Abstract
The “Personnel” chapter deals with professions, potential population sources, operational needs in specific scenarios, and adjustments to the personnel packages, readiness and preparedness, and mobilization. It contains a discussion on the differences between operations in a field hospital to that of a regular “brick and mortar” hospital, as well as the different aspects of health-care operations in various disaster situations and varied cultural environments. It contains a discussion on the importance of “tailor force packaging,” as well as the role of deliberate and adaptive planning. The chapter includes sections on personnel planning, sourcing of personnel, guidance on force health protection initiatives to ensure the safety and health of deployable personnel, an overview of a notional personnel package, which describes a required mix of clinical and nonclinical personnel, “planning pearls” gleaned from recent operational experiences with field hospitals, and – finally – some thoughts on ad hoc team-building initiatives for successfully coalescing personnel to meet mission requirements. Its conclusion infers that there are several reasons for believing that we will continue to see an increase in the frequency, scope, and scale of disasters, making guidance on formulating adequate personnel staffing packages for field hospitals all the more important in the modern era.
Introduction
In the early 1990s, a US Navy admiral named Paul David Miller shook up the American defense establishment by introducing a concept that was initially dubbed “tailor force packaging.” Miller had become increasingly concerned with what he perceived as the US Department of Defense’s (DoD) overly rigid doctrine and policy that underpinned the tactics, techniques, and procedures governing the use of operational forces. Speaking to the demise of the former Soviet Union – our former malefactor partner in the concept of mutually assured destruction – Miller noted that:
A national security policy that proved successful for forty years is not easily discarded. A military organization that successfully deterred global war, contained a militarily powerful adversary, and projected presence for stability in regional hot spots is not easily reoriented[1].
In Miller’s view, US military forces had become stuck in a cold war state of mind. During that period of time, the US DoD had architected its forces around a doctrine focused on force-on-force engagement operations against a sole, state-level peer vying for regional/hemispheric – if not global – hegemony, even though the USA had engaged in numerous regional conflicts and operations other than war in the same extended time frame. Although radical – and, at first, widely rejected – Miller’s concept of tailor-force packaging led to what came to be known in the US DoD doctrine as “adaptive force packaging”: “A new concept … which envisions using geographically and mission tailored joint forces to conduct forward presence operations[2].”
Miller’s initiative was merely the opening gambit to a more tectonic shift in the USA’s approach to force planning: the move away from requirements-based (or threat-based) planning (RBP) to capabilities-based planning (CBP); the former having dominated our approach to the development of operational force structures since the US Defense Reorganization Act of 1947. The antiquated requirements-based planning approach was largely focused on point (or individual) scenarios. The major shortcoming in this earlier analytical method was that it was more focused on the point scenarios rather than types of threats, limiting the ability to plan for the larger range of threats forces may encounter in the operational environment. CBP, on the other hand, is planning that is conducted (albeit under uncertainty) to accommodate for providing capabilities suitable for a wide range of modern-day challenges and circumstances, while still working within an economic framework that necessitates choice.
The primary distinctions between these types of analyses, then, are in how planners deal with uncertainty, in the reckoning of risk, and in the way of making choices. The core idea central to the CBP approach is to confront – rather than discount – uncertainty, to express risk in meaningful terms, and to weigh costs and benefits simultaneously. The objective of CBP is to put a premium value on portfolios of assets (including organizations and skill sets) which best satisfy operational needs while offering flexibility, adaptability, and robustness to hedge risk across a wide range of possible futures[3]. In many ways, Miller’s paradigm-shifting initiative on the employment of military operational assets is now recognized as prescient not only to the transition from RBP to CBP but also to the requirements associated with the “transformation” efforts (led by former defense secretary Donald Rumsfeld) that have dominated the global security environment of the post 9/11 era for the USA and its allies. Also known as the “Rumsfeld doctrine”, US DoD initiatives underpinning the transformation included the enhanced use of high-technology combat systems, the reliance on air power, and the use of small, nimble ground forces capable of responding to rapidly developing situations in any combatant command theater[4]. This initiative was and remains so far-reaching that it has fundamentally changed the theoretical and philosophical approach to the process of planning that is conducted in the USA military, leading to changes in the time-proven practices of deliberate planning to the more modern and refined approach of adaptive planning[5].
