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US Army Health Facilities Assessments Colonel Guy Kiyokawa Asst. Chief of Staff, Facilities / Director, Facilities HQ, US Army Medical Command / Office of the Surgeon General UNCLASSIFIED December 2010

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Page 1: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

US Army Health Facilities

Assessments

Colonel Guy Kiyokawa

Asst. Chief of Staff, Facilities / Director, Facilities

HQ, US Army Medical Command / Office of the Surgeon General

UNCLASSIFIED

December 2010

Page 2: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected] 2

PRESENTATION OUTLINE

PURPOSE: To provide an overview of US Army health facility assessment

processes and application to military assistance in foreign countries.

• US Army Medical Command (MEDCOM)

• Facility Life Cycle Management

• Deployable Health Facilities Expertise

• Decision Making Process

• Developing Facility Solutions Supporting a Health Care System

• Case Studies

• Ivory Coast

• US Army Kwajalein Atoll, Republic of the Marshall Islands

Page 3: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected] 3 of 36

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Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected] 4

Planning

Owner’s Rep for DesignOwner’s Rep for

Construction

Sustainment

Programming

Medical Facilities Life Cycle Management

Commissioning

31 years

Page 5: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

SMRC- HS

Mission

Provide deployable health

facilities expertise worldwide to

support the AMEDD’s healthcare

mission

• Assessments and assistance

– Engineering, architectural, equipment &

healthcare infrastructure consulting

– Design, construction, & management

oversight

– Infrastructure development in maturing

theatre

– Support to reestablish civilian medical

infrastructure

– Liaison with engineer units and staffs

• Multi-disciplinary solutions/teams

– Architects

– Engineers

– Nurses

– Biomedical Equipment Specialist

– Environmental Science Officers

– Facility Managers

– Logisticians

Readiness:

First Team: configured to support

and ready to deploy (C-1).

Second Team: Sourcing (personnel)

required from MSCs/RMCs (C-3).

Special Medical Response Contingent - Health Systems

Slide 5

Page 6: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Nation Building

Disaster Relief

Humanitarian Assistance

Peacekeeping/Mil Spt.

Peace Enforcement

Low Intensity Conflict

War

US Army Health Facility Planning Agency

Operational Support to Army / DoD Missions

GeorgiaGeorgia19921992

CroatiaCroatia19941994Virgin IslandsVirgin Islands19951995

FloridaFlorida19941994

HaitiHaiti19941994

KuwaitKuwait 19951995

19951995

EritreaEritrea 19961996

KazakhstanKazakhstan 19951995

EgyptEgypt 19971997

CambodiaCambodia19971997

HondurasHonduras19981998

El SalvadorEl Salvador19981998

NicaraguaNicaragua19981998

ParaguayParaguay19981998

BosniaBosnia19981998

LebanonLebanon19981998

Guinea-BissauGuinea-Bissau19981998

Ivory CoastIvory Coast19981998

RussiaRussia19991999

QatarQatar 19991999

MacedoniaMacedonia1999199920002000

KosovoKosovo199919992000200020012001

KenyaKenya 20002000

20012001

NepalNepal20012001

JapanJapan20002000

TrinidadTrinidad20002000

KwajaleinKwajalein20002000

Dover AFBDover AFB20012001

20002000

North CarolinaNorth Carolina19961996

19921992

20022002

UzbekistanUzbekistan 20022002

War

Nation Building

Peace Enforcement

Peacekeeping

Humanitarian Assistance

Disaster Relief

Low Intensity Conflict

IraqIraq 20032003

AfghanistanAfghanistan 20032003

20042004

20042004

20042004

20042004

20042004

20042004 2005200520032003 20062006

20052005 20062006

20052005 20062006

GeorgiaGeorgia19921992

CroatiaCroatia19941994Virgin IslandsVirgin Islands19951995

FloridaFlorida19941994

HaitiHaiti19941994

KuwaitKuwait 19951995

19951995

EritreaEritrea 19961996

KazakhstanKazakhstan 19951995

EgyptEgypt 19971997

CambodiaCambodia19971997

HondurasHonduras19981998

El SalvadorEl Salvador19981998

NicaraguaNicaragua19981998

ParaguayParaguay19981998

BosniaBosnia19981998

LebanonLebanon19981998

Guinea-BissauGuinea-Bissau19981998

Ivory CoastIvory Coast19981998

RussiaRussia19991999

QatarQatar 19991999

MacedoniaMacedonia1999199920002000

KosovoKosovo199919992000200020012001

KenyaKenya 20002000

20012001

NepalNepal20012001

JapanJapan20002000

TrinidadTrinidad20002000

KwajaleinKwajalein20002000

Dover AFBDover AFB20012001

20002000

North CarolinaNorth Carolina19961996

19921992

20022002

UzbekistanUzbekistan 20022002

War

Nation Building

Peace Enforcement

Peacekeeping

Humanitarian Assistance

Disaster Relief

Low Intensity Conflict

War

Nation Building

Peace Enforcement

Peacekeeping

Humanitarian Assistance

Disaster Relief

Low Intensity Conflict

IraqIraq 20032003

AfghanistanAfghanistