for NCR MTFs

• Closure of WRAMC and placement of consolidated medical facilities and functions at Bethesda (North) and Fort Belvoir (South).

• No loss of capability and continue to serve as a world class center for casualty care

• Based on actual workload, no purchased care recapture • 1.3M new SF in the NCR

– 300 bed tertiary care MEDCEN in the north – 300K SF– 165 bed community hospital in south - 1M SF

• $781M capital investment• 1376 manpower eliminations from closure of WRAMC

installation• Downsize Malcolm Grow Medical Center to an outpatient

facility with ambulatory surgery capability.

NCR MHS BRAC Intent

  “Let me describe what this new Walter Reed National Military Medical Center would look like.  It will be the centerpiece of military health care, clinical practice, education, and research.  It will rival Mayo Clinic, Johns Hopkins, and the other great medical institutions of the world, and it will be jointly staffed. ”

LtGen Peach Taylor, Medical Joint Cross Service Group, 13 May 05

“Whatever it costs, we need to incur that cost to provide that world-class care to an extraordinary group of men and women in harm’s way.”

Anthony Principi, Chairman, 2005 BRAC Commission

“In Washington, the new Walter Reed National Military Medical Center will be a joint medical facility, and the – not a – but the world leader in military medicine – in quality, in research, in technology, and in training…”

Dr. William Winkenwerder, Jr., Assistant Secretary of Defense for Health Affairs, 30 Jan 06

ICD

WRAIRChem.

WRAIRInf Dis

WRAIRCCC

WRAIRChem.

WRAIRBio

Chemical Biological Defense RDA COE

Aberdeen Proving Ground, MD

Dept of Retrovirology

NMRCBio

NMRCCCC

NMRCCCC

WRAIRCCC

Dover AFB, DE

Rockville, MD

Forest Glen Annex, MD

Infectious Disease Research COE

NMRC Inf Dis

Ft Detrick

RIID

WRAIRBio

NMRCBio

Medical Biological Defense Research COE

DoD Vet Path

AFIP

Ft. Belvoir

WRAMC Migration Diagram

Not moving

New location

Old location

5 Dec 05

Dept of Retrovirology

Non-TertiaryCare

Ft. Sam Houston, TX

WRAMCMAIN POST

PDAPEB

MEDCEN

MedicalExaminer

DNA Repository

AccidentInvestigation

Bldg 503

Forest Glen, MD

Non-Tertiary Care

Tertiary Care

MSMO

CIDNARCONARMCNARVC2290TH

AMSA

Bethesda, MD

Walter ReedNationalMilitaryMedicalCenter

PDA/PEB

Medical Examiner

DNA Repository

Accident Invest

Medical MuseumLegal Med

Ctr for Clin LabDoD Pt Safety

Program Mgmt Off

Enlisted Histology

(AFIP) ACTUR

Tissue Repository

Borden Institute

Bldg 509/510

(AMEDDC&S)

Borden Inst

Enlisted Histology

NARDC

NCR MHS Missions

• Force Health Protection– Deploying a medically ready force– Deploying a ready medical force

• Maintaining clinical competence• Support to other MTFs

– GME and Non-GME training – Mobilization/De-mobilization mission

• Active Duty and Beneficiary Care– Tertiary Care– Casualty Care– World-wide referral– Executive Medicine

• Research– Force Health Protection Related– Health Professions Education Related– Collaborative Research with other Federal Agencies

NCR BRAC Planning Principles

NCR BRAC Planning:• Is Workload based• Does not go beyond intended throughput• Approaches planning from a Market perspective• Considers BRAC actions at individual facilities to be

indivisibly linked • Seeks to maximize seamless beneficiary care between

the North and South, and throughout the NCR

Methodology Used for Joint Service NCR BRAC Planning

• Divided NCR into North and South based on distance/drive time to Bethesda and Fort Belvoir

• Pulled data (visits, admits, RVUs/RWPs) for NNMC, WRAMC, and Fort Belvoir based on geographic distribution (patients home zip code)

• Redistributed South “tertiary care” workload to the North based on a combination of qualitative and quantitative clinical service data and input

• Approximately 20% of South-generated inpatient activity (and 13% Ambulatory care) is expected to migrate to the North

North and South Markets

Workload Distribution Based on Market-Based Analysis

• The FY04 Inpatient (ADPL & RWPs) and Outpatient (RVU) projections used in planning facilities for the NCR (in response to BRAC) are below MJCSG COBRA estimates.

