Business Management WB - Case Analysis

KS1127 Case Number 2035.0

This case was written by Linda Bilmes, Daniel Patrick Moynihan Senior Lecturer in Public Policy at the John F. Kennedy School of Government (HKS), Harvard University and Matt Mabe (MPP’12), former Army captain and a veteran of Iraq and Afghanistan. Funding for this case was provided by the Center for Public Leadership, Harvard Kennedy School and the U.S. Department of Defense. HKS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. Copyright © 2015 President and Fellows of Harvard College. No part of this publication may be reproduced, revised, translated, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means without the express written consent of the Case Program. For orders and copyright permission information, please visit our website at http://www.case.hks.harvard.edu/ or send a written request to Case Program, John F. Kennedy School of Government, Harvard University, 79 John F. Kennedy Street, Cambridge, MA 02138.

Walter Reed National Military Medical Center (A)

Vice Admiral John Mateczun and JTF CapMed

John Mateczun climbed carefully up the hill that formed the final stretch of the Way of Saint James, a

centuries-old, 700-kilometer Catholic pilgrimage in northwestern Spain. He had been contemplating this trip for

years, less for his religious devotion than for the mental and physical endurance the route demands. 1 He also

needed an escape. Three months earlier, in March 2012, Mateczun (pronounced MAD-i-suhn) had retired after 41

years of military service.2 He was a doctor, a three-star admiral and had served in or supported every major

conflict during his career. He was also the outgoing commander of Joint Task Force National Capital Region

Medical (JTF CapMed), a new kind of military medical organization that was formed under his leadership.

JTF CapMed was created in 2007 to guide the congressionally mandated consolidation of military medical

facilities in the greater Washington D.C. area, which served military patients, their families and retirees. That

consolidation included the construction of a brand new community hospital at Fort Belvoir, Virginia, and, more

significantly, the complicated, controversial and unprecedented merger of two historic hospitals: the Walter Reed

Army Medical Center and the National Naval Medical Center at Bethesda, Maryland.

As the first commander of the joint task force, Mateczun was charged with overseeing the integration of these

facilities, the centerpiece of a move to improve the delivery of health care in the region and to cut costs, all at a

time when the most grievously wounded troops from Iraq and Afghanistan were arriving for treatment.

Over the course of four years, Mateczun oversaw what became a nearly $3 billion project for the Department

of Defense (DoD), pioneering solutions to integrate military medicine and upending the military medical

bureaucracy. He achieved what many considered to be a minor miracle—integrating Walter Reed and Bethesda

Naval in the face of fierce institutional resistance. But Mateczun’s determination at JTF CapMed came at a cost. His

dream of making greater Washington a model for the eventual unification of the disjointed Military Health System

was in doubt. In his drive to see the plan through, Mateczun had stretched the limits of military authority,

expended his political capital and alienated friends and colleagues he had known for decades.

“When you go to war, people are going to try to kill you,” Mateczun told the audience at his 2012 retirement

ceremony,

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HKS Case Program 2 of 50 Case Number 2035.0

…and they have a clarity of purpose that is amazing…In retrospect, I appreciate that

clarity, and it’s kind of a direct contrast to the working environment inside the Beltway,

where what people say and what they do can be completely separate themes…You can’t

predict who on your team is going to save you on a really bad day when the chips are

down. You might think you know who they are. But you don’t.

Vice Admiral John Mateczun

John Mateczun was a career military man. In 1966, just as the Vietnam War was heating up, he dropped out of

college to enlist in the Army. Mateczun’s first job was as a bomb defuser, or Explosive Ordnance Disposal

Technician in military parlance. The Army describes this role as requiring an interest in math, chemistry, and

physics, an aptitude for planning and organizing, and the ability to “work calmly under stress.” 3

Mateczun spent two grueling tours of duty in Vietnam, where his job required calm, patience and caution and

where mistakes could be fatal. Mateczun would later say that knowing the enemy wanted to kill him permanently

sharpened his senses.

After Vietnam, Mateczun left the Army, finished college and enrolled in medical school. Four years later he

entered the Navy as a psychiatrist. Mateczun had not intended to re-join the military, but he had run out of money

on the GI Bill* and a Navy recruiter persuaded him and several other Vietnam veterans in his medical school to do a

Navy internship in San Francisco. Mateczun was hooked. His education elevated him from enlisted military service

to being commissioned as an officer, a member of the military’s professional corps. His experience re-adjusting

from the stresses of Vietnam pushed him toward psychiatry; he saw the potential to help others cope with what

he had endured.

I loved being a psychiatrist…being a physician has been redemptive for me in that

respect. In dealing with my own readjustment I had to learn to go beyond myself. There

are dark places when you come back from war, and you have to deal with yourself. And

the best way to do that is to get beyond yourself to find a way to be of service to others

and to be of service to our country. And so those of us who are in military medicine are

really twice blessed. We’re able to be of service in both of those areas.

Over the next three decades, Mateczun worked his way up the Navy medical hierarchy. He treated patients

from the 1983 Marine barracks bombing in Beirut and from the invasion of Grenada that same year. In 1991, he

volunteered for duty in Operation Desert Storm and deployed with the Marines as a consultant on the

establishment of combat stress centers. During that tour he was a member of the medical team that aided the

repatriation of the first returning American prisoners of war.4

By the late 1990s, Mateczun’s climb up the Navy ladder had brought him out of the purely clinical realm and

onto a medical executive track. He led two of the Navy’s three psychiatry teaching departments and later

* The GI Bill is a colloquial term for a number of congressionally authorized programs that have paid for tuition and other higher education expenses for veterans, the first of which was established after World War II.

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HKS Case Program 3 of 50 Case Number 2035.0

commanded two naval hospitals: a small clinic in Charleston, South Carolina, where he received his first star, and

the Navy’s largest medical center in San Diego. As a one-star rear admiral Mateczun held assignments in the Navy’s

medical command—the Navy Bureau of Medicine and Surgery—and at the Pentagon, where he was serving as the

Joint Staff Surgeon when the building was attacked on September 11, 2001.

Mateczun went on to coordinate medical planning for U.S. operations in Afghanistan (Operation Enduring

Freedom) and Iraq (Operation Iraqi Freedom) for the Chairman of the Joint Chiefs of Staff. In July 2007, he was

appointed Deputy Surgeon General of the Navy. In this position Mateczun headed the Military Health System

Office of Transformation. The office was chartered to reform military health care delivery based on findings from

the Department of Defense’s 2006 Quadrennial Defense Review, a strategy and planning self-examination required

by Congress and jointly conducted by all four military services and the Office of the Secretary.5

These last two postings were classified as “joint” assignments, which transcend the traditional service

structures of the Army, Navy and Air Force. It was unusual for a medical officer to have so much “joint” experience,

and it was one of the reasons that the Pentagon leadership tapped him for command of JTF CapMed. “Had I not

had joint experience I would never have been able to navigate the system,” Mateczun said. “The nuances in ‘joint’

are endless.”6

The Military Health System

The military health system was not a single, centrally run organization, but a confederation of the independent

medical systems for each military service. The military services provided the entire spectrum of health coverage to

their patients and administered TRICARE, the DoD’s medical insurance program.

The medical systems of the Army, Navy and Air Force had evolved separately over the years, each with its own

structure, procedures and culture. Each answered to its own Surgeon General, a three-star officer who oversaw

medical matters. A two-star Joint Staff Surgeon at the Pentagon coordinated medical policy across the services and

advised the Chairman of the Joint Chiefs of Staff on medical affairs.7 The Assistant Secretary of Defense for Health

Affairs supervised military health care spending. But the services themselves ultimately controlled the health care

budgets.

Creeping military health care expenditures were already a concern inside the Pentagon by the end of the

1990s.8 Between 2001 and 2011, a rapidly growing beneficiary population increased spending from $24 billion to

$52 billion (adjusted for inflation). With health care costs rising steeply in the private sector, service members and

their families relied on the Military Health System, where the enrollment fees and co-pays were heavily subsidized.

By 2011, a typical service member with a family of four paid $460 per year for TRICARE, versus almost $4,000 per

year for a private plan.9 The growing number of beneficiaries coincided with heavy demands on the Military Health

System created by wars in Afghanistan and Iraq. Advances in battlefield medicine and equipment were allowing

troops to survive wounds that would have killed them a generation earlier. In addition, Congress had enacted

increasing benefits under the program, including the addition of “TRICARE for Life” for retirees over 65 and

“TRICARE Reserve Select” for personnel serving in the reserves. As a result, by 2007 the Military Health System had

become one of the largest, most comprehensive medical systems in the country,10 with 165,000 doctors, nurses,

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HKS Case Program 4 of 50 Case Number 2035.0

administrators and other medical personnel providing care to more than 9.1 million beneficiaries.11 (This system is

separate from the medical system operated by the U.S. Department of Veterans Affairs for those who have left

military service). Leaders in the Pentagon were becoming increasingly alarmed by the growth in health care

costs.12 As one General remarked in 2011, “We're on the path, in the Department of Defense, to turn it into a

benefits company that may occasionally kill a terrorist.”13

The National Capital Region

Washington, D.C., was at the center of the military’s health care spending crisis. Greater Washington-—or the

“National Capital Region”—was home to America’s most historic and prestigious military medical institutions:

Walter Reed Army Medical Center and the National Naval Medical Center at Bethesda, Maryland ("Bethesda

Naval"). For close to a century, these had been institutes of medical education and research and were the primary

destination for thousands of war wounded in America’s global triage and evacuation network. Located just five

miles apart, they had built up formidable reputations for medical excellence.

Walter Reed, founded in 1909, occupied a 113-acre plot in downtown Washington, D.C., and covered more

than 28 acres of floor space. It was named after Major Walter Reed, an Army physician whose groundbreaking

work confirmed yellow fever as a mosquito-borne disease. Walter Reed provided care to soldiers, their families,

military retirees and elected government officials. The hospital stood at the peak of the Army’s medical network

and served as its worldwide referral center. Most recently, Walter Reed had become known as the world’s

preeminent facility for cutting-edge prosthetics research and amputee rehabilitation.14

President Franklin Roosevelt, who had served as Secretary of the Navy during World War I, founded Bethesda

Naval in 1940. The hospital was a regional landmark, identifiable by its famous central tower. The Navy had a much

smaller and more decentralized medical system than the Army. This governance structure and the latitude the

service gave its hospital commanders reflected the Navy’s historical mission of sending ships over the horizon,

allowing their captains great independence and discretion in how to accomplish their mission.15 Consequently,

although Bethesda Naval was the Navy’s most visible medical facility, it was not a referral hospital and was half the

size of Walter Reed. Bethesda Naval was also known as the “Presidents’ Hospital,” providing treatment to every

president from Roosevelt onward (although President Dwight Eisenhower, a former Army general, spent the final

months of his life at Walter Reed). Even today, almost an entire floor of the central tower is a secure suite where

the Commander In Chief receives his medical care, a source of pride for the people who work there.

The staffs at both Walter Reed and Bethesda Naval were exceptionally dedicated to their respective

institutions. Unlike most military personnel, many had spent their entire careers in the same location. “My first

assignment as a junior officer was at Walter Reed,” said one administrator, an Army colonel whose first child was

born at the hospital and whose grandmother worked there for years. “I always had a connection to it.” 16

The hospitals’ proximity to the capital, where Congress, the Pentagon and national media attention converged,

had benefits and drawbacks. They provided care to many senators, congressional members and staffers who were

especially fond of one or the other of the hospitals, but rarely both. “We have 535 friends right down the road who

love to give out their business cards,” said one Army physician. “It makes it very hard to get anything done.”17

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HKS Case Program 5 of 50 Case Number 2035.0

The Defense Base Realignment and Closure Commission (BRAC)

When the Cold War ended, the military no longer needed all the real estate it had acquired. Congress set up

an unusual process for deciding how to downsize facilities. It established the Defense Base Realignment and

Closure Commission (BRAC) to recommend which facilities should be closed, combined or consolidated based on

the recommendations of the Secretary of Defense and the Commission’s own broad criteria. In order to avoid

political backlash against closing any individual military base, the BRAC drafted all-or-nothing lists of bases to close,

which must be approved by the president and then sent to Congress for a vote up or down on the whole list.

In September 2005, the BRAC issued its fifth list of recommendations since 1989. In this iteration, the BRAC

added a new criterion for its decision-making: “jointness.” This concept–-a desire to consolidate bases from the

different services--reflected an entirely new way of thinking about military basing.

The focus on “jointness” placed Walter Reed and Bethesda Naval squarely in the BRAC’s crosshairs. The two

hospitals already cooperated to a degree in integrating services such as pediatrics, obstetrics and graduate medical

education, but for the most part they operated independently.18 The BRAC mandated that the two hospitals be

“realigned” to operate jointly. Rear Admiral Matthew Nathan, the officer who took command of Bethesda Naval in

2008, reflected:

I came in with the following impression: The decision was made that there was too

much capacity in hospital care in the north Beltway between Walter Reed and Bethesda.

You couldn’t make a business model to have both hospitals operating. There wasn’t

enough workload to support both, and the only reason they were both being

maintained was for the political iconism that they each offered their services. So as

difficult as it was, everybody sort of swallowed hard.19

The decision to close Walter Reed was finalized in November 2005, after President George W. Bush approved

the BRAC’s recommendations, and the House of Representatives took no steps to “disapprove” them. The BRAC

mandated that Walter Reed be closed and “realigned” at Bethesda. The newly consolidated Army-Navy hospital

would be called the Walter Reed National Military Medical Center (WRNMMC). The deadline for the consolidation

was set for September 15, 2011—six years later.

On the surface, it made sense to shutter Walter Reed. Its campus was 30 years older than Bethesda’s, and its

buildings needed major restoration.20 Bethesda Naval’s campus was far larger, with room to expand.21 It was also

more accessible, because it was located near the Beltway and shared a Metro stop with the National Institutes of

Health. “It made sense to close one of them,” one senior doctor said. “They are five miles from one another. It was

ridiculous. But the further away you are, the simpler the picture is.”22

Indeed, to personnel with strong personal and professional ties to the hospitals, it was anything but simple.

Doctors, staff and patients felt a powerful allegiance to one facility or the other.

Beyond closing Walter Reed, the BRAC recommended a complete reorganization of military medical care in

the Washington region. This included a $209 million rehabilitation of clinical and administrative structures on the

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HKS Case Program 6 of 50 Case Number 2035.0

Bethesda campus and expansion of the hospital’s inpatient and outpatient facilities.23 In addition, the BRAC called

for the construction of a brand new, state-of-the-art hospital at Fort Belvoir, an Army base in Virginia, to replace

the aging DeWitt Army Community Hospital there. This was (originally) estimated to cost $432 million.24 The initial

estimate for all the work at Walter Reed, Bethesda and Fort Belvoir totaled $853 million. The BRAC predicted that

this would be offset by a roughly similar amount of budgetary savings over 20 years.25

The decision to close Walter Reed sent shock waves through the entire military. For physicians across the

Army’s medical system, losing Walter Reed was devastating. Many of them had spent their formative professional

years there. There was a profound sense of loss of identity and disbelief. “It was like learning that Harvard would

close and join Yale in New Haven,” one doctor said.26

Down the road at Bethesda, however, the mood was jubilant. Personnel welcomed the news that Bethesda

Naval would remain with a mix of relief and triumph. But the elation was short-lived.

The BRAC told the services to merge operations, but did not direct them on how to do it nor did it offer a clear

vision of what the end result would look like. The confusion boiled down to semantics. The BRAC specifically called

for Walter Reed to “realign” with Bethesda Naval to form a new Walter Reed National Military Medical Center. The

ambiguity of this word led to a variety of interpretations and endless questions. Did “realign,” mean simply

shutting down Walter Reed? Integrating it with Bethesda Naval? Would the new facility at Bethesda remain a

“Navy hospital” as it had been since Roosevelt? Or would the Army “invade” and “occupy”—as some naval officers

feared—to form a larger and better-resourced Army medical center, name and all?

The continued use of the "Walter Reed" name was particularly irksome to people at Bethesda Naval. For the

Army, preserving the Walter Reed name in the newly merged hospital seemed a small but important consolation

for the loss of the old facility. Many powerful people in Washington shared that feeling, and pointed out that

"Walter Reed" already had worldwide name recognition. The Navy, however, resented that the Walter Reed name

had been inserted into the BRAC legislation without public discussion and despite its strong opposition.

First Steps Toward Consolidation (November 2005 – February 2007)

The services were expected to execute BRAC-mandated projects. Since this was a “joint” directive, there was

no one specifically in charge of implementing the changes to Washington’s military medical activities and no

decision-making authority to intervene where disputes arose. Merging Walter Reed and Bethesda Naval thus

depended heavily on the willingness and ability of each hospital’s command to collaborate.

The commander of Walter Reed at the time was Army Major General Ken Farmer, a family practice physician.

Navy Rear Admiral Adam Robinson, a colorectal surgeon, had the helm at Bethesda Naval. “No one ever told us

how this was going to get done,” Robinson said. “Ken Farmer came and walked the ground at Bethesda in 2006. I

didn’t walk with him. I knew the ground. We met in the pool.” Robinson admitted to “initial animosity” but added

that Farmer eventually became a “wonderful partner to work with.”27

Robinson and Farmer made modest moves toward integration, each appointing “Deputy Commanders for

Integration and Transition” to examine operations at each hospital and to synchronize best practices.28 But with

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HKS Case Program 7 of 50 Case Number 2035.0

the BRAC’s deadline still five years away, little real progress was made. Many staff members simply refused to

believe the merger would happen. “People were waiting for the ‘joint’ thing to die,” said one administrator.

“People all along the way thought this was not going to happen.”29

Meanwhile, this was a period of escalating violence in Iraq. The United States was deeply enmeshed in the

country’s Shia-Sunni sectarian conflict, with more than 138,000 troops deployed—the vast majority from the Army.

American casualties—particularly wounds from “improvised explosive devices”—rose sharply. The influx of

grievously wounded troops from Iraq and Afghanistan strained Walter Reed’s resources; no one had much time or

imagination to contemplate the hospital’s closure and relocation to Bethesda. In August 2006, Farmer was

replaced as Walter Reed’s commander,30 and the rapport between the leadership at Walter Reed and Bethesda

Naval deteriorated. Admiral Robinson said, “Ken Farmer and I had worked together to find the right decision-

making system. My relationship with Farmer’s successor was not as good. The atmosphere of antagonism in the

hospital’s command suites filtered down to the clinical floors, where uniformed military personnel worried about

the future of their institutions and hundreds of staff civilians worried about their job security, all while struggling to

cope with increasing workloads.31

It didn’t help that communication about the merger was muddled and inconsistent. When the BRAC’s decision

to close Walter Reed was first announced, the hospital commanders held “town halls” to inform the workforce,

but those meetings were scripted, and hard questions went unanswered.32 As time passed, rumors filled the

messaging vacuum. Communicating details of a complex and evolving plan in such a large organization was

challenging. As Mateczun pointed out later:

It is a difficult question, how to communicate with 13,000 people, 9,000 of whom are

going to be moving either down the hall, across the street, five miles to another medical

center, or across town for a new job. It is an extraordinary challenge. We try, in the

military, to use a hierarchical system. We tell the commanders, the commanders tell

their people. …The message gets garbled very quickly, and in fact, each commander

that’s out there reinterprets it. And so we started doing town hall meetings, particularly

with those that were going to have to change the most. I mean you’ve got to kind of

target your intervention efforts—those that are having the most difficulty, those that

have the most to lose, those that have the most needs.33

Admiral Nathan, who would become Bethesda’s commander in August 2008, pointed out that the BRAC’s

decision was poorly formulated:

The mistake that [BRAC] made was that Bethesda had more room than Walter Reed to

build, but it didn’t necessarily have enough room to do all the things they wanted to do.

But BRAC projects started off like that and then they sort of left it to the Navy and the

Army to figure out how to get together. Well they didn’t. There was too much

polarization. You couldn’t get the commanders at Walter Reed and the commanders at

Bethesda to decide who was going to be in charge, or how the new clinics were going to

look.34

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HKS Case Program 8 of 50 Case Number 2035.0

Deputy Secretary of Defense Gordon England Intervenes

Meanwhile, officials in the Pentagon began to search for another solution. Deputy Secretary of Defense

Gordon England, the second highest-ranking civilian leader at the Pentagon, had been appointed in May 2005.

England was a former Secretary of the Navy who had held senior positions at General Dynamics and Lockheed (the

two largest defense contractors). England felt strongly that the adversarial relationship between the two services

(he compared their natural state to that of opposing magnets) made them institutionally incapable of cooperating

to execute the BRAC’s mandate.35

The supercharged emotions swirling around the Walter Reed and Bethesda campuses did not help matters. A

mid-level officer who worked through some of the transition issues explained, “The Navy was terrified that Army

would take over, and the Army was losing its flagship medical facility.”36 England came to believe that service

parochialism would result in the merger’s failure. “Each side was afraid that [the new Walter Reed National

Military Medical Center] would not be the best of both worlds but something less than the sum of the individual

parts,” England said.37 He began to see the problems in the region as an opportunity to radically transform the

Military Health System by unifying it.

England was not the first person to try to tackle the disjointed Military Health System. Numerous studies and

reports over more than 60 years had recommended that the DoD unify its medical services. As early as 1949, the

Joint Chiefs of Staff (which comprises the chiefs of the Army, Navy, Marines and Air Force and is the most powerful

authority in U.S. defense) had recommended unanimously to the Secretary of Defense that he support a single,

unified medical service. Commissions chartered by Presidents Hoover and Reagan, together with numerous official

and private bodies, had concurred. In 2006, two influential bodies reinforced this view. In February the

Quadrennial Defense Review proposed to improve the Military Health System by reorganizing command structures

and streamlining resources. In September the Defense Business Board, a federal advisory committee to the

Secretary of Defense, also recommended a wholesale reorganization of the system into a “Unified Medical

Command.”38 However, the unified model had never gained traction among the services. As a 1995 GAO report

explained:

Past studies have suggested changes in the way military medicine is organized, including

consolidating the Services’ medical departments into a single defense health agency.

However, the Services have always resisted these efforts...primarily on the grounds that

each has unique medical activities and requirements. However, others have pointed out

that the Navy handles sea, land, and air functions, indicating that one system can

perform all functions. Furthermore, in wartime, the U.S. military fights and provides

medical care under the authority of unified and specified commands, not as individual

Services...39

Despite the historical lack of support, England believed that this time conditions were ripe to succeed. In

November 2006, he directed Pentagon medical planners to prepare for the establishment of a "joint" medical

command in greater Washington. He proposed that all the medical facilities of all the services in the region,

regardless of affiliation, should report to a joint senior flag officer. Significantly, he indicated that the restructuring

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HKS Case Program 9 of 50 Case Number 2035.0

of medical activities in the National Capital Region might serve as an example—even a precursor—for the

consolidation of military medicine in other regions.

The Walter Reed Scandal

On February 18, 2007, the Washington Post published a shocking front page article that read: “Soldiers Face

Neglect, Frustration at Army's Top Medical Facility.” Washington Post staff writers Dana Priest and Ann Hull exposed sub-standard living conditions for wounded Army veterans in Walter Reed’s outpatient housing

facilities.40 Their revelations did not center on the quality of medical care, but on mold, filth, mouse droppings,

cockroaches and other residential building squalor.41 This was the first of a detailed series for which the journalists

later won a Pulitzer Prize for investigative reporting.

The scandal rocked Washington. The national media descended on Walter Reed. Congress launched

investigations. The Secretary of the Army, the Army Surgeon General and Walter Reed’s commander were

summarily fired.42

It was not clear whether the neglect was caused by a leadership failure, mismanagement, overcrowding due

to the spike in war casualties, or simply of a practical decision not to renovate the facilities at Walter Reed that

were slated for closure. But the effect of the scandal was to focus attention on the Walter Reed and Bethesda

Naval hospitals.

Immediately, scrutiny turned to Bethesda Naval. On the morning that the Walter Reed story broke, Chief of

Naval Operations Mike Mullen called the commander of Bethesda Naval, Rear Admiral Adam Robinson: 43

“Do you have anything to tell me?” Robinson recalled Mullen asking him.

“It’s a beautiful day, sir,” Robinson replied.

“And on this beautiful day, do you have anything to tell me?”

“No, sir. It’s a beautiful day.”

Within hours, Bethesda, too, was swarming with cameras and reporters. But Bethesda was in decent condition.

Under Robinson’s leadership, Bethesda had renovated its barracks in 2005.44 The hospital was also coping with a

smaller population of wounded troops; the Marines and Navy had fewer than 40 percent of the casualties in Iraq

and Afghanistan (see Exhibit 8). Moreover, the Navy had a different concept of care than the Army: while Army

patients were often transferred to Walter Reed for lengthy stays, the Navy treated patients and then sent them

back to their units, or back home, as soon as possible. This may have prevented the sort of overcrowding that had

plagued Walter Reed.

Pressure mounted on the Pentagon to reckon with Walter Reed’s future, which had been in limbo since the

BRAC’s decision two years earlier. This was the catalyst for speeding up the consolidation. Over the following

months, the Pentagon added $700 million to “enhance and accelerate” the construction at Bethesda and Fort

Belvoir, adding new clinics, expanded housing and mess facilities, fitness centers, more parking and administrative

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HKS Case Program 10 of 50 Case Number 2035.0

support facilities. This spending increase came on top of a $473 million budget increase the previous year to cover

“BRAC refinements and adjustments,” bringing the total cost of the military medical consolidation in the region to

nearly $2 billion dollars, more than twice the original estimate.

The scandal also sealed Walter Reed’s fate. It was the turning point when the staff at Bethesda Naval finally

realized that the merger was going to become a reality. “I looked out my window and saw tower cranes and giant

holes in the ground,” said one nurse. “And then I understood that this BRAC idea I had heard about was actually

going to happen.”45

But as the construction raced ahead, it remained unclear how the merger would evolve and who would be in

charge of the consolidation. Adding to the confusion, there was a new commander at Walter Reed, Major General

Eric Schoomaker. “When Schoomaker came in, everything we had done before stopped,” Robinson said. “Army

medical was in chaos. The [scandal] had killed generations of Army medical knowledge and leadership…but when

there’s a fire on your ship, you hold course and put out the fire below deck.”46

JTF CapMed

With the Walter Reed scandal still red hot in Washington, Deputy Secretary England moved forward on his

plan to reconfigure the Military Health System. In September 2007, he established a “Joint Task Force National

Capital Region Medical” (JTF CapMed), a single echelon of command, outside any one service, that reported

directly to him. This was a highly unusual step – reflecting how important and politically sensitive he viewed the

integration effort. England cited the 2006 Quadrennial Defense Review, which had recommended streamlining the

Military Health System, to justify this structure.

“This was our opportunity,” England said. With the wars in Iraq and Afghanistan making extraordinary sums of

money available for discretionary defense spending, pet projects and new initiatives could be undertaken with

little scrutiny. “After the war ended, there would be no money for it anymore. That’s the politics of it.” 47

Deputy Secretary England envisioned the “new Walter Reed” as a global center of excellence for military

medicine, adopting the best practices from the Army and Navy and raising the bar for military medicine in general.

In England’s words:

My view on this was that it was not going to be a combination of Walter Reed and

Bethesda. It was going to be the absolute best facility assembled in the military. It would

be the center of a wheel with spokes going out. Bethesda would become a center of

expertise for all military medicine. But to do that it had to be more than just a hospital.

It needed to be a teaching facility, a care facility and a research facility, and they had to

be in the same place to get that level of excellence.48

England expected the new JTF CapMed to oversee it all. He issued a short memo stating that JTF CapMed

would be a standing joint task force directed to “ensure the effective and efficient delivery of world class military

healthcare within the [National Capital Region] using all available military healthcare resources,” and “oversee the

consolidation and realignment of military healthcare.”

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HKS Case Program 11 of 50 Case Number 2035.0

However, JTF CapMed was a peculiar command structure for the military medical system. The majority of staff

at Walter Reed and Bethesda Naval had spent their entire careers in the Army or the Navy reporting to the

hierarchy. Hardly anyone was familiar with the joint task force model. One doctor compared it to a “liger”—a cross

between a tiger and lion that had been bred in the National Zoo.49

The whole concept of military jointness had arisen in quite different circumstances. In 1986, Congress had

passed the Goldwater-Nichols Act, which reorganized the military’s command structure to promote cooperation

among the Army, Navy, Marines and Air Force. This was in response to a series of military humiliations resulting

from the services’ inability or unwillingness to coordinate their tactical operations. The most public example was

the failed “Operation Eagle Claw,” an attempt to rescue American hostages from Tehran in 1980, which resulted in

the loss of eight U.S. servicemen and several aircraft.50

With the Goldwater-Nichols reorganization, “joint assignments” became important stepping-stones to

promotion for officers working in special areas and a requirement for generals and admirals. However, joint task

forces were designed to operate in theaters of war, which increasingly required sophisticated coordination of the

various skills each service brought to battle, like timing air support for ground troops. They were not intended to

govern the operations of peacetime units on the home front, and they were only rarely intended to be permanent

or “standing.” Moreover, the military’s medical operations and officers had been specifically exempt from

Goldwater-Nichols personnel standards.51 Thus there were very few high-ranking military doctors with joint service

experience.

One of the few medical doctors who had such experience was Rear Admiral John Mateczun. In 2007,

Mateczun was the two-star deputy Surgeon General of the Navy and looked like the leading contender to become

Surgeon General, the Navy’s top doctor.52 But in a last minute shake-up, it was not Mateczun but Rear Admiral

Adam Robinson, the one-star Bethesda Naval commander, who was tapped for that post. Robinson became the

first African American to lead Navy medicine.53 The Pentagon selected Mateczun instead to command JTF CapMed

and to report directly to Deputy Secretary England.

Mateczun was a weathered physician who had served in the Army as an enlisted soldier and in several joint

assignments as a high-ranking naval officer. He was respected for his intellect. With a tall, broad frame that belied

his soft-spoken—even introverted—manner, colleagues regarded Mateczun as an affable, reasonable person to

work with. He had also spent years inside the Beltway, including several at Bethesda Naval, where he cultivated a

gift for getting things done in a political environment. “Mateczun was the logical person to be appointed,” England

said later. “He was highly qualified and very competent. He was the highest ranking among the candidates. He was

respected by both services. And he was seen as being joint, so he was accepted by the rest of community.” 54 It

would be Mateczun’s final command.

Setting Sail: September – December 2007

Mateczun’s command of JTF CapMed began amid turmoil. The military medical establishment in Washington

was still reeling from the Walter Reed scandal, its hospitals were struggling to keep up with the influx of wounded

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HKS Case Program 12 of 50 Case Number 2035.0

troops from Iraq and Afghanistan, and it had made little progress in implementing the BRAC’s mandated

consolidation.

For Mateczun the mission was clear: transform health care delivery in the National Capital Region to make it

more effective and efficient, and ensure the BRAC succeeded by consolidating Washington’s three major hospitals

into two.

He shared the Deputy Secretary’s sweeping ambitions for what the merger should achieve. “The Walter Reed

National Military Medical Center is going to be a center of excellence for military medicine, not just for the next

generation but for the next several generations of military medicine,” Mateczun said. “It is a facility which is run by

the military. It’s not identified with any specific service. It’s identified with America and America’s responsibility

and America’s covenant to take care of the wounded and their families as they come back.”55 But with only four

years left to meet the BRAC’s deadline, Mateczun would need support from people in powerful places,

unambiguous authority and swift action in order to realize his vision.

Mateczun had several reasons for concern. JTF CapMed's charter was to oversee the orderly execution of the

BRAC-mandated military medical consolidation and to “ensure the effective and efficient delivery of world-class

military health care.” Deputy Secretary England gave Mateczun broad powers but little specific guidance.

Mateczun had flexibility and room to maneuver, but his many opponents within the entrenched cultures and

institutions of the Defense Department and the services also had plenty of room to resist.

Moreover, what England perceived as one of Mateczun’s key advantages—his experience with “jointness”—

was a double-edged sword. Because the medical field was exempt from joint requirements, medical officers

retained a fierce loyalty to their own services, making the Admiral’s joint bonafides suspect within the ranks.

Concept of Operations

In November 2007, shortly after assuming command of JTF CapMed, Mateczun articulated his strategic vision

for the new organization. He communicated it through a “Concept of Operations,” a technical document

traditionally used in coordinating joint force operations that “clearly and concisely expresses what the [Joint Force

Commander] intends to accomplish and how it will be done using available resources.”56 Mateczun’s Concept of

Operations laid out his strategic plans and priorities and outlined his authority to implement them. It was

distributed to the hospitals ostensibly under his command and, from a tactical standpoint, doubled as an opening

salvo to legitimize his position.

The Concept of Operations called for a sense of urgency and expressed Mateczun's broader vision to create a

joint model of medicine that could eventually be adopted elsewhere:

We must not squander this narrow window of opportunity that has been entrusted to

us to provide a model world-class healthcare system for our beneficiaries and

demonstrate the effectiveness of a JTF to direct regional healthcare.

The document also identified “threats” that might imperil the mission, including “time,” “stovepipe operations”

and “reluctance to change.” It made an appeal to the Army, Navy and Air Force medical cultures, which Mateczun

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HKS Case Program 13 of 50 Case Number 2035.0

expected might balk at his agenda:

Each Service brings unique and critical capabilities, but they can only be as effective as

the contribution they make to the overall mission. As members of the JTF CapMed Team,

we require…an unprecedented level of teamwork aimed at giving our best for

something larger than ourselves, putting aside personal ambition, ego and pride and

embracing a joint view.

The Concept of Operations document was remarkable for several reasons. First, the very issuance of Concept

of Operations for a medical mission seemed odd. Second, the document emphasized the strengths of JTF CapMed,

but it also subtly revealed its weaknesses. For example, the document stated that Mateczun reported directly to

the Secretary of Defense, through the Deputy Secretary of Defense. This was a bold assertion even if technically

correct. However the document also stated that Mateczun’s authority as a joint force commander rested on

“tactical control” (TACON), admitting rather conspicuously that he lacked the more sweeping powers of

“operational control” (OPCON). While OPCON is a level of military authority enjoyed by combatant commanders

(e.g., General David Petraeus at Central Command in the late 2000s), TACON was perceived as a relatively weak

level of control associated with lower echelons of command. TACON is also a far lower level of authority than

administrative control (ADCON), the control over service budgets and personnel.

The net effect of the Concept of Operations was that the services—particularly the Navy—felt threatened by

the tone of the document and feared that Mateczun would seek to gain OPCON. The wrangling for authority had

begun. Mateczun promised to publish a more explicit “execution order” within 30 days, but in the face of

immediate service resistance to the Concept of Operations, this never happened.

Strategic Decisions: January 2008 – January 2009

At the start of 2008, Mateczun needed to establish his command more firmly. He was responsible for

implementing the merger but had only nominal oversight of the merging institutions and no control over the

budget, which was in the hands of the services. It was critical to reorganize the stove-piped reporting structures of

the hospital commands. “Who’s in charge, and who is paying for it?” Mateczun found himself asking repeatedly.

He needed to place the hospitals under the primary authority of JTF CapMed.57 Such a restructuring would be

controversial, especially at Bethesda Naval, where it would threaten the hospital’s autonomy in managing its

workforce and influencing Navy budget decisions.

The staff at Bethesda was still not sure who was in charge. JTF CapMed was another layer of authority, but it

did not control the budget. “Getting JTF CapMed was like getting a new set of parents while your own parents

were still in the house,” said one staff member. “The new parents tell you they’re in charge. But they can’t spank

you and they can’t you give an allowance. And they are new parents, with no experience of raising kids!”58

Mateczun knew he was up against the clock. Gordon England was entering his third year as Deputy Secretary

and his eighth year in the Pentagon—an eternity there. It was also a presidential election year. Within 12 months,

the creator of JTF CapMed and Mateczun’s chief supporter would likely be replaced. Mateczun scrambled to

identify key strategic decisions that England could make before vacating his post. “If you don’t make the key

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HKS Case Program 14 of 50 Case Number 2035.0

strategic decisions early you’re not going to get to the end,” Mateczun said. “So we had to get decisions on the

organizational structure, command and control and manpower early. If we didn’t, we would never have been able

to finish.”59

At this point, Mateczun faced two key challenges: the immediate managerial and logistical issues of combining

the facilities, staff, operations and systems of two distinct medical centers and the important strategic challenge of

gaining the authority to make these changes under JTF CapMed’s command.

A New Governance Model for the Hospitals

The most pressing decision was the choice of a governance model. The question of governance boiled down to

whether the “realigned” hospitals would be “truly joint” or not. There were three large military hospitals in the

region: Walter Reed, Bethesda Naval and DeWitt. Each had its own governance system with different hierarchies

and procedures that reflected service idiosyncrasies. Walter Reed and DeWitt were organized on similar Army

hospital models, but Bethesda Naval had an entirely different administrative framework. Mateczun wanted to

harmonize these structures without adopting in full either of the systems already in use. This meant new

management structures for all three hospitals. Mateczun viewed this as a critical step to avoid the impression of

“winners” and “losers,” but the hospitals resisted the convergence.

Mateczun hoped that the new common structure would anticipate the organization of the fully integrated

Walter Reed National Military Medical Center. “We had to fight for a year on this organizational structure. Are they

going to be truly joint hospitals or are they going to be something else?” Mateczun asked. The answer to that

question held consequences for the legitimacy and endurance of JTF CapMed. In addition, whatever governance

structure Mateczun recommended to England had to facilitate the merger without impairing patient care. “I had to

run these hospitals while we were fighting the war and keep the civilian staff from leaving. Then I had to close,

combine and run those hospitals afterwards. And so how do we do that was the primary question.” 60

The BRAC’s order to “realign” was open to interpretation. Taken liberally, it could mean transforming the

hospitals into “service-agnostic facilities” that, while employing staffs and treating patients from the Army, Navy,

Marines and Air Force, belonged to none of them. Interpreted narrowly, the “new Walter Reed” might simply

remain two separate Army and Navy hospitals squeezed onto Bethesda’s campus. A hybrid solution might involve

two jointly staffed hospitals, each run by one service: the Navy would run Walter Reed National Military Medical

Center while Fort Belvoir Community Hospital would fall under Army control.

Mateczun was a joint commander, but different actors had different ideas about what precisely he

commanded. “We struggled with this early,” Mateczun said. Since Mateczun reported directly to the civilian

Deputy Secretary of Defense, his authority circumvented the traditional reporting chains in military medicine,

whereby hospital commanders answered to their service surgeons general, who in turn answered to the service

chiefs themselves. With Mateczun in the picture, hospital commanders around Washington might be plucked from

their familiar chains of command and repositioned beneath Mateczun in his new organizational framework. More

problematically, commanders might find themselves in the awkward position of serving two masters: their own

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HKS Case Program 15 of 50 Case Number 2035.0

surgeons general and Mateczun. Though this kind of matrix structure was common in the private sector, the

military functioned in a strict chain-of-command hierarchy.

Mateczun believed that the best model for the hospitals would be a joint model—in the most muscular sense

of the term. “I am a firm believer in the unity of effort and unity of command,” he said.61

x First, as Mateczun envisioned it, the hospitals would be “jointly run.” He wanted the hospital commanders to report directly to him and not to the surgeons general of each service.

x Second, he wanted each hospital to be “jointly manned” by military personnel from all three services, even though their parent services would still have administrative control over discipline, awards and

promotions, etc.

x Third, Mateczun insisted that the new hospitals would provide care to patients from across the military family, regardless of what uniform they wore.

The Civilian Question

Another crucial decision concerned the hospitals’ civilian employees. One of the growing trends in the military,

over the previous two decades, had been to outsource many functions that were previously handled by military

personnel. There were hundreds of thousands of civilian contractors working in Iraq and Afghanistan, in positions

ranging from cooks, mechanics and computer specialists to prison guards and truck drivers. This shift was

happening in medicine, too. Throughout the military, civilian doctors, nurses, x-ray technicians and other staff had

become fully integrated in the care of patients. (In fact, one of the reasons cited for the Walter Reed scandal was

that (former Secretary of Defense) Donald Rumsfeld and the BRAC had ordered surplus civilians and contractors

who made up “unnecessary overhead” be “eliminated.”)62

At this point, Walter Reed depended on the support of its civilian contract force, which comprised about half

of its staff.63 And unlike military personnel--who could be ordered to work at the newly relocated hospital--the

civilians could decide to leave if they wanted to. If JTF CapMed failed to assure civilians at Walter Reed that their

jobs would be protected, attrition at the hospital might jeopardize its ability to care for patients and new casualties

returning from Iraq and Afghanistan.64 As Mateczun explained:

We had to keep Walter Reed up and running as a world class medical center despite the

fact that it was going to close in a couple of years…There’s no shortage of hiring

opportunities for highly skilled medical personnel in the National Capitol Region or

across the country…We had a highly skilled, highly trained workforce used to these

kinds of casualties, and trained to handle them, and we needed to keep them there.65

In August 2007, just before Mateczun took command of JTF CapMed, Deputy Secretary England signed an

order guaranteeing the jobs of some 800 civilians and contractors working in critical clinical positions at Walter

Reed. This “Guaranteed Placement Program” was unique for a BRAC site and reassured the Army civilians that they

would find commensurate employment at Bethesda, Fort Belvoir or some other military medical facility in the

Washington area.66

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HKS Case Program 16 of 50 Case Number 2035.0

For Mateczun, this meant that instead of eliminating jobs to cut costs, JTF CapMed would have to redistribute

Walter Reed’s civilian workforce among other hospitals. Walter Reed had already increased its clinical staff after

the scandal. Now other non-clinical personnel at Walter Reed—cooks, plumbers, landscapers, etc.—demanded

and received similar job protection.67

The civilian personnel systems of the Army and Navy had evolved separately, with different coding, pay scales

and qualifications for otherwise identical medical staff jobs. Transferring employees to Bethesda from Walter Reed

would mean aligning their job descriptions and titles with their counterparts at the Navy hospital. In effect, this

would mean elevating the official titles of some workers and demoting others, creating a sense of winning and

losing that could multiply into a crisis.

Mateczun’s solution was to recommend a complete reclassification of the 4,410 civilians who worked for

either the Army or the Navy systems into a brand new system as “DoD civilians” effectively under JTF CapMed’s administrative control.68 “Transferring this many personnel to a new human resources system had not been done

before,” Mateczun said, adding that it was the only way that model did not create winners and losers. “If you

looked ahead you could say all our people could really benefit from a medical work force across the country where

opportunities would come not just within the Navy system or the Army system but we could actually have a whole

system of clinics across the country where this might be adaptable.”69

Making the Case for Joint Hospitals

Having laid the groundwork to harmonize management structures across the region and to reclassify Army

and Navy civilians as “DoD” in all facilities under JTF CapMed control, Mateczun’s next step was to seek full “joint”

authority to implement these changes from senior Pentagon leadership.

There were two layers Mateczun needed to go through before he could take his proposals to the Deputy

Secretary. First he had to vet his proposed joint governance structure with the National Capital Region

“Overarching Integrated Product Team,” an oversight committee established in JTF CapMed’s charter with the

responsibility to “evaluate the overall medical…program prior to major decisions and…address issues that may

impact those major decisions.” Second, he had to brief the Joint Chiefs of Staff. He had reason to hope for a

relatively easy road; people in influential positions at the Pentagon supported giving broad powers to JTF CapMed.

The vice chairman of the Joint Chiefs of Staff, Marine General James Cartwright, was a proponent and supporter of

joint commands and operations. Additionally, the influence of Mateczun’s patron, Deputy Secretary England,

carried far. “There was a message that [JTF CapMed] was important because it was important to me,” England said.

“John Mateczun carried the authority of the Secretary with him.”70

In addition, the idea of jointness for the military medical system was gaining some traction. The Defense

Business Board, as well as some think tanks and defense analysts were renewing calls for a “Unified Medical

Command,” an idea that had emerged in 2006.71 All of this created an environment in which Mateczun felt

confident that he could move forward.

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HKS Case Program 17 of 50 Case Number 2035.0

Pushback from Navy Medical

But the individual services did not share Mateczun’s enthusiasm. They favored a more conservative definition

of jointness—collocation rather than integration.72 Army and Navy medicine answered to their own three-star

surgeons general, who in turn reported to the service chiefs. All the medical personnel in each service--from

doctors and nurses to orderlies and medics--were under the administrative control of those same services. The

systems each service employed in the delivery of health care too varied widely: everything from how the hospitals

were organized to the credentialing of physicians to the allocation of funds to the computer systems that held

medical records.73 Configuring the new Walter Reed and Fort Belvoir Community Hospital into joint hospitals

would demand an overhaul of command relationships and the complicated integration of all these systems. Simply

put, a joint construct would threaten the control, authority, and power that defined the prerogatives of the Army,

Navy and Air Force.

The Navy in particular balked at Mateczun’s plans. During the wars in Iraq and Afghanistan, the total size of

the Navy had been reduced from 377,810 to 328,227, while the Army had grown from 480,801 to 570,719. The

Navy was in no mood to concede more power. “Can one service say no to joint?” mused Mateczun. “The answer

today is yes.” Vice Admiral Robinson, the former commander of Bethesda Naval now the new Navy Surgeon

General, was opposed from the start. He viewed the Navy’s methods of delivering health care as superior to the

Army’s, especially in light of the turbulent period for Army medicine that the Walter Reed scandal had

precipitated.74 And Robinson believed that JTF CapMed was trying to take over a process that he had already

initiated with his Army counterparts at Walter Reed. Robinson was adamant that the Army and Navy did not need

a “babysitter” during the integration. “Gordon England was convinced that Army/Navy would never accept this

without a command placed over them, but Farmer and I would have gotten it done if we had been kept in

together.”75

Mateczun’s response to the Navy’s opposition was to work faster to push his recommendations through to

Deputy Secretary England, lest the critical decisions be left hostage to a potentially less friendly successor. In

September 2008, Mateczun delivered a brief to the Joint Chiefs of Staff recommending that Walter Reed National

Military Medical Center and Fort Belvoir Community Hospital be joint facilities with their commanders reporting to

JTF CapMed. 76

In a memorandum to the services the following month, Vice Chairman of the Joint Chiefs of Staff James

Cartwright recommended that the military members of the hospital staffs occupy billets “coded as joint.”77 This

would give military medical officers credit for time served in a joint position. In addition, the vice chairman

recommended that the commanders of Walter Reed National Military Medical Center and Fort Belvoir Community

Hospital report to JTF CapMed.78

Three months later, on January 15, 2009, Deputy Secretary England accepted the recommendations of JTF

CapMed and the Joint Chiefs by signing a memo that: (1) confirmed approval of a DoD civilian personnel model; (2)

approved the establishment of Joint Commands at [Walter Reed National Military Medical Center] and [Fort

Belvoir Community Hospital]; and (3) deferred a decision on ultimate organizational governance of the JTF CapMed. 79

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HKS Case Program 18 of 50 Case Number 2035.0

In a final statement that signaled more uncertainty to come, England scribbled in the margins the following:

“Regarding deferral of an ultimate governance decision: These deliberations need to continue and

recommendations brought forth expeditiously.” But the proposal by the Joint Chiefs along with England’s memo

convinced Mateczun he had the green light—16 months after his appointment—to see his vision through. “At the

start we knew that to get to the end successfully, there were decisions that had to be made early. This was one of

them.”80

Mateczun Promoted to Three-Star: February 2009 – August 2010

By February 2009, Mateczun had survived a year and a half as commander of JTF CapMed. He had laid out his

vision to his staff and to the hospitals over which he presumed JTF CapMed had control. He had worked to make

progress on decisions he thought were key to the long-term success of the organization and received England’s

blessing. In addition, the recently released 2009 National Defense Authorization Act had made JTF CapMed a

“three-star billet.”81 Mateczun was therefore promoted from rear admiral to vice admiral, putting him among the

top 50 officers in the entire U.S. Navy.

Mateczun believed that he had momentum. His detractors, however, continued to eye his ambitions with

suspicion. As one administrator at Bethesda remarked “It was evident that JTF CapMed was trying to establish

itself as a fourth Surgeon General.”82 And Mateczun’s fortunes were about to change.

Deputy Secretary England Departs

After Barack Obama was elected President in the fall of 2008, there were personnel changes at the top of the

Pentagon. Although Secretary of Defense Robert Gates stayed on at Obama’s request, Deputy Secretary England

resigned at the conclusion of President Bush’s term. His replacement, William Lynn, was an experienced hand, with

stints at Raytheon and as Undersecretary of Defense (Comptroller) during the Clinton administration. But

England’s departure meant that JTF CapMed had lost its creator. “When I left as Deputy Secretary there was not

one single piece of paper left in the office,” England said later. “All of it had gone to the archives. I had a lunch-time

changeover.”83 Such evaporation of institutional knowledge is not uncommon in government, but for Mateczun it

was a tough blow. With the BRAC’s deadline of September 2011 little more than two years away, Mateczun feared

that support for JTF CapMed and its mission might trickle away.

Authority Matters

Running with Deputy Secretary England’s support for a “joint” hospital configuration, Mateczun’s next

objective was to secure the authority necessary to control operations and spending within his command. He had

persuaded England and Vice Chairman Cartwright that JTF CapMed’s governance model should resemble a post-

Goldwater-Nichols combat command. To Mateczun it followed logically that he should therefore possess the same

authority as a combat commander—i.e., “operational control,” or OPCON.

Mateczun saw two options. The JTF CapMed Charter had only given him TACON. He could move ahead with

that authority, coordinating (not commanding) activities among JTF CapMed’s subordinate units, under the

guidance of the new Deputy Secretary Lynn. Or he could attempt to wrest additional control from the services.

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HKS Case Program 19 of 50 Case Number 2035.0

Mateczun decided he needed OPCON. To him, it was the difference between being the custodian of bureaucratic

hospital reorganization or the architect and implementer of a grand vision for a new kind of military health care

delivery. “With the clock ticking, I needed to clarify all that before every issue became an issue of TACON versus

OPCON,” Mateczun said.

Navy Protests Push for OPCON

To the officers in charge of the hospitals, Mateczun’s plan to gain OPCON far exceeded his mandate. The

stiffest resistance came from Mateczun’s own service, the Navy. Mateczun’s broad interpretation of jointness

troubled Rear Admiral Matthew Nathan, who had replaced Johnson as the commander of Bethesda Naval in

August 2008. To Nathan, JTF CapMed had a very limited and specific purpose: to finish the job of integrating the

hospitals. What rankled Nathan most was that Mateczun’s experiment to transform the Military Health System

could not come at a more difficult time for the military medical operations of the nation’s largest casualty receiving

treatment centers.

I had warriors Medevac’d in with, by far, the most complicated and catastrophic injuries

in number and severity since any time during the war. I had a medical staff that was

exhausted. Part of my staff was at the breaking point…so my job was to keep being the

cheerleader for them to figure out how to try to keep them from breaking, try to keep

them on point. And JTF was more of a problem than it was a help.84

Mateczun’s increasing tendency to involve JTF CapMed in the day-to-day provision of care at Bethesda Naval

further upset Nathan: “I’m a flag officer,” Nathan said. “I’m running Bethesda. Why would JTF call me up and tell

me how to run the hospital? But they did. They tried at every turn to run the hospital.”85

Pressure from Congress

Meanwhile, Mateczun faced resistance from a different source: Congress. The Walter Reed Scandal had led to

intense and continuing scrutiny from Congress on the state of the BRAC-mandated medical realignment. Mateczun

already met regularly with individual legislators and testified at hearings by the House Appropriations

Subcommittee on Defense. Now he was required to deliver more information more frequently. In 2008 the House

of Representatives put a temporary hold on merger-related construction until a more coherent plan for integration

could be drawn up. The hold was almost enacted into Congress’s fiscal year 2009 National Defense Authorization

Act, but the House eventually backed down. Its plan would have breached construction contracts that had already

been signed, set a precedent for cancelling individual BRAC projects, and would likely have faced a veto by

President Bush.86

Instead, Congress mandated in the 2009 National Defense Authorization Act that the new Walter Reed be

brought to a “world-class” standard of medical care:

World-class medical facilities are defined as incorporating the best practices of the

premier private health facilities in the country as well as the collaborative input of

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HKS Case Program 20 of 50 Case Number 2035.0

military health care professionals into a design that supports the unique needs of

military personnel and their families.87

Congress ordered the Secretary of Defense to form an “Independent Design Review Panel” that comprised

“medical facility design experts, military health care professionals, representatives of premier health care facilities

in the United States, and patient representatives” to define a world-class standard, review the current design plans

at Bethesda and make recommendations within 90 days.88 The review panel would fall under the Defense Health

Board, a federal advisory committee to the Secretary of Defense. JTF CapMed was required to provide information

and access to the Defense Health Board and to host the review panel’s hearings.

The independent panel found that while some of the construction in the National Capital Region met the

world-class standard, much of what was planned for Bethesda did not.89 Mateczun welcomed these findings. The

BRAC’s original plan was, he believed, a slapdash cost-saving scheme that did not take into account the complexity

of merging Walter Reed and Bethesda Naval. The new plan would turn the new Walter Reed into one of the best

and most advanced hospitals in the world.

Incorporating the Defense Health Board’s findings, the 2010 National Defense Authorization Act ordered the

DoD to produce a “Comprehensive Master Plan” to address the identified shortcomings. The law ordered, among

other things, that the DoD delineate a clear budget, make the case for giving JTF CapMed full operational authority,

list personnel requirements and— most tellingly to Mateczun—write the plan to “be used as a basis to develop

similar master plans for other military medical facilities of the Department of Defense.”90 Congress seemed to be

keeping alive the prospect that JTF CapMed might yet become a model for the rest of military medicine.

Still, Mateczun continued to face skeptics. An introvert by nature, and a man who had spent his youth in a

solitary role while detonating bombs in Vietnam – Mateczun now found himself deeply enmeshed in the Beltway

fray – mingling with congressmen, speaking to various congressional oversight committees and Hill staffers to keep

the Walter Reed-Bethesda merger from imploding.

In December 2009, two subcommittees of the House of Representatives Armed Services Committee held a

hearing to probe whether JTF CapMed was developing world-class hospitals, titled “The New Walter Reed: Are We

On the Right Track?” The opening remarks by the chairman, Representative Solomon Ortiz of Texas, set the tone.

“The Defense Health Board recently stated that the current design would not attain world-class. I find this to be

unacceptable…. Four years have passed since the BRAC reported its findings, and yet we still have a disorganized

medical command, a disjointed funding authority and an inconsistent construction design in support of a $2.5

billion effort.”91 The co-chair of the hearing, Representative Susan Davis of California, called the independent panel

report “unsettling”:

Among the troubling descriptions of the current plan are that it would not result in a

world-class facility, that it would not meet joint commission accreditation standards and

that it was ambiguous about the vision, the goals and expectations of the new century.92

Mateczun and other Pentagon health officials spent hours trying to convince the committee that the BRAC

projects were on track and the world-class standard was foremost in their minds.

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Four more hearings before March 2010 revealed concerns on the part of Congressmen—in particular

Representative Joe Wilson of South Carolina—about the pace of progress. Wilson repeatedly expressed concern

that wounded warrior support at the new hospital would not meet the standard set by the old Walter Reed.

Wounded warriors who move to the new medical center will experience a significant

degradation of services and support. This is unacceptable. What assurances can you give

me and military families that all of the wounded warrior support now provided at

Walter Reed—including barrack space at [the] Bethesda campus—will be available when

the new medical center opens in 2011?93

Mateczun Finally Gets OPCON

Mateczun helped persuade Congress that JTF CapMed needed more authority in order to meet the BRAC

deadline without harming patient care. At the Defense Department, Mateczun finally convinced his superiors to

give him full operational control (OPCON). In March 2010, he completed coordination of the “Comprehensive

Master Plan” and delivered the 200-page document to Deputy Secretary Lynn.94 The following month, Lynn

approved the plan and directed JTF CapMed to assume OPCON of Walter Reed, Bethesda Naval and DeWitt.

Mateczun saw this as a full endorsement of his authority. “Congress decided ‘world-class’ needed a singular

budgetary and organizational authority,” Mateczun said. “After that I got OPCON.”95

Lynn also affirmed DoD’s intent to have the new Walter Reed and Fort Belvoir Community Hospital report to

JTF CapMed even after the BRAC’s deadline. This was another controversial idea. Many senior figures in the

services regarded the JTF model as a temporary command structure that would be dismantled after the merger.

Mateczun’s desire to cement JTF’s authority above the individual hospital commands was seen as a pure grab for

power.96

The Navy still resisted the idea of allowing Bethesda Naval to become a joint hospital at all. Vice Admiral

Robinson, now the Navy Surgeon General, and Rear Admiral Nathan, the commander of Bethesda Naval,

repeatedly circled back to the ambiguity of the BRAC’s original language, which simply ordered Walter Reed to

“realign” and “relocate.” For example, Nathan pointed to a discreet line at the start of the BRAC’s report stating

that “collocation” is not synonymous with “integration,” and “transformation” is not synonymous with “jointness.”

Mateczun even sought counsel from the Pentagon’s legal experts, who told him that nothing in the BRAC’s

language precluded the DoD from taking the actions it had chosen.

Nevertheless, JTF CapMed and the Navy built up arsenals of competing language from the various laws,

memos, directives and orders that had originated in Congress, the Pentagon or independent reviews. “In a

bureaucracy, [the person who] can delay, procrastinate and obstruct [wins],” Mateczun said.97 Robinson was a

close friend of Chairman of the Joint Chiefs of Staff Admiral Mike Mullen, which ensured that the Navy position

was being aired at the most senior levels.

With the BRAC’s deadline now just a year away, and armed with renewed backing from Deputy Secretary Lynn,

Mateczun decided to ignore the continued opposition from the Navy and its supporters on the Hill and sprint for

the finish line, regardless of the consequences.

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Heading to the “Tank”

By the summer of 2010, the storm winds between JTF CapMed and the Bethesda Naval command had blown

south to the Pentagon. Project costs were ballooning. The total cost of BRAC-mandated construction in the

Washington area hit $2.7 billion, more than three times the original estimate. (It would grow to $2.9 billion by

September 2011.) Officials at Bethesda Naval had long felt shut out of the decision-making process. “JTF CapMed

demanded these changes,” said one member of Nathan’s staff who oversaw construction and outfitting. “They

didn’t even listen to us.”98

The controversy over JTF CapMed rose to the Joint Chiefs of Staff, the very top echelon of the Defense

Department. These high priests of America’s defense establishment found themselves dedicating their so-called

“Tank” sessions—periodic closed-door meetings on the most pressing national security matters—to mediating

disputes between JTF CapMed and the Navy over medical minutiae. Lieutenant General Bruce Green, the Air Force

Surgeon General at the time, remembered that more Tank sessions were devoted to JTF CapMed during this

period than to the war in Afghanistan.99

Mateczun found himself being hauled into the Tank sessions to defend his decisions. “Things were portrayed

sometimes in ways that weren’t real, so we went up there repeatedly,” Mateczun recalled.

If you get a concerted enough attack, just like in political campaigns, if you repeat

something enough, then pretty soon people recognize it. Well here it’s like, ‘Bethesda

should be a Navy hospital, or the JTF is bad.’ It’s easier to attack something as bad than

to portray something as good. When you’re able to, for instance, say, ‘No JTF JTF JTF;

Marine care is going to suffer, suffer, suffer,’ you keep up that drumbeat, and it’s hard

to rebut in the department, even if it’s not true.100

Emotions ran high. Major General Carla Hawley-Bowland, Army commander of Walter Reed at the time,

recalled one session in which Mateczun suggested that the newly consolidated hospitals would keep the Army’s

credentialing system for physicians, sending Robinson into a rage. “Steam was coming out of his ears,” Hawley-

Bowland said.101 Yet despite the intensity and frequency of the Tank discussions, little got resolved. “If you talk

with the four-stars today you would find that they have a terribly negative view towards a joint medical command

based on what [Mateczun] tried to do,” said Lieutenant General Green, who attended many of the Tank sessions in

2012.102

Still, Mateczun remained defiant on the issues he championed, at times stubbornly reminding the panel of JTF

CapMed’s reporting line. “He would come back when there were conflicts,” Green remembered. “And in one

particular session, after being told to do it this way by the chairman of the Joint Chiefs, Mateczun essentially said, ‘I

will talk with the [Deputy Secretary] because I don’t work for you.’ It’s not the way to win friends and gain

influence.” 103 Things were so tense that Mullen, whose children had gone to school with Mateczun’s, told Admiral

Robinson behind closed doors that he would fire Mateczun if he could.104

The Joint Chiefs seemed to consider JTF CapMed just another joint task force, and expected it to operate as

such. As they saw it, Mateczun’s mission was to integrate Walter Reed and Bethesda Naval as efficiently as

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possible. The ever-rising costs of the project lent credibility to the notion that Mateczun was less interested in

saving money than in entrenching control for JTF and himself.105

Mateczun, for his part, felt that since he had received direction from his boss, he could not in good conscience

agree to a different course of action in the Tank without losing integrity. Despite mounting criticism, Mateczun

listened most carefully to his own instincts, as he had throughout his career.

The Final Stretch: September 2010 – September 2011

Late 2010 brought a series of reviews, investigations and reports that recommended scaling back JTF CapMed,

or ending it altogether. In October, the Undersecretary of Defense for personnel and readiness recommended that

JTF CapMed be terminated in the name of efficiency.106 A month later, the Secretary of the Navy, the Chief of

Naval Operations and the Commandant of the Marine Corps wrote a memo to Secretary of Defense Robert Gates

recommending that JTF CapMed be “disestablished” after the merger was completed.107

The Joint Chiefs were leaning toward a five-step plan to disestablish JTF CapMed.108 This plan would include a

measure that downgraded the command of JTF CapMed from a three-star flag officer to a one- or two-star billet.

Mateczun would be directed to draft the plan, a move that effectively asked JTF CapMed to dig its own grave.

Mateczun responded to the barrage of recommendations with a memo of his own to the Undersecretary of

Defense for Personnel and Readiness that questioned key assumptions in the proposal to eliminate JTF CapMed. 109

As the BRAC’s deadline approached, the friction between Congress, the Office of the Secretary of Defense and

the Joint Chiefs intensified. Mateczun, who had begun his command in the aftermath of one crisis with what he

interpreted to be a broad mandate, now felt stranded. “I expected that there would be resistance as we went

through the system before the decision got made,” Mateczun said of his original vision for a joint hospital. “I didn’t

realize the number of ways that opponents would work to reopen the decision over the years.” 110

A Final Test: The Joint Medical Network

Mateczun’s focus shifted to completing the merger by the deadline. But even that would not come easily. In

the spring of 2011, as the future of JTF CapMed was being debated, Mateczun moved forward with implementing

a “Joint Medical Network,” which would facilitate the transfer of medical records in the National Capital Region.

As late as 2010, the National Capital Region’s file-sharing network prevented the seamless sharing of medical

records between facilities operated by the various services. “It took less time to drive an X-ray image around the

Beltway from one hospital to another than it did to send it electronically,” Mateczun said.111 Mateczun’s staff

conceived the Joint Medical Network as a solution to this problem. By early 2011, after more than a year of

designing the system, purchasing hardware and laying cable, the final connection was ready to be made, and the

contractor prepared to flip the final switch.

Vice Admiral Robinson, the Navy Surgeon General, found out about the plan in a conversation as he prepared

to deliver a eulogy at the funeral of the son of one of his subordinates. He was furious. The network would cut

Bethesda Naval off from other Navy hospitals in the region that did not fall under JTF CapMed. “This was just a way

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for JTF to put their fingers on something and say ‘We own this,’” Robinson said. He saw the plan as more evidence

that Mateczun was trying to increase his own authority at the expense of the Navy’s mission.112 Robinson

immediately intervened to delay the completion until he could get answers. “I didn’t think the Navy had the

organizational or legal authority to resist,” Mateczun said. “The contractor was at the Navy’s door. He was a rare

asset and had traveled from Atlanta.” Mateczun offered to bring the Navy’s satellite facilities under the aegis of JTF

CapMed, take it or leave it. Robinson did not accept. “Why try to change the spark plug on the train engine when it

is moving 100 mph? You’ll drive it off the cliff!” Robinson said later.113 There were e-mail “shouting matches”

between Mateczun and Robinson that got forwarded to other high-ranking officers. The Assistant Secretary of

Defense for Health Affairs, Dr. Jonathan Woodson, worried about leaks to the press and intervened to calm the

heated rhetoric.114

The Joint Medical Network question degenerated into one of the final rows in a three-year saga that had left

Mateczun and JTF CapMed with few friends.

To resolve the dispute, Mateczun had two choices. He could use his direct reporting relationship to appeal

directly to Deputy Secretary Lynn for a decision, or he could bring the issue before yet another Tank session with

the Joint Chiefs.115 He decided to do the latter. “Joint doctrine requires that when a joint commander and a service

differ over an issue that the matter should go to the Joint Chiefs,” Mateczun said. “I took the matter there for a

resolution. The JTF position was that there was already a [DoD] decision on the matter and that I was working

within my authorities.” [The Joint Medical Network was part of the approved Comprehensive Master Plan.]

Besides, Mateczun figured that going to the Joint Chiefs would serve as a litmus test for the mandate of JTF

CapMed and for the resolution of other issues as the BRAC’s deadline loomed and resistance increased. However

it didn’t work out that way.

“The Joint [Chiefs of] Staff did not provide a legal opinion [about whether I was authorized to do this],”

Mateczun said, “and proceeded to design a compromise plan with ‘logical separation’ of the networks.” This

technical fix was a half-measure that allowed both JTF CapMed and the Navy networks to share the infrastructure

that had already been built. The new scheme cost an additional $3.5 million and added six months to the project. It

also convinced Mateczun that using the Joint Chiefs as a dispute forum was useless for completing the

realignment.116 “We were barely able to design and complete the plan in time to activate the network and this

ended up being the closest we came to being unsuccessful,” Mateczun said.117 Even worse, in the end, Lynn chided

Mateczun for not bringing the matter to his attention. “Close as I came to breaking the BRAC [mandate], I learned

not to use the Joint Chiefs as an appeal. I should have gone to the Deputy Secretary, but I wanted to save him for

very big decisions.”

The Finish Line

By the summer of 2011, Mateczun was exhausted from the bruising battles over JTF CapMed’s authority and

future. In the effort to merge Walter Reed and Bethesda in the middle of a war, Mateczun had expended what

political capital he had had with the Joint Chiefs. His personal relationships with fellow naval officers were in

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tatters. “He’ll forever be known as the naval officer that gave away Bethesda,” lamented one former naval

officer.118 Nevertheless, Mateczun remained committed to finishing his mission.

By this time even Deputy Secretary Lynn doubted whether JTF CapMed was the best vehicle for delivering a

new vision of military health care. Lynn ordered a special task force to review the Military Health System and to

address medical management in the National Capital Region.119 Dr. George Peach Taylor, former Air Force Surgeon

General and a recent Assistant Secretary of Defense for Health Affairs led the task force. Taylor and a co-chair

recommended that JTF CapMed become one of six DoD-wide “Market Management Offices” and report to a new

“Defense Health Agency.” The proposed agency would manage all administrative support functions for military

medicine but leave control of the hospitals to the services. Under the recommended plan, the present JTF CapMed

would cease to exist. There was no mention of JTF CapMed’s mission to create a “center of excellence for military

medicine.” The final report was delivered to Deputy Secretary Lynn on Sept. 29, 2011, two weeks after the BRAC’s

deadline.

In late August, Walter Reed Army Medical Center transferred its last inpatients and staff to Bethesda, the

culmination of over two years of planning, preparation and construction. Many of the Army staff members new to

Bethesda Naval were gradually settling into their new environment.

But the final move was anything but uneventful. Just prior to the BRAC’s deadline, an earthquake struck

Washington, the first in more than a century. Later in August, Hurricane Irene slammed into the Mid-Atlantic

region. In the swirling winds and pouring rain that followed, a few soldiers took down the flag at the old Walter

Reed Army Medical Center for the last time.

Opponents of JTF CapMed and its joint hospital vision might have found poetic justice in nature’s attempt to

sabotage Mateczun’s final task. For Mateczun, the transfer marked the triumphant end of a process that had

already survived man-made storms that were far worse. The deadline of September 15, 2011, had been met.

Mateczun had overseen a complex merger that would be a historical first.

