Lower Costs, Better Performance

A New Strategy for Supporting Combat Hospitals

The U.S. Army uses CSHs – mobile hospitals built in tents and extendable containers – to provide surgical and trauma care close to the battlefield. The CSH unit includes a 248-bed hospital, about 500 personnel and $26 million worth of medical equipment. There are 26 CSH units in the ground forces, which can deploy once every three years (active component) or once every five years (reserve component). At the height of the Iraqi operation, there were four CSH units: three in Iraq and one in Afghanistan.

Experience has shown that CSH units use their own equipment. However, in practice, these units have either received new medical equipment or have used existing and upgraded equipment. When not deployed, CSH medical personnel are deployed to military hospitals around the country and the world. CSH medical equipment is partially stockpiled at home stations for training or potential local medical emergencies. The remainder of the stockpile is stored long-term at a military depot in Sierra, northern California.

This equipment strategy has created maintenance and obsolescence problems. For example, CSH medical equipment at home stations tends to be older, unevenly maintained, and rarely if ever used. Because the Army has recognized that its acquisition strategy is inefficient and ineffective, RAND asked the Arroyo Center to help it develop a better strategy.

Hardware requirements for stations

The Arroyo team conducted surveys, focus groups, interviews, and site visits to learn about base station hardware requirements. Many active component commanders requested fewer beds and rooms, but some wanted more hardware for home stations to better train for deployments and increase local medical capability.

Other active duty commanders were concerned about their ability to maintain more local facilities and wanted different and better facilities in the field. Reserve commanders wanted much less equipment at home base: their units had too little time to maintain them. They wanted to keep only the equipment needed to develop individual and collective skills. Reservists already use military training sites with CSH equipment for unit-level training.

Key points

• The Army's current strategy for equipping combat support hospitals does not allow for cost-effective management of medical equipment maintenance and obsolescence.
• Non-deployed active duty soldiers want more medical capability at their base, but less equipment to maintain; non-deployed reservists want even less equipment.
• The RAND Arroyo team used feedback from HSC commanders and others to design base station equipment packages that would significantly reduce maintenance and costs.
• An overall equipment strategy would provide commanders with localized equipment packages that would meet the training needs described, reduce the overall quantity of equipment, require wider equipment distribution, and allow for continuous and affordable equipment upgrades.

Options for docking station equipment

To address the needs and concerns of CSH staff, the research team developed three new options for home station equipment. The following table presents these options and compares them to existing equipment in the home stations:

1. Expanded Capabilities: If the military decides that domestic CSH units should be able to provide expanded training and medical capabilities, they should use “expanded” capabilities that include more on-site medical equipment. The expanded plan would have fewer beds than the current plan, but would double the capacity for surgical and trauma care.
2. Enhanced Capability: If active component HSC units can train more intensively off-site, e.g., at a regional training site, the Army should adopt an “enhanced” model with even fewer beds but still improve local medical capability.
3. Lean capability: in the Lean plan, the CSH staff has very limited space to perform some of the basic functions of the hospital. In a Lean design, almost all medical equipment would be sent to a warehouse.

Based on a risk analysis that took into account maintenance, training and local medical missions, Arroyo researchers recommended that the active component use a simplified model and the Army Reserve a very small amount of equipment at the home base.

Equipment packages at training centers and depots

The study team also made recommendations on CSH equipment at training centers and depots. The Task Force recommends that training centers tailor training equipment to the specific needs of the CSH.

With respect to Sierra Army Depot equipment (approximately two dozen 164-bed hospitals and two full 248-bed hospitals), the Task Force recommends a significant reduction in 164-bed hospital equipment, improvement of the condition and timeliness of the remaining equipment, and sharing of ownership (i.e., CSH units should not maintain a one-to-one correspondence between owned and depot equipment).

Lower costs and better equipment

Arroyo's proposed overall strategy would significantly reduce the cost of equipping and maintaining Army civilian units. Less complete hospital equipment means less medical equipment. According to a detailed cost analysis conducted by Arroyo's task force, the total cost of HSC medical equipment packages would be reduced from about $1 billion to about $740 million. The resulting reduction in maintenance and replacement costs will allow the ground forces to maintain and upgrade their remaining equipment.

Proposed strategy is consistent with the Army's overall restructuring

Senior military leaders are concerned that the Army cannot afford to fully equip all units at all times. The proposed equipping strategy is radically different from the current one, but is consistent with the military leadership's emphasis on increasing efficiency while improving capabilities: “more with less.” The proposed strategy seeks to achieve both objectives: improve training and operational capability and reduce costs through efficiency.