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

Pre-BRAC

COBRA DD1391

NCA RVUs

South

North

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Pre-BRAC COBRA DD1391

NCA RWPs

South

North

MJCSG and Current Working Estimates of Workload

Pre-BRAC COBRA DD1391ADPL 322 356 354

NORTH 302 240 262 SOUTH 20 116 92

RWPs 28,900 31,000 28,075 NORTH 27,000 18,000 17,270 SOUTH 1,900 13,000 10,806

RVUs 2,555,000 2,556,000 1,850,771 NORTH 1,987,000 1,184,000 1,143,863 SOUTH 568,000 1,372,000 706,907

COBRA Omissions

COBRA Omissions: Fort Belvoir

  Cost

Central Energy Plant $12,310,000

Helipad $250,000

Ambulance Shelter/Decon Facility   $224,000

Intrusion Alarm System $7,000

Commissioning $5,407,000

Special Foundation $3,000,000

Total $21,198,000

COBRA Omissions: Dover AFB

  Cost

Demolition at Dover AFB $400,000

COBRA Omissions: Bethesda

  Cost

None $ -

Inadequate Scope at NNMC

Inadequate Scope

  SF

Ambulatory & Other 75,408

Ancillary 34,374

Amputee Center 3,500

Non-GME Training 22,680

Renovations 117,040

Demolition 167,669

Total 420,670

Inadequate Scope

  SF

Clinical Investigation 8,640

NCR MTF Realignment Recap

WRAMC294 Beds189 ADPL

1,148K RVUs16.5K RWPs

2.8M GSF

Bethesda196 Beds113 ADPL

839K RVUs10.5K RWPs

1.4M GSF

Ft Belvoir45 Beds20 ADPL

568K RVUs1.9K RWPs

377K SF

WRNMMC300 Beds

240 ADPL (80%)1,184K RVUs

18K RWPs1.9M GSF

Ft Belvoir165 Beds

116 ADPL (70%)1,372K RVUs

13K RWPs1.05M GSF

Shutdown2.8M SF clinical7.8M SF total

Pre-BRAC COBRA

Shutdown377K SF clinical

WRNMMC346 Beds276 ADPL

1,143K RVUs19K RWPs2.1M GSF

Ft Belvoir147 Beds109 ADPL

706K RVUs12K RWPs977K GSF

DD1391

Net Shutdown1.8M SF clinical6.8M SF total

Net Shutdown1.6M SF clinical6.6M SF total

Renovations = 167K SF

Renovations = 260K SF

Shift subspecialty

inpatient North

WRNMMC345 Beds262 ADPL

1,143K RVUs17.2K RWPS1.76M GSF

Ft Belvoir120 Beds92 ADPL

706K RVUS10.8K RWPS

872K GSF

After 14 Nov 05

Reduce77.5K SFclinical337K SFtotal

Reduce105K SFclinical

Net Shutdown1.8M SF clinical6.7M SF total

MGMC60 Beds33 ADPL

314K RVUs2.7K RWPs

MGMC0 Beds

0 ADPL 300k+/- RVUs

0 RWPs

MGMC0 Beds

0 ADPL 300k+/- RVUs

0 RWPsNo change in SF

Inpatient workload to the Network.

595 Beds 322 ADPL 60% Occupancy

465 Beds356 APPL76% Occupancy

465 Beds354 ADPL76% Occupancy

Cost Scope

NCR MHS BRAC Scenarios $1.543 B 2.019 M GSF WRNMMC and Fort Belvoir $1.125 B* 1.750 M GSF

• Use existing market assets to decrease capital construction investment and still be fully mission capable.

• Optimizes direct care system• Does this comply with BRAC Law? Yes• Does this exceed COBRA Model? Yes

– Includes omissions, inadequate scope due to test-fit, and community support services, but further decreases 14 Nov 05 construction requirements by using existing market spaces and other alternatives minimize MILCON requirements.