To others, Mateczun’s singular focus and his reluctance to bring people along with him had imperiled the

whole project. As Lieutenant General Bruce Green, the Air Force Surgeon General who had once supported JTF

CapMed put it:

I do believe it’s a leader’s job to get people working together toward a common end,

and I can tell you that this would not have succeeded without John…but I think John

made this harder on himself because he made it solely about him and ‘joint’…. By his

force of will, was he able to get this done? Yes. Did he alienate nearly everybody? Yes. Is

that what’s required of a leader? Perhaps, at times. But I don’t think it was necessary

here. I don’t think that it had to be purely by his force of will. I think that he had enough

support to get the mission done when this thing started so that he could have taken

steps that would have made his life a lot easier and would have made it very obvious

what things have to be integrated. I still look at it and cannot tell you how integrated

they truly are. They’re collocated. I don’t know whether they’re integrated.120

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HKS Case Program 26 of 50 Case Number 2035.0

The work of integrating the two culturally disparate workforces still lay ahead. It would require the creation of

a new culture, new rules and new common medical processes. As the colors of the new Walter Reed National

Military Medical Center ascended the pole in front of Bethesda Naval’s famous tower, the task of turning this new

entity into Mateczun’s vision of a joint military center of excellence remained daunting.

Reflections

On his post-retirement trip to Spain, Mateczun at last ascended the hill and approached the Cathedral of

Santiago de Compostela. For the first time in years, he felt he could stretch his legs and really breathe.121 Like the

JTF CapMed fight, the pilgrimage had been punishing. With blistered feet and a sunburned face beneath a fresh

beard, Mateczun approached the doors of the cathedral. He reflected on the past four years. The new Walter Reed

National Military Medical Center was being run as a joint hospital, but the future of JTF CapMed was in question.

He celebrated completion of one of the most complex BRAC projects in the history of the Department of Defense.

He gave thanks for the support he had received inside and outside the Department and for being able to keep

what he saw as the covenant between America and its returning wounded warriors. He wondered what he might

have done differently. He wondered whether he had been successful in leading JTF CapMed and the 13,000 people

under his command because of his leadership attributes or, sometimes, in spite of them. Still, his journey was done.

It would be up to others to carry the banner from here.

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Exhibit 1: Glossary of Case Acronyms ADCON Administrative Control ASD(HA) Assistant Secretary of Defense (Health Affairs) BRAC Base Realignment and Closure CMP Comprehensive Master Plan CNO Chief of Naval Operations CONOPs Concept of Operations DepSecDef Deputy Secretary of Defense DHA Defense Health Agency DHB Defense Health Board DHP Defense Health Program DMOC Defense Medical Oversight Committee DoD Department of Defense EOD Explosive Ordnance Disposal FBCH Fort Belvoir Community Hospital GAO Government Accountability Office GPP Guaranteed Placement Program IDS Integrated Delivery System JCS Joint Chiefs of Staff JMED Joint Medical Network JOA Joint Operating Area JTF CapMed Joint Task Force National Capital Region Medical MHS Military Health System NCR National Capital Region NDAA National Defense Authorization Act NNMC National Navel Medical Center OPCON Operational Control PTSD Post-traumatic Stress Disorder QDR Quadrennial Defense Review SecDef Secretary of Defense TACON Tactical Control UMC Unified Medical Command WRAMC Walter Reed Army Medical Center WRNMMC Walter Reed National Military Medical Center

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Exhibit 2: Cast of Characters Vice Admiral John Mateczun Commander, JTF CapMed, September 2007 to February 2012 A Navy psychiatrist, Mateczun was appointed as the first commander of JTF CapMed, an organization created to guide execution of the congressionally mandated consolidation of military hospitals in the national capital region. Mateczun was selected for the job in part for his familiarity with “joint” military operations and doctrine, an unusual distinction for a military medical officer. Mateczun began his military service as an enlisted Army bomb diffuser in Vietnam. The Honorable Gordon England U.S. Deputy Secretary of Defense, January 2006 to February 2009 A businessman and former Secretary of the Navy under President George W. Bush, England rose to be the DoD’s number two official, a post he held for four years. It was during England’s tenure as DepSecDef that he helped conceive, establish and implement JTF CapMed, a new kind of military medical unit that adopted the structure and philosophy of tactical joint task forces that had been in use among combatant commands since the late 1980s. In creating JTF CapMed, England made the decision of making its commander answer only to his own office. The Honorable William Lynn U.S. Deputy Secretary of Defense, February 2009 to October 2011 Lynn replaced England as DepSecDef when President Barack Obama came into office. Lynn had made a career in Defense policy circles and served under President Clinton as the Pentagon’s Comptroller. Lynn served as DepSecDef at a time of increased focus on the war in Afghanistan and the drawdown in Iraq. Vice Admiral Adam Robinson U.S. Navy Surgeon General, 2007 to 2011 A career colorectal surgeon and the first African-American to become Surgeon General of the Navy, Robinson was opposed to the plan to make Bethesda Naval a joint military hospital. Robinson commanded Bethesda Naval during and after the BRAC announcement and saw it as an embodiment of Navy medicine’s unique culture. He cited the Army’s Walter Reed scandal and the potential or disruption to patient care as his primary reasons for urging caution in the hospital merger. Rear Admiral Matthew Nathan Commander, NNMC–Bethesda, August 2008 to September 2011 A career Navy internist, Nathan commanded Bethesda Naval during the critical years of the BRAC hospital consolidation and over the last three years of Mateczun’s leadership of JTF CapMed. Initially a supporter of plans to integrate Walter Reed with his own hospital, Bethesda Naval, Nathan differed fundamentally from Mateczun on the reasons for which JTF CapMed was created. Nathan viewed JTF CapMed as a temporary entity, not a fully empowered military command. Colonel Charles Callahan served as the Deputy Commander for Clinical Services at Walter Reed Army Medical Center, Commander of DeWitt Army Community Hospital, National Naval Medical Center Chief of Staff, Walter Reed National Military Medical Center Chief of Staff, and Director of Belvoir Hospital. Callahan is the only military officer to serve in five leadership positions within the National Capital Region Medical Directorate. He held key leadership positions at both Walter Reed and National Naval Medical Center, serving as a critical link during the transition to the new Walter Reed National Military Medical Center.

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Exhibit 3: Timeline for the Case September 2005 – Congress authorizes BRAC recommendations, including an $853M cost to consolidate and realign military medical facilities in the National Capital Region. November 2006 – Deputy Secretary of Defense Gordon England approves a “Unified Medical Command Way Ahead” concept. November 2006 – BRAC cost rises by $473M to reflect “refinements and cost adjustments.” February 2007 – Washington Post exposes unfit conditions at Army outpatient housing facility. August 2007 – England signs Guaranteed Placement Program order, retaining 800 personnel. September 2007 – BRAC cost rises by $679M based on a “decision to enhance and accelerate.” September 2007 – England establishes JTF CapMed and RADM John Mateczun takes command. November 2007 – Mateczun publishes Concept of Operations. July 2008 – Crews break ground on WRNMMC construction. October 2008 – Congress authorizes Mateczun’s promotion to three-star admiral. England approves civilian manning model that removes their service identity. November 2008 – BRAC cost rises by $393M, of which $140M was for “additional construction” and $253M was for “outfitting full pricing.” January 2009 – England expresses his preference for National Capital Region hospitals to be joint and then is replaced by William Lynn after Barack Obama becomes President. October 2009 – Lynn reports to Congress that National Capital Region hospitals will be joint. October 2009 – Congress writes “world class military medical facilities” standard into statute. December 2009 – BRAC cost rises by $281M, of which $125M was for “WRNMMC deficiencies, scope changes, and new RQTs [requirements]” and $156 was for “FBCH contract definitization.” April 2010 – Lynn releases Comprehensive Master Plan for meeting the “world-class” standard. July 2010 – Mateczun assumes operational control. August 2010 – Lynn releases $829M estimate for implementing Comprehensive Master Plan. September 2011 – BRAC deadline is reached. March 2012 – Mateczun retires.

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HKS Case Program 30 of 50 Case Number 2035.0

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HKS Case Program 31 of 50 Case Number 2035.0

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HKS Case Program 32 of 50 Case Number 2035.0

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HKS Case Program 33 of 50 Case Number 2035.0

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Exhibit 13: Summary of Base Realignment and Closure What is BRAC? ‘BRAC’ stands for Base Realignment and Closure, a process by which a Commission reviews the

military’s domestic infrastructure and elected officials make changes to it. Congress defined current BRAC process

in Public Law 101-510, the “Defense Base Closure and Realignment Act of 1990.”

Why was BRAC created? Major economic boons can be tied to the location, size, and structure of military bases.

This makes infrastructure decisions very politically charged and, since 1977, Congress has denied the Pentagon a

free hand in realigning or closing larger bases.122 Yet the same concerns also make it very difficult for Congress to

act. Members resist change in their districts and spare others’ districts from one-off changes, which unduly irritate

political relationships. BRAC is a response to inaction.123

When are Commissions convened? BRAC occurs only when Congress specifically authorizes it, often at the request

of an administration. BRAC does not recur on a fixed schedule.

How does BRAC work? BRAC is a uniquely rigid process. The Pentagon first reviews its plans on the military’s size,

equipment, and organization (§2903a) and drafts recommendations.124 Commission members are appointed by

the White House after consultation with Congress’ leaders and subject to the Senate’s consent. These members

exhaustively and publicly review the draft options before revising and finalizing their recommendations (§2903d).

The President can choose to reject their package and end the process or to forward it to Congress, but without any

modification (§2903e). If the President does the latter, the package is authorized automatically unless Congress

acts quickly to disapprove it (§2904b). Disapproval legislation cannot be amended, postponed, or debated longer

than two hours (§2908d). By its own design, Congress acts on a wide suite of choices once, immediately, and

decisively.

What does BRAC accomplish? Tying all the BRAC options together in an up-or-down vote concentrates the public

interest in management efficiency and creates an incentive for Congress to act. Members whose districts may

suffer can save face by protesting publicly, but they cannot sink the process.125

Was the Walter Reed decision unique? Decisions to realign or close bases are so contested that Congress had to

build a unique process for handling them. Closing the Army’s Walter Reed facility was necessarily tense. Yet

Congress also introduced a new concept for the 2005 BRAC, directing the Pentagon to consider “any efficiencies

that may be gained from joint tenancy by more than one branch of the Armed Forces.”126 Not only was this

efficiency metric new to BRAC, it introduced a new model of military basing.

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Exhibit 14: BRAC Commission Findings and Recommendations (Abridged) Walter Reed National Military Medical Center, Bethesda, MD Recommendation # 169 (MED 4) One-Time Cost: $988.8M Annual Recurring Costs/(Savings): ($145.3M) 20-Year Net Present Value: ($830.6M) Payback Period: 6 YEARS COMMUNITY CONCERNS

The Washington, DC community argued that moving Walter Reed Army Medical Center to the National Naval

Medical Center in Bethesda, MD would disrupt the mission of the premier military medical facility, and have a

negative effect on the economy of the District of Columbia and homeland security in the nation’s capital. Concerns

were also expressed about whether there would be sufficient housing for family members visiting [patients]. They

claimed the DoD substantially deviated from the BRAC criteria by incorrectly calculating Walter Reed’s military

value, underestimating the costs for closure and realignment, and ignoring environmental cleanup costs. They

suggested Walter Reed remain open, and the mission of the National Naval Medical Center be aligned with Walter

Reed to ensure there are no disruptions during a time of war.

COMMISSION FINDINGS

The Commission acknowledged Walter Reed Army Medical Center’s rich heritage and earned reputation as a

world-class medical center. However, the Commission found that service members deserve a state-of-the-art 21st

century medical center and that the Secretary’s proposal would increase military value. The Commission

considered the community’s concerns that realigning medical services will disrupt Walter Reed’s mission, but the

Commission found that the Walter Reed legacy will be preserved in the plan for the new facility and that service

members would continue to receive needed medical services during the implementation period. The Commission

concurred with the Department’s objective to transform medical infrastructure within the National Capital Region.

However, the Commission agrees with the communities’ concern about whether sufficient housing will be

available for family members at the Bethesda Campus and urges the DoD to address this.

COMMISSION RECOMMENDATIONS

The Commission found that the Secretary of Defense deviated substantially from final selection criteria 1, as well

as from the Force Structure Plan. Therefore, the Commission recommends the following: Realign Walter Reed

Army Medical Center, Washington, DC, as follows: relocate all tertiary (sub-specialty and complex care) medical

services to National Naval Medical Center, Bethesda, MD, establishing it as the Walter Reed National Military

Medical Center Bethesda, MD; … relocate all non-tertiary (primary and specialty) patient care functions to a new

community hospital at Fort Belvoir.†

† Department of Defense Base Closure and Realignment Report, May 2005, http://www.defense.gov/brac/.

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HKS Case Program 37 of 50 Case Number 2035.0

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Exhibit 16

Source: Deputy Secretary of Defense Memorandum, http://www.defense.gov/pubs/.

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Exhibit 17: Concept of Operations (ABRIDGED)* Published by RADM (Upper Half) John Mateczun on 20 November 2007 Mission: Deliver integrated healthcare in the [national capital region joint operational area], ensure readiness and

disaster preparedness of the assigned forces, and execute the BRAC business plans to achieve a world-class

medical center at the hub of the Nation's premier regional healthcare system.

Command and Control:

(1) JTF CAPMED is a fully functional standing Joint Task Force reporting directly to the Secretary of Defense through

the Deputy Secretary of Defense.

(2) [The Commander] directly supervises the JTF Component Commanders within the JOA.

(3) [The Commander] has Tactical Control of the military medical units assigned or attached to the JTF.

(4) The Services retain operational and administrative control of the personnel assigned to JTF CAPMED.

Threat: The threat is a composite of ongoing or potential adversarial actions, conditions or attitudes that can reduce the effectiveness of this [Concept of Operations].

(1) Time. We must not squander this narrow window of opportunity that has been entrusted to us to provide a

model world-class healthcare system for our beneficiaries and demonstrate the effectiveness of a JTF to direct

regional healthcare.

(2) Stove Pipe Operations. The future of the Military Health System lies in interoperability and cooperation...Each

Service brings unique and critical capabilities, but they can only be as effective as the contribution they make to

the overall mission. As members of the JTF CAPMED Team, we require an alignment of resources and processes to

support the mission, vision and priorities; and an unprecedented level of teamwork aimed at giving our best for

something larger than ourselves, putting aside personal ambition, ego and pride and embracing a joint view.

(3) Reluctance to Change. We must be willing to reinvent our way of doing business and center our thinking on

interoperability, joint operations, and teamwork.

(4) Environment. We must be prepared to respond to, reduce vulnerability to, and recover from [natural, man-

made, or technological] emergencies or disasters...

(5) Constrained Resources. We have an obligation to our beneficiaries and the American people to appropriately

prioritize and optimally utilize our resources.

Timeline of JTF CAPMED milestones:

(1) [The Commander] will publish an [execution order] that details the CONOPS Way Ahead [no later than] 30

working days from publication of this [Concept of Operations].

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HKS Case Program 40 of 50 Case Number 2035.0

(2) JTF-CAPMED Headquarters Full Operational Capability [no later than] 30 SEP 08.

(3) By 2011, in accordance with current BRAC law, the regional healthcare system will be supported by two new

healthcare facilities [WRNMMC and FBCH].

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Exhibit 19: Roster of the Defense Health Board Independent Advisory Committee From Appendix E of “Achieving World Class: An Independent Review of the Design Plans for the Walter Reed National Military Medical Center and the Fort Belvoir Community Hospital,” as of May 2009.

Kenneth W. Kizer, M.D., M.P.H., Chair

Dr. Kizer is Director of the University of California at Davis Health System’s Institute for Population Health

Improvement. He has served as President, CEO and Chairman of Medsphere Systems Corporation; founding

president and CEO of the National Quality Forum; Under Secretary for Health in the Department of Veterans

Affairs; Director of the California Department of Health Services; and Director of the California Emergency Medical

Services Authority. He has held senior academic positions at the University of California Davis and the University of

Southern California. Dr. Kizer is board certified in six medical specialties and/or subspecialties, and he has received

numerous awards, including from the Association of Military Surgeons, the Department of Veterans Affairs, and

the Navy League of the United States.

Col (Ret) Richard J. Andrassy, M.D.

Dr. Andrassy serves as the Surgeon-in-Chief at Memorial-Hermann Hospital, Chairman of the Board for University

of Texas Physicians, Professor of Surgery and Pediatrics in the UT MD Anderson Cancer Center, and Professor of

Surgery at Uniformed Services at The University of the Health Sciences in Maryland. He completed his internship

and residency in Surgery and served as Chief Resident in Surgery at Wilford Hall USAF Medical Center in Texas, and

he retired from the Air Force as a Colonel.

Lt Gen (Ret) Paul K. Carlton, Jr., M.D.

Dr. Carlton serves as the Director of the Office of Homeland Security for the Texas A&M University System Health

Science Center and is a former Chief Medical Officer of the United States Air Force. His is a Clinical Professor of

Surgery at both the University of Texas Health Science Center and the Uniformed Services Division of the

University of Health Sciences. Among other honors, he has been awarded the Surgeon General’s Award from the

Air Force Society of Clinical Surgeons, Airman’s Medal (for lifesaving initiatives following the Pentagon attack on

9/11), and Distinguished Community Service Award (for actions taken during Hurricane Rita). Dr. Carlton is a

Founding Member of the American Board of Physicians Specialties in Disaster Medicine.

Mr. Raymond F. DuBois

Mr. DuBois is currently a Senior Adviser for the Center for Strategic and International Studies. His focus in this

position is on international security policy, defense management reform and initiatives emanating from the 2006

Quadrennial Defense Review. Mr. DuBois has served as Acting Under Secretary of the Army, Director of

Administration and Management of the Office of the Secretary of Defense, Director of Washington Headquarters

Services, Deputy Under Secretary of Defense for Installations and Environment, and Special Assistant to the

Secretary and Deputy Secretary of Defense. In addition, Dr. DuBois was also the President and CEO of Potomac

Strategies International LLC and a Marketing Executive at Digital Equipment Corporation.

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HKS Case Program 42 of 50 Case Number 2035.0

Ms. Cheryl L. Herbert, B.S.N., M.B.A.

Ms. Herbert is the President of the Dublin Methodist Hospital, a part of the OhioHealth Corporation. Her

responsibilities include overseeing the overall operation of Dublin Methodist Hospital’s, managing 400 full-time

equivalent employees and a budget of $191 million. As President, Ms. Herbert has led planning, design,

construction, medical staff development, recruitment and hiring of associates, as well as the opening of a unique

94-bed community hospital. Ms. Herbert’s previous positions include the President and Chief Executive Officer

(CEO) of the Morrow County Hospital; Vice President of the Marion General Hospital; President of the MedCenter

Hospital, Marion, Ohio; as well as the Vice President of Patient Care Services at the MedCenter Hospital, Marion,

Ohio.

BG (Ret) James J. James, M.D., Dr.P.H., M.H.A.

Dr. James serves as the American Medical Association’s Director of the Center for Public Health Preparedness and

Disaster as well as Editor-in-Chief, AMA Journal of Disaster Medicine and Public Health Preparedness. He fulfilled

his internship at Los Angeles County, performed two years of General Surgery training at Dartmouth Affiliated

Hospital, and completed a residency in General Preventive Medicine. Dr. James awards include the Governor’s

Sterling Award for Performance Excellence awarded to the Miami-Dade County Health Department and UCLA

Alumni Award for Academic Distinction. He is a Fellow of the American College of Preventive Medicine, the

American College of Physician Executives, and the American College of Physicians. Dr. James is a retired Army

Brigadier General.

Dennis S. O'Leary, M.D.

Dr. O’Leary is President Emeritus of the Joint Commission. Under his leadership, the Joint Commission successfully

transformed its accreditation process to focus on actual organization performance in the provision of patient care.

This transformation set the stage for the progressive introduction of care-related outcomes and process measures,

as well as national patient safety goals, into the accreditation process. Most recently, he spearheaded the

launching of a series of Joint Commission public policy initiatives. Dr. O’Leary is board certified in Internal Medicine

and Hematology and has served as President and Chairman of the Board of the District of Columbia Medical

Society as well as a founding member of the NCA Health Care Coalition.

Mr. Phillip E. Tobey

Mr. Tobey is currently Senior Vice President and National Healthcare Leader of SmithGroup. Prior to entering

private practice, he served as an officer with the U.S. Air Force’s Office of the Surgeon General and held review

responsibility for medical projects worldwide. A registered architect and interior designer, Mr. Tobey is a Fellow of

the American Institute of Architects (AIA) and Fellow and Founding Member of the American College of Healthcare

Architects. He is a board member of the AIA Academy on Architecture for Health and an advisor to the National

Institutes of Health as well as to Health Systems 2020, a consortium studying the future of health care.

Note: All biographical sketches are current as of May 2009, the time of this report’s publication.

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HKS Case Program 44 of 50 Case Number 2035.0

Endnotes

1 Elizabeth, Holmes, Captain (Ret.), U.S. Navy, Personal interview, The U.S. Naval Academy, Annapolis, Maryland, October 22, 2012. (Audio recording.) 2 “Navy Vice Admiral John Mateczun Concludes Service Career, Relinquishes Command of Joint Task Force National Capital Region Medical,” Defense Health Agency National Capital Region Medical Directorate website, March 30, 2012, available from: http://www.capmed.mil/SitePages/Article.aspx?NewsID=19. 3 “Careers and Jobs: Explosive Ordnance Disposal Technician (EOD) Specialist (89D),” GoArmy.com, available from: http://www.goarmy.com/careers-and-jobs/browse-career-and-job-categories/intelligence-and-combat-support/explosive- ordnance-disposal-specialist.html. 4 “United States Navy Biography. Vice Admiral John M. Mateczun, Commander, Joint Task Force National Capital Region Medical,” Navy.mil, available from: http://www.navy.mil/navydata/bios/navybio.asp?bioID=198. 5 Samantha L. Quigley, “Transformation Office to Streamline Military Healthcare,” American Forces Press Service, September 16, 2005, available from: http://www.defense.gov/News/NewsArticle.aspx?ID=17281. 6 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 7 “Biography of Major General (Dr.) Nadja Y. West, Joint Staff Surgeon,” Joint Chiefs of Staff website, available from: http://www.jcs.mil/biography.aspx?ID=198. 8 Richard A. Best, “Military Medical Care Services: Questions and Answers,” Congressional Research Service, 03 January 2001, p. 3, available from: http://www.policyarchive.org/handle/10207/bitstreams/848.pdf. See also Richard Davis, “Defense Health Program: Future Costs are Likely to be Greater than Estimated,” GAO, February 1997, p. 2, available from: http://www.gpo.gov/fdsys/pkg/GAOREPORTS-NSIAD-97-83BR/pdf/GAOREPORTS-NSIAD-97-83BR.pdf. 9 Congressional Budget Office, Health-Related Options for Reducing the Deficit: 2014-2023, December 2013, available from: http://www.cbo.gov/sites/default/files/cbofiles/attachments/44906-HealthOptions.pdf. 10 “VA and DOD Health Care: Department-Level Actions Needed to Assess Collaboration Performance, Address Barriers, and Identify Opportunities,” Government Accountability Office, September 2012, p. 1, available from: http://www.gao.gov/assets/650/648961.pdf. 11 “Fiscal Year 2009 Budget Estimates: Personnel Summary (PB11A),” Defense Health Program, February 2008, available from http://comptroller.defense.gov/defbudget/fy2009/budget_justification/pdfs/09_Defense_Health_Program/VOL_1/Vol_1_Sec_ 6_-_B_PB-11A_PERSONNEL_09PB_DHP.pdf. “Fiscal Year 2009 Budget Estimates: Medical Workload and Productivity Data (PB11B),” Defense Health Program, February 2008, available from http://comptroller.defense.gov/defbudget/fy2009/budget_justification/pdfs/09_Defense_Health_Program/VOL_1/Vol_1_Sec_ 6_-_C_PB-11B_MEDICAL_WORKLOAD_09PB_DHP.pdf. 12 Congressional Budget Office, “Long-Term Implications of the FY2013 Future Years Defense Program,” July 2012, Figure 2-2. Department of Defense, “National Defense Budget Estimates for FY2013,” March 2012, Table 2-1. Office of Management and Budget, “Historical Table 10-1: Gross Domestic Product and Deflators Used in the Historical Tables,” February 2012. 13 Tamara Keith, “Health Care Costs New Threat To U.S. Military,” Morning Edition, NPR, June 7, 2011, available from: http://www.npr.org/2011/06/07/137009416/u-s-military-has-new-threat-health-care-costs. 14 Fred W. Baker, “New Amputee Care Center Opens at Walter Reed,” American Forces Press Service, September 13, 2007, available from: http://www.defense.gov/News/NewsArticle.aspx?ID=47432. 15 Charles T. Callahan, Colonel, U.S. Army, Commander, Fort Belvoir Community Hospital, Telephone interview, September 3, 2013. (Written notes.).

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HKS Case Program 45 of 50 Case Number 2035.0

16 John Gaal, Colonel, U.S. Army, Personal interview, Walter Reed National Military Medical Center, Bethesda, Maryland, December 4, 2012. (Audio recording.) 17 Focus group, Conducted by the case-writers, Walter Reed National Military Medical Center, Bethesda, Maryland, October 18, 2012. (Written notes.) 18 Philip Perdue, Captain, U.S. Navy, Personal interview, Walter Reed National Military Medical Center, Bethesda, Maryland, December 4, 2012. (Written notes.) 19 Matthew L. Nathan, Vice Admiral, U.S. Navy, Personal interview, U.S. Navy Bureau of Medicine and Surgery, Falls Church, Virginia, December 3, 2012. (Audio recording.) 20 Anne Hull and Dana Priest, “Soldiers Face Neglect, Frustration At Army’s Top Medical Facility,” The Washington Post, February 18, 2007, available from: http://www.washingtonpost.com/wp- dyn/content/article/2007/02/17/AR2007021701172.html. 21 Matthew L. Nathan, Vice Admiral, U.S. Navy, Personal interview, U.S. Navy Bureau of Medicine and Surgery, Falls Church, Virginia, December 3, 2012. (Audio recording.) 22 Focus group, Conducted by the case-writers, Walter Reed National Military Medical Center, Bethesda, Maryland, October 18, 2012. (Written notes.) 23 “Total COBRA Military Construction Assets Report (COBRA v6.10),” p. 3, May 6, 2005, Supplied by Mr. David Oliveria, Assistant Deputy Chief for Installations and Logistics, Bureau of Medicine and Surgery, U.S. Navy, on August 14, 2013. 24 Ibid. 25 Briefing to the Joint Chiefs of Staff, January 15, 2010, Supplied by Mr. Bill Bradley, Director, Executive Support Services, Joint Task Force National Capital Region Medical, on August 13, 2013. 26 Philip Perdue , Captain, U.S. Navy, Personal interview, Walter Reed National Military Medical Center, Bethesda, Maryland, December 4, 2012. (Written notes.) 27 Adam M. Robinson, Jr., Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., October 18, 2012, (Written notes.) 28 Louis A. Damiano, Captain (Ret.), U.S. Navy, Personal interview, Walter Reed National Military Medical Center, Bethesda, Maryland, November 15, 2012. (Audio recording.) 29 Focus group, Conducted by the case-writers, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, March 30, 2013. (Written notes.) 30 Bernard S. Little, “Weightman takes NARMC, WRAMC helm,” dcmilitary.com, August 31, 2006, available from: http://ww2.dcmilitary.com/stories/083106/stripe_20060831001.shtml. 31 Focus group, Conducted by the case-writers, Walter Reed National Military Medical Center, Bethesda, Maryland, October 18, 2012. (Written notes.) 32 Focus group, Conducted by the case-writers, Walter Reed National Military Medical Center, Bethesda, Maryland, October 18, 2012. (Written notes.) 33 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., May 15, 2013 (Video recording.)