So, what is the relevance of all of this to a chapter devoted to a discussion on personnel for field hospitals? First off, it is important for planners involved with the development and deployment of field medical assets – whether in the military or in nongovernmental organizations (NGOs)/private volunteer organizations (PVOs) – to understand how changes in planning doctrine and theory can and should lead to improvements in implementing successful end states for deployable assets (i.e., the ability of those assets to meet operational mission requirements). Secondly, and by extension, to borrow from the concept of operations on adaptive force packaging and the tenets of CBP, any personnel package developed for field medical platforms should mirror the goals already enumerated for both: a priori to satisfy operational requirements while simultaneously offering flexibility, environmental and situational adaptability, and robustness to hedge against risks encountered in the operational environment.
This chapter will examine required operational capabilities and projected operational environments for field-hospital platforms; discuss potential personnel packages for use in these platforms; and offer some considerations derived from lessons learned from recent military, disaster response, and humanitarian engagements, which can assist planners with developing the most capable resources for operational environments.
Discussion
Personnel Planning
Field hospitals and their accompanying personnel packages can be employed for a wide variety of operations. Examples include:
military operations, with subsets including:
combat operations
low-intensity conflict operations
peacekeeping/peace-enforcement operations
security operations
humanitarian assistance and disaster relief operations
noncombatant evacuation operations (hostile and nonhostile)
military operations other than war
defense support to civil authorities
nonmilitary operations, normally supported by civilian NGOs/PVOs, including:
humanitarian assistance
disaster relief
complex emergencies
disease outbreaks
resiliency building through education and training and community assistance
Historically, planning for the employment of field medical assets was largely the province of military medical planners, since the military was the first formal organization to utilize field medical platforms to support their operations. Over the years, medical planners have developed fairly comprehensive processes associated with deliberate/adaptive planning to determine the required capabilities and the associated staffing and equipment requirements necessary to support the platform’s mission. All these processes are now applicable to planning for both military and nonmilitary operations, and include the following:
1. Describing a comprehensive mission statement for the purpose and use of the field hospital platform.
2. Determining the size, constitution, and location of the population at risk (PAR) they would be supporting. As expected, this could vary widely based on the type of operational environment the field hospital would be operating in.
3. Conducting a medical intelligence assessment of the projected operational environment. Planning for operational use of field hospital platforms must include an assessment of geography and topography; dangerous flora and fauna; disease vector risks; availability of water, sanitation, and hygiene assets (or lack thereof); and, in the case of purely military operations, the enemy order of battle, including weapons systems and the availability of asymmetrical or novel weapons.
4. It follows that the medical intelligence (MEDINT) assessment leads to the development of a “force health protection” (FHP) plan for the personnel assets deployed to the field platform.1 This is meant to ensure that there are no degradations in the capabilities of the deploying forces once they are on mission point.
5. Determining historical casualty rates associated with location and type of deployment to be applied against the PAR (to include both combat casualty rates and those associated with disease and nonbattle injuries). These should ideally lead to the development of predictive requirements for associated morbidity and mortality.
6. Projecting the period of operational employment (i.e., length of time in the deployed environment).
7. Determining deployment and redeployment requirements.
While it may seem these steps are only applicable to the overall development of a field-hospital employment plan, it is important to note that all these requirements are directly applicable to the process of determining the constitution of the personnel packages that support them. For example, the mission, size of the PAR, the MEDINT “snapshot,” application of historical casualty rates, length of operational employment, and deployment and redeployment requirements are all directly relevant to the process of determining the size and makeup by specialty of the field hospital’s personnel complement. In other words, planning for the personnel portion of the field hospital is inextricably linked to the basic planning associated with utilization of the platform in the first place.
In the USA, the DoD is the only organization within the family of federal partner agencies that trains full-time professional medical planners for career roles in the mission of determining health-service support requirements against the spectrum of operations they may be involved with in both traditional and nontraditional military operations (i.e., war fighting, peacekeeping and security operations, foreign humanitarian assistance and disaster relief, and now, in the post-9/11 era, domestic support to disaster relief operations).
To facilitate the assurance of comprehensive medical planning, US DoD planners use a sophisticated information management/information technology (IM/IT) tool known as the Joint Medical Analysis Tool (JMAT). The JMAT works by front-loading the PAR, casualty rates to be assigned against the PAR, and the period of operational employment, and then “running” them through a series of algorithms known as the “time-task-treater” files to determine the health-service support requirements (i.e., output) associated with the operation. These requirements include, but are not limited to, identifying providers by individual specialty and number required, type of beds (e.g., medical, surgical, and intensive care) needed to support the PAR, medical logistical requirements, blood, patient movement requirements for theater evacuation, and rations for hospitalized patients – all computed to address the requirements in aggregate on a day-to-day basis for their projected length of the operational employment. While planners utilizing this chapter for assistance in determining personnel and other operational requirements may not have access to the JMAT or any other mechanism for automating the planning process, knowing the functional areas needing to be addressed can still assist them with their efforts to ensure maximized capabilities and operational readiness.
Sourcing of Personnel
Once planning has been initiated, the sourcing of personnel to staff the field hospitals must be addressed. Military organizations that staff fixed brick-and-mortar medical treatment facilities (MTFs) will find they are the most convenient sourcing organizations for deployable facilities. Medical staff members across the spectrum of professional specialties will already be familiar with the delivery of care within a hospital environment. That said, the field environment can be radically different from that of a fixed facility. Field conditions can run the spectrum from remote and austere to hostile and dangerous. Sourcing MTFs within military organizations should ensure staff members assigned to deployable medical platforms receive adequate training prior to a field assignment. This can be accomplished in any one of several ways:
1. Having a formal field medical service school or training center where personnel who are projected to receive assignments to deployable platforms can receive training in an environment that replicates expected field conditions.
2. Conducting partial- or full-scale live exercises, which involve projected deployment staff setting up and either utilizing portions or complete packages of the field hospital platform.
3. Conducting routine professional military education classes, which cover topics on operational field medicine.
In the late 1990s, the US Navy developed an interesting model for sourcing medical personnel to operational platforms, whether they were for field hospitals, deployable surgical and specialized medical teams, or the hospital ships. Known as the “total health care support for readiness requirements” model, the construct matched personnel one-for-one from fixed brick-and-mortar MTFs to deployable platform billets, which would operate in field environments. The main benefit to this model is that it allowed planners to determine not only exactly where personnel were coming from by sourcing agency and specialty but to likewise determine exactly what backfill requirements would be needed (largely from the military’s reserve force) to ensure services would remain at those sourcing facilities since, more often than not, the fixed MTFs would have to play a role in the continuum of care if casualties were returned for definitive treatment and rehabilitation.
For NGO/PVO organizations, the recruitment and sourcing of personnel can be a much more complex matter, since few – if any – maintain a standing cadre of health-care professionals who can be employed in field deployable platforms on a moment’s notice. In the USA, NGO/PVO organizations (such as the International Medical Corps, Project HOPE, and Americares) that are medical-centric and public-health-centric, and can deploy personnel to field platforms in response to complex emergency and disaster scenarios, maintain extensive relationships – usually through expressly written memorandums of understanding – with academic-affiliated teaching hospitals, which can source personnel in times of a crisis requiring deployable assets. Teaching hospitals usually have much larger numbers of professional staff (i.e., physicians, nurses) to draw from when events require them, and many believe that the field experience can be value-added to their overall training of junior health-care professionals, at a minimum because they tend to see patients and conditions that are outside of the norm of their usually stable hospital environments.
Other sources of personnel for field hospital platforms include organizations such as national disaster medical systems, which maintain active rosters of volunteers that can be activated (and in some cases, federalized) in times of crisis or disaster (including the Medical Reserve Corps, a USA initiative, which leverages retired health-care professionals for mobilization in times of disaster), dedicated national and state-based organizations such as Voluntary Organizations Active in Disasters, and faith-based organizations.
Beyond issues related to the sourcing of personnel for field hospital employment are those associated with legal, administrative, and medical preparedness for deployers.
Credentialed health-care personnel (i.e., those who require a license to practice such as physicians and nurses) generally have no problem with the portability of their licensure in international disaster response environments. Military and NGO/PVO organizations, which are deployed to provide foreign humanitarian assistance and disaster relief, are generally vetted and accepted by foreign governments when they either request or agree to have foreign response assets support them in times of crisis. In these cases, validation of an individual’s licensure or accreditation occurs when the individual has their credentials and licensure vetted to participate with the organization’s mission in the first place.
Domestically, licensure review and credentialing may be another case entirely. In the USA, for example, physicians usually maintain licensure in only one state at a time. If a disaster occurs in another state, physicians (other than those in the military) who attempt to deploy without obtaining licensure in the state of the disaster face stiff penalties, including heavy fines and possible permanent loss of license in their home state. This is less of an issue for nurses in the USA as the American Nursing Association has lobbied for and received agreements of licensure portability in some 85% of USA states and territories.
One way to get around the licensure issue in times of disaster is for either the senior national or state public health official, or their emergency management counterparts, to have a standing waiver agreement available for signature approval by an appropriate level of authority (e.g., president or state governor). This would not only grant blanket access to credentialed health-care providers who could deploy to provide assistance but would also eliminate the risk of medical tort liability against these practitioners, eliminating the need for them to maintain medical malpractice insurance outside their home of origin.
The issue of FHP was previously mentioned in the context of needing an adequate MEDINT assessment for deploying forces, but the implications of FHP go beyond simple awareness of what deployers may face in the field. Firstly, it is well known that disaster zones are dangerous environments. Personnel deploying to field environments should be generally healthy and physically capable of operating in what may be a dangerous, stressful, and environmentally challenging arena (e.g., consider the Ebola treatment units [ETUs], which deployed to West Africa during the 2014–2015 Ebola virus disease outbreaks). They should expect to have to work – often well beyond simple eight-hour shifts – for potentially significant periods of time. They will also be required to work in environments that may have suffered significant disruption or complete collapse of critical infrastructure and key resource sectors, placing them at greater risk of injury and illness while in a deployed status. While it seems a common-sense assumption, deploying personnel should recognize they largely assume the same amount of risk of illness and injury as the PAR they have been deployed to support; it is a bad assumption to believe they will somehow remain immune to risk simply because they are providing the medical and public-health support the PAR may need.
The FHP program, which was adopted by the USA military in the wake of the US DoD’s experience with the first Persian Gulf War and the subsequent Gulf War illness experience, represents an excellent model to be emulated by any organization – military or civilian – sourcing personnel for field-hospital deployments.
The program consists of three active phases: (1) predeployment phase, (2) deployment phase, and (3) postdeployment phase. In the first phase, deployers receive a baseline health assessment to: (1) check they are qualified to deploy, (2) identify and document any ongoing physical ailments or conditions that may change during their deployment experience, and (3) provide any vaccines, prophylaxis, or medicines they may require based on their current medical conditions or the known threats they may face in the specific geographic location of the deployment (which should, again, be derived from the MEDINT assessment, which goes with the deployment).
The second phase involves active health, injury, and disease surveillance in the deployed location. In the same fashion that deployed health-care personnel track morbidity and mortality data for the PAR they support, an active surveillance program for the deployers themselves should be initiated as soon as they arrive in the geographic theater of operations. The third phase is a follow-up phase. Deployed personnel should be tracked for any changes in their health status that may have occurred because of their deployment. While many international military organizations have some variant of the “Feres Doctrine”, which prevents the USA military from being sued because of the adverse health effects associated with their service, this is not the case for civilian volunteer organizations. Tracking the postdeployment health status of participating personnel ensures that any organization – military or civilian – is protecting the health interests of its staff. Tracking also helps civilian organizations to stay ahead of any claims that may arise after the fact, potentially limiting excessive tort liability (an additional way to avoid this, which is widely employed by NGOs/PVOs, is to have deployers voluntarily sign waivers, which releases the parent organization from any liability associated with their service).
As it relates to planning, recruitment, and sourcing of personnel for field-hospital deployments, it should be noted that there are numerous commercial, off-the-shelf emergency management software programs, which can aid organizations deploying personnel with tracking information related to the personnel they employ. IM/IT professionals associated with the human-resource departments of deploying organizations should look for software programs that, at a minimum, facilitate the creation of recruitment databases, which provide comprehensive individual contact information, help to automate the licensing and credentialing process, and track requirements for updating required training and certification programs such as Basic and Advanced Cardiac Life Support for deploying personnel. Many of these software programs double as emergency management tools, which can be used in the operation centers of the parent organizations and linked to IM/IT platforms in the deployed environment to facilitate the exchange of real-time data.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 15 – Pediatrics in a Field Hospital
Chapter 18 – Orthopedics in a Field Hospital
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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