NCR Market Solution

*PA and PD cost only. Does not include Initial Outfitting & Transition, or CAT E & F Equipment

• Reducing the Supporting Facility cost factor from 20% to 13%

• Reducing the Army’s Corps of Engineers and the Navy’s Facilities Engineering Command Supervision, Inspection & Overhead (SIOH) rate from 5.7% to 3%.

• $80M reduction in Initial Outfitting and Transition in FY11

• Unit cost escalation fixed at 2.45%

• Business Plan is tightly constrained and assumes vigorous control of costs and full realization of savings.

Risks included in the NCR MHS BRAC Business Plan

% of PA

Cost ($,000) % of PA Cost ($,000)

Bethesda MEDCEN Add/Alt 30% 98,775$ 5% / 10% 19,994$ 118,769$

FT Belvoir Station Hospital 25% 113,750$ 5% 22,750$ 136,500$

212,525$ 42,744$ 255,269$

% of PA

Cost ($,000)

% of PACost

($,000)

Bethesda MEDCEN Add/Alt 18%* 59,169$ 4% / 8% 15,995$ 75,164$

FT Belvoir Station Hospital 18% 81,900$ 4% 18,200$ 100,100$

141,069$ 34,195$ 175,264$

71,456$ 8,549$ 80,005$

* I.O. for MEDCEN Admin renovation portion @ 7%

Savings :

Current Initial Outfitting

Current Transition

Totals ($,000)

Reduced Reduced

Totals

Initial Outfitting and TransitionReductions

• Reduced planning factors:– Initial Outfitting from 30/25% to 18%– Transition from 5% (10% for renovations) to 4% (8%)

• Risk = $80M• Risk mitigation:

– Maximize reuse and relocation of existing equipment– Standard planning factors not scaled for extremely large projects.

BRAC Facility Planning Process

• COBRA Analysis – Spring 2005• NCR BRAC Planning – Summer 2005• Solicit NCR User Group input in developing

Program for Design (PFD) requirements – Fall 2005

• NCR MHS BRAC Business Planning – Winter 2006

• Complete the Program for Design – Summer 2006

• NNMC Master Plan – Summer/Fall 2006• Design Authority – Summer 2006• Engage architects to design facilities – Fall 2006

NCR MHS BRAC and Integration

• Inherent in MHS BRAC 2005 actions is the integration of MTFs such that they begin to function as an Integrated Delivery System.

• MEDCENS, Inpatient facilities, and Ambulatory commands in the NCR are proceeding with Integration as we plan and execute BRAC.

NCR Portfolio Integration Planning NCR Portfolio Integration Planning

BRAC

Demand Analysis

Mission Population ForecastingWorkload ForecastingStaffing/Manpower RqmtsDirect vs. Purchased Care

Capital Asset Inventory

Facility Planning Scenarios Functional & Facilities Analysis

Alternative Architectural SolutionsProject IdentificationFacility Planning

& Development

Documentation

Consolidation Maximize use of Capital AssetsIncrease Beneficiary AccessRecapture Purchased CareLower Operating Costs

Functional Integration

2 MEDCENs to 1Market Inpatient IntegrationMarket Direct Care IntegrationNetwork Integration

Provider RequirementsVolume Thresholds/OptimizationFunctional Alignment

Planning Scenarios

Market AssessmentDefining CharacteristicsSupply Management

Space Requirements

Forecast

Space Program Functional OptionsOptimize Capital Assets

Health Care Planning/PFD Integration Planning

Establish Program Management Office tied to NCRMarket Governance, Office of Integration and MSMO

“VISION”

Evolutionary Change

MEDCEN #1

MEDCEN #2

TIME

ONE MEDCEN

Advantages: less traumatic; people know where they are going; less degradation of MEDCEN assets; earlier you start the easier it will be.

“VISION”

MEDCEN #1

MEDCEN #2

TIME

ONE MEDCEN

“Business as usual”

Disadvantages: too many last minute details – won’t get it right; appears disorganized; will disenfranchise patients and staff; probably take longer to get where you want to be.

Revolutionary Change

BRAC, Integration, and Change

MSMO Focus

National Capital Area (NCR) Military Health System (MHS)

NNMC

WRAMC

MG

Ft. Belvoir

Other NCR

#1

#4

#3

#2

Priority of efforts:1. Build an Integrated

Delivery System (IDS) in the NCR

2. Include MGMC BRAC actions in the NCR integration plans

3. Develop a seamless continuum of care between the North/South

4. Functionally integrate WRAMC and NNMC

The circle diagram describes a single NCR-wide integrated entity with WRAMC and NNMC integration of specialized, tertiary-level care and support functions at the center. Through

this Northern merger of people, processes, and structure, North/South functional integration, and along with other NCR component facilities, health services are aligned.

Integration Office

Priority of efforts:1. Functionally integrate

WRAMC and NNMC2. Develop a seamless

continuum of care between the North/South

3. Include MGMC BRAC actions in the NCR integration plans

4. Build an IDS in the NCRNational Capital Area (NCR)

Military Health System (MHS)

NNMC

WRAMC

MG

Ft. Belvoir

Other NCR

#4

#1

#2

#3

Focus - Clinical Care, Healthcare Care Ops, & GME/Research

NCR Integration

• The NCR is approaching Integration from both a MEDCEN perspective and a Market perspective

• The Office of Integration focuses on functionally merging the MEDCENS and functionally integrating the MEDCENS with the community hospital at Fort Belvoir

• The MSMO focuses on developing the NCR Market as an integrated health care delivery system.

• Building Blocks1. MEDCEN = WRAMC + NNMC + USUHS2. Inpatient/Specialty care = MEDCEN + DeWitt + MGMC3. Direct Care = Inpatient & Specialty Care + Primary Care

ambulatory commands

SMM/FLAGS

ADVISORY INTEGRATIONSTEERING COMMITTEE

CHAIR: DI

CEBCHAIR: SMM

OFFICE OF INTEGRATION MSMO

WORKING GROUPSINTEGRATION STEERING

COMMITTEE

NCR Integration Org Chart

IMPLEMENTATIONIMPLEMENTATION

Areas of Intense Focus

• Office of Integration1. Health Care Operations2. Administrative Services3. Information Systems4. Communications and Marketing5. Nursing6. Clinical Services7. Health Professions Education8. Research

• MSMO1. Manpower2. Healthcare Operations3. Logistics4. Resource Management

Questions?

Shared Vision for Integration18 Aug 05

In concert with the medical provisions of BRAC 2005, we envision one unified NCR military health care system. Jointly staffed inpatient campuses at the Walter Reed National Military Medical Center at Bethesda (North) and Fort Belvoir (South), and other NCR MTFs - also jointly staffed - will provide high quality, efficient and convenient care for our beneficiaries. The WRNMMC will serve as a world class academic medical center focused on highest quality tertiary care, graduate medical education, and clinical research while serving as a worldwide military referral center. The Ft. Belvoir community hospital will be the major satellite teaching hospital. Both campuses will be sized to provide health care at the closest facility to the beneficiary whenever clinically appropriate.

1. BRAC plans based on NCR MSMO analysis2. NCR MSMO BRAC plans workload based, used FY04,

vice COBRA (more accurate plan based current workload)

3. Eligible Population will remain stable at 450,0004. Enrolled population will remain stable:5. Worldwide referral capability is an enduring mission

and the volume of patients will remain stable in the near and mid-term

6. MHS Workload in the NCR will remain relatively stable7. GME programs will remain relatively stable8. Current MTF-based research missions in the NCR will

remain stable

NCR BRAC Planning Assumptions

9. In regards to Manpower, planning will achieve at least 1,376 fewer people in Federal employment as a result of BRAC Scenario 169 A & B.

10. The 543 AF staff moving into the NCR will allow additional Manpower savings above the 1,376 positions identified through the COBRA model.

11. There will be ongoing Forest Glen/Glen Haven BASEOPS requirement after Walter Reed compound closure

12. BRAC transition plans will include moving some service to WRAMC during Bethesda renovations.

13. Walter Reed compound will not close until construction at Bethesda and Belvoir completed.

NCR BRAC Planning Assumptions