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HKS Case Program 46 of 50 Case Number 2035.0

34 Matthew L. Nathan, Vice Admiral, U.S. Navy, Personal interview, U.S. Navy Bureau of Medicine and Surgery, Falls Church, Virginia, December 3, 2012. (Audio recording.) 35 Gordon R. England, Deputy Secretary of Defense (Ret.), Personal interview, Cosmos Club, Washington, D.C., December 16, 2012. (Written notes.) 36 Gregory J. Jolissaint, Colonel (Ret.), U.S. Army, Personal Interview, Hilton, Rockville, Maryland, September 5, 2012. (Audio recording.) 37 Gordon R. England, Deputy Secretary of Defense (Ret.), Personal interview, Cosmos Club, Washington, D.C., December 16, 2012. (Written notes.) 38 Defense Business Board, Report FY06-5. “Military Health System – Governance, Alignment and Configuration of Business Activities Task Group Report,” p. 3, Washington, D.C.: Defense Business Board, September 2006. 39 United States General Accounting Office, Defense Health Care: Issues and Challenges Confronting Military Medicine, March 22, 1995, available from: http://www.gao.gov/assets/230/220993.pdf. 40 Anne Hall and Dana Priest, “Soldiers Face Neglect, Frustration At Army’s Top Medical Facility,” The Washington Post, February 18, 2007, available from: http://www.washingtonpost.com/wp- dyn/content/article/2007/02/17/AR2007021701172.html. The two journalists won a Pulitzer Prize for their reporting. 41 Ibid. 42Tony Capaccio and Ken Fireman, “Army Medical Chief Forced Out in Walter Reed Scandal,” Bloomberg News, March 12, 2007, available from: http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aPlDAEVzpJm0&refer=home. 43 Adam M. Robinson Jr., Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., October 18, 2012. (Written notes.) 44 Ibid. 45 Focus group, Conducted by the case-writers, Walter Reed National Military Medical Center, Bethesda, Maryland, October 18, 2012. (Written notes.) 46 Adam M. Robinson Jr., Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., October 18, 2012. (Written notes.) 47 Gordon R. England, Deputy Secretary of Defense (Ret.), Personal interview, Cosmos Club, Washington, D.C., December 16, 2012. (Written notes.) 48 Ibid. 49 Focus group, Conducted by the case-writers, Walter Reed National Military Medical Center, Bethesda, Maryland, October 18, 2012. (Written notes.) 50 Mark Bowden, “The Desert One Debacle,” The Atlantic, May 1, 2006, available from: http://www.theatlantic.com/magazine/archive/2006/05/the-desert-one-debacle/304803/2/. 51 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 52 Charles W. Callahan, Colonel, U.S. Army, Personal interview, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, September 4, 2012. (Audio recording.)

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HKS Case Program 47 of 50 Case Number 2035.0

53 “African Americans in the United States Navy,” Navy History and Heritage Command, 2011, Slide 19, available from: http://www.history.navy.mil/Special%20Highlights/AfricanAmerican/afa2011ppt2.pdf. 54 Gordon R. England, Deputy Secretary of Defense (Ret.), Personal interview, Cosmos Club, Washington, D.C., December 16, 2012. (Written notes.) 55 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., May 15, 2013. (Video recording.) 56 “Joint Publication 5-0: Joint Operation Planning,” page IV-44, available from: http://www.dtic.mil/doctrine/new_pubs/jp5_0.pdf. 57 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 58 Focus group, Conducted by the case-writers, Walter Reed National Military Medical Center, Bethesda, Maryland, October 18, 2012. (Written notes.) 59 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 60 Ibid. 61 Ibid. 62 “2005 Defense Base Closure and Realignment Report,” Base Realignment and Closure Commission, September 8, 2005, p. 258, available from: https://mail- attachment.googleusercontent.com/attachment/u/0/?ui=2&ik=ec81557d14&view=att&th=14280d9dc45a941b&attid=0.1&dis p=inline&safe=1&zw&saduie=AG9B_P-0my9_5ljV6ZWz5RvbKsM8&sadet=1385143846679&sads=w-CySusYwwlJQ-VmF61Ajrw- xp8. 63 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 64 Ibid. 65 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., May 15, 2013. (Video recording.) 66 Gordon R. England, Deputy Secretary of Defense (Ret.), Memo: “Implementation of the President’s Commission on Care for America’s Returning Wounded Warriors (The Dole/Shalala Report),” The Pentagon, Washington, D.C., August 29, 2007. 67 Gregory J. Jolissaint, Colonel (Ret.), U.S. Army, Personal Interview, Hilton, Rockville, Maryland, September 5, 2012. (Audio recording.) 68 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 69 Ibid. 70 Gordon R. England, Deputy Secretary of Defense (Ret.), Personal interview, Cosmos Club, Washington, D.C., December 16, 2012. (Written notes.) 71 Defense Business Board, Report FY06-5, “Military Health System – Governance, Alignment and Configuration of Business Activities Task Group Report,” p. 3, Washington, D.C.: Defense Business Board, September 2006.

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72 Charles T. Callahan, Colonel, U.S. Army, Commander, Fort Belvoir Community Hospital, Telephone interview, September 4, 2012. (Audio recording.) 73 Carla G. Hawley-Bowland, Major General (Ret.), U.S. Army, Telephone interview, September 20, 2012. (Audio recording.) 74 Adam M. Robinson Jr., Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., October 18, 2012. (Written notes.) 75 Ibid. 76 James E. Cartwright, “Hoss,” General (Ret.), U.S. Marine Corps, Memo: “Joint Task Force National Capital Region Medical (JTF CapMed) Military Staffing Option for WRNMMC and FBCH,” The Pentagon, Washington, D.C., October 8, 2008. 77 Ibid. 78 Ibid. 79 Gordon R. England, Deputy Secretary of Defense (Ret.), Memo: “Civilian and Military Personnel Management Structures for the Joint Task Force National Capital Region – Medical (JTF-CapMed),” The Pentagon, Washington, D.C., January 15, 2009. 80 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 81 Matthew L. Nathan, Vice Admiral, U.S. Navy, Personal interview, U.S. Navy Bureau of Medicine and Surgery, Falls Church, Virginia, December 3, 2012. (Audio recording.) 82 Ibid. 83 Gordon R. England, Deputy Secretary of Defense (Ret.), Personal interview, Cosmos Club, Washington, D.C., December 16, 2012. (Written notes.) 84 Matthew L. Nathan, Vice Admiral, U.S. Navy, Personal interview, U.S. Navy Bureau of Medicine and Surgery, Falls Church, Virginia, December 3, 2012. (Audio recording.) 85 Ibid. 86 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Email response to case writers, December 6, 2013. 87 Matthew L. Nathan, Vice Admiral, U.S. Navy, Personal interview, U.S. Navy Bureau of Medicine and Surgery, Falls Church, Virginia, December 3, 2012. (Audio recording.) 88 “Duncan Hunter National Defense Authorization Act of Fiscal Year 2009,” October 14th, 2008, §2721, available from: http://www.gpo.gov/fdsys/pkg/BILLS-110s3001enr/pdf/BILLS-110s3001enr.pdf. 89 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Email response to case writers, December 6, 2013. 90 National Defense Authorization Act for Fiscal Year 2010, Pub. L. No. 111-84, § 2714, 123 Stat. 2656 (2008), available from: http://www.intelligence.senate.gov/pdfs/military_act_2009.pdf. 91 U.S. Congress, House of Representatives, Committee on Armed Services, 2009, The New Walter Reed: Are We On the Right Track? 111th Congress, 1st session 2 December, pp. 1-2, available from: http://www.gpo.gov/fdsys/pkg/CHRG- 111hhrg55173/pdf/CHRG-111hhrg55173.pdf. 92 Ibid., p. 3.

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HKS Case Program 49 of 50 Case Number 2035.0

93 U.S. Congress. House of Representatives, Committee on Armed Services, 2010, The 2010 Quadrennial Defense Review, 111th Congress, 2nd session, February 4, pp. 31-32, available from: http://www.gpo.gov/fdsys/pkg/CHRG-111hhrg57833/pdf/CHRG- 111hhrg57833.pdf. 94 “Comprehensive Master Plan for the National Capital Region Medical,” Joint Task Force National Capital Region Medical, HQ, Joint Task Force National Capital Region Medical, Bethesda, Maryland, April 2010, available from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CDMQFjAA&url=http%3A%2F%2Fwww.capme d.mil%2FAbout%2FReports%2520to%2520Congress%2FDoD%2520Comprehensive%2520Master%2520Plan%2520Provided%25 20to%2520Congress.pdf&ei=lf9aUbKoE4u80AHSiYHQCA&usg=AFQjCNEW6XpmteGjpOMpzLFJQnqsnl9OCg&sig2=IkppaPB5x4rIK oKGPIJXlw&bvm=bv.44697112,d.dmQ&cad=rja. 95 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 96 Adam M. Robinson Jr., Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., October 18, 2012. (Written notes.) 97 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 98 David Oliveria, Assistant Deputy Chief for Installations and Logistics, Bureau of Medicine and Surgery, U.S. Navy, Phone interview, August 14, 2013. (Written notes.) 99 Charles B. Green, Lieutenant General (Ret.) U.S. Air Force, Personal interview, Arlington, Virginia, November 14, 2012. (Audio Recording.) 100 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 101 Carla G. Hawley-Bowland, Major General (Ret.), U.S. Army, Telephone interview, September 20, 2012. (Audio recording.) 102 Charles B. Green, Lieutenant General (Ret.) U.S. Air Force, Personal interview, Arlington, Virginia, November 14, 2012. (Audio Recording.) 103 Ibid. 104 Elizabeth Holmes, Captain (Ret.), U.S. Navy, Personal interview, The U.S. Naval Academy, Annapolis, Maryland, October 22, 2012. (Audio recording.) 105 Charles B. Green, Lieutenant General (Ret.) U.S. Air Force, Personal interview, Arlington, Virginia, November 14, 2012. (Audio Recording.) 106 Clifford L. Stanley, Under Secretary of Defense for Personnel and Readiness (Ret.), Memo: “Improving OUSD (P&R) Business Operations,” The Pentagon, Washington, D.C., October 22, 2010. 107 Ray Mabus, Secretary of the Navy; James F. Amos, General (Ret.) U.S. Marine Corps; and Gary Roughead, Admiral (Ret.) U.S. Navy, Memo: “Response to SECDEF Efficiencies Questions at the 20 October Small Group Meeting,” The Pentagon, Washington, D.C., November 2, 2010. 108 Joint Task Force National Capital Region Medical, Memo: “Information Paper: Chronology of Events Shaping JTF CapMEd and the NCR Medical,” p.3, March 30, 2012. 109 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Memo: “Improving OUSD(P&R) Business Operations,” HQ, Joint Task Force National Capital Region Medical, Bethesda, Maryland, November 23, 2010.

For the exclusive use of T. Adelmund, 2016.

This document is authorized for use only by Torben Adelmund in Change Leadership Methods and Models taught by Ken Rossi, Hawaii Pacific University from January 2016 to July 2016.

HKS Case Program 50 of 50 Case Number 2035.0

110 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 111 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Sofitel, Washington, D.C., August 30, 2012. (Audio recording.) 112 Adam M. Robinson Jr., Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., October 18, 2012. (Written notes.) 113 Ibid. 114 Ibid. 115 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Cosmos Club, Washington, D.C., September 18, 2012. (Audio recording.) 116 Ibid. 117 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Email response to case writers, December 6, 2013. 118 William P. Bradley, Captain (Ret.) U.S. Navy, Personal Interview, Walter Reed National Military Medical Center, Bethesda, Maryland, August 29, 2012. (Written notes.) 119 William J. Lynn, III, Deputy Secretary of Defense (Ret.), Memo: “Review of Governance Model Options for the Military Health System,” The Pentagon, Washington, D.C., June 14, 2011. 120 Charles B. Green, Lieutenant General (Ret.) U.S. Air Force, Personal interview, Arlington, Virginia, November 14, 2012. (Audio Recording.) 121 John M. Mateczun, Vice Admiral (Ret.), U.S. Navy, Personal interview, Sofitel, Washington, D.C., August 30, 2012. (Audio recording.) 122 10 USC 2687: http://www.gpo.gov/fdsys/pkg/USCODE-2011-title10/html/USCODE-2011-title10-subtitleA-partIV-chap159- sec2687.htm. 123 David Lockwood and George Siehl, “Military Base Closures: A Historical Review from 1988 to 1995,” Congressional Research Service, October 18 2004, pp. 1-3, available from: http://www.fas.org/sgp/crs/natsec/97-305.pdf. 124 “National Defense Authorization Act for Fiscal Year 1991, Title XXIX: Defense Base Closures and Realignments [‘The Defense Base Closure and Realignment Act of 1990’],” Version as amended through FY 05 available from: http://www.brac.gov/docs/BRAC05Legislation.pdf. 125 Lockwood and Siehl, p. 3. 126 “National Defense Authorization Act for Fiscal Year 2002, Title XXX.” See §2912(a)(3) of version as amended through FY05.

For the exclusive use of T. Adelmund, 2016.

This document is authorized for use only by Torben Adelmund in Change Leadership Methods and Models taught by Ken Rossi, Hawaii Pacific University from January 2016 to July 2016.

__MACOSX/WB 2/readings/._Walter Reed A.pdf