United States Government Accountability Office Report to the Subcommittee on Military GAO Construction, Veterans Affairs, and Related Agencies, Committee on Appropriations, U.S. Senate May 2012 DEFENSE INFRASTRUCTURE Documentation Lacking to Fully Support How DOD Determined Specifications for the Landstuhl Replacement Medical Center GAO-12-622 May 2012 DEFENSE INFRASTRUCTURE Documentation Lacking to Fully Support How DOD Determined Specifications for the Landstuhl Replacement Medical Center Highlights of GAO-12-622, a report to the Subcommittee on Military Construction, Veterans Affairs, and Related Agencies, Committee on Appropriations, U.S. Senate Why GAO Did This Study What GAO Found Landstuhl Regional Medical Center Department of Defense (DOD) officials considered current beneficiary population (LRMC) is DOD’s only tertiary medical data, contingency operations, and most of the expected changes in troop center in Europe that provides strength when planning for the replacement medical center. However, recently specialized care for servicemembers, announced posture changes in January 2012 have yet to be assessed for their retirees, and their dependents. impact on the facility. DOD estimates that the replacement medical center will Wounded servicemembers requiring provide health care for nearly 250,000 beneficiaries. A majority of those who are critical care are medically evacuated expected to receive health care from the center come from within a 55-mile from overseas operations to the 86th radius of the facility. DOD officials told us that because the replacement medical Medical Group clinic at Ramstein Air center was designed for peacetime operations—with the capacity to expand to Base to receive stabilization care meet the needs of contingency operations—reductions in ongoing contingency before being transported to LRMC for operations in Afghanistan would not have an impact on facility requirements. At intensive care. According to DOD, both the time of this review, DOD officials said they were in the process of assessing facilities were constructed in the 1950s proposed changes in posture to better understand their possible impact on the and are undersized to meet current sizing of the replacement medical center. and projected workload requirements. DOD plans to consolidate both facilities DOD officials incorporated patient quality of care standards as well as into a single medical center at an estimated cost of $1.2 billion. In this environmentally friendly design elements in determining facility requirements for report, GAO (1) describes how DOD the replacement medical center. DOD also determined the size of the facility considered changes in posture and the based on its projected patient workload. Internal control standards require the beneficiary population when creation and maintenance of adequate documentation, which should be clear developing facility requirements, and readily available for examination to inform decision making. However, GAO’s (2) assesses DOD’s process for review of the documentation DOD provided in support of its facility requirements determining facility requirements, and showed (1) inconsistencies in how DOD applied projected patient workload data (3) reviews DOD’s process to develop and planning criteria to determine the appropriate size for individual medical the facility’s cost estimate. GAO departments, (2) some areas where the documentation did not clearly examined posture planning demonstrate how planners applied criteria to generate requirements, and documentation, beneficiary (3) calculation errors throughout. Without clear documentation of key analyses— demographic data, plans for the including information on how adjustments to facility requirements were made— replacement medical center, and and without correct calculations, stakeholders and decision makers lack relevant DOD guidance, as well as reasonable assurances that the replacement medical center will be appropriately interviewed relevant DOD officials. sized to meet the needs of the expected beneficiary population in Europe. What GAO Recommends DOD’s process for developing the approximately $1.2 billion cost estimate for the GAO recommends that DOD provide replacement medical center was substantially consistent with many cost clear and thorough documentation of estimating best practices, such as cross-checking major cost elements to confirm how it determined the facility’s size and similar results. However, DOD minimally documented the data sources, cost estimate, correct any calculation calculations, and estimating methodologies it used in developing the cost errors, and update its cost estimate to estimate. Additionally, DOD anticipates that the new facility will become the hub reflect these corrections and recent of a larger medical-services-related campus, for which neither cost estimates nor posture changes. In commenting on a time frames have yet been developed. Without a cost estimate for the facility that draft of this report, DOD concurred with includes detailed documentation, DOD cannot fully demonstrate that the GAO’s recommendations and stated proposed replacement medical center will provide adequate health care capacity that it has conducted a reassessment at the current estimated cost. Further, DOD and Congress may not have the of the project that will be released once information they need to make fully informed decisions about the facility. approved by the Secretary of Defense. View GAO-11-622. For more information, contact James R. McTigue, Jr. at (202) 512- 7968 or [email protected] or Debra A. Draper at (202) 512-7114 or [email protected]. United States Government Accountability Office Contents Letter 1 Background 4 DOD Considered Beneficiary Data, Contingency Operations, and Posture Changes in Sizing Its Replacement Medical Center but Has Not Assessed More Recent Posture Changes 8 DOD Incorporated Quality Standards When Determining Facility Requirements, but Inadequate Documentation Makes It Unclear Whether DOD Adhered to Its Own Guidance 19 DOD’s Cost Estimate Was Not Well Documented, and Cost Elements for Associated Facilities Have Yet to Be Developed 28 Conclusions 37 Recommendations for Executive Action 38 Agency Comments and Our Evaluation 39 Appendix I Objectives, Scope, and Methodology 41 Appendix II Catchment Area Populations by Beneficiary Category, Fiscal Years 2006 through 2011 44 Appendix III Detailed Information on Each of the Cost Estimating Characteristics 45 Appendix IV Comments from the Department of Defense 47 Appendix V GAO Contacts and Staff Acknowledgments 50 Tables Table 1: Landstuhl Regional Medical Center (LRMC) Catchment Areas, by Beneficiary Category, as of March 2010 12 Table 2: Patient Migration Patterns for the Landstuhl Regional Medical Center (LRMC) and the 86th Medical Group (MDG) at Ramstein Air Base in Fiscal Year 2009 13 Table 3: Proposed Sizing Requirements for the Replacement Medical Center 23 Page i GAO-12-622 Replacement Medical Center at Landstuhl Table 4: Summary Assessment of the Results of DOD Cost Estimating Process for the Replacement Medical Center as Compared to Best Practices 30 Table 5: Characteristics of High-Quality and Reliable Cost Estimates 45 Figures Figure 1: Overview of DOD Medical Treatment Facilities Requirements and Project Costs Process 7 Figure 2: Location of Four Catchment Areas Used to Define Patient Migration to Landstuhl Regional Medical Center 10 Figure 3: DOD Military Installations in Europe with Expected Posture Changes That May Affect Replacement Medical Center Facility Requirements 15 Abbreviations DOD Department of Defense EUCOM European Command ICU intensive-care unit LEED Leadership in Energy and Environmental Design LRMC Landstuhl Regional Medical Center MDG Medical Group MHS Military Health System OMB Office of Management and Budget USAG U.S. Army Garrison This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-12-622 Replacement Medical Center at Landstuhl United States Government Accountability Office Washington, DC 20548 May 25, 2012 The Honorable Tim Johnson Chairman The Honorable Mark Kirk Ranking Member Subcommittee on Military Construction, Veterans Affairs, and Related Agencies Committee on Appropriations United States Senate The Army’s Landstuhl Regional Medical Center (LRMC), in Germany, is the Department of Defense’s (DOD) only tertiary care medical center in the European Command (EUCOM) area of responsibility. As a tertiary care center, LRMC provides specialized diagnostic and treatment services, such as cardiology and neurosurgery, which are not available at all medical facilities that provide acute inpatient care, for approximately 248,000 beneficiaries, including servicemembers and their families as well as retirees and their families. Wounded servicemembers requiring critical care are medically evacuated from overseas operations—including Afghanistan—to Ramstein Air Base where the 86th Medical Group (MDG) provides them immediate stabilization care on the flight line and then transports them directly to LRMC for definitive care. Both of these facilities were initially constructed in the 1950s and according to DOD are deficient in meeting the department’s life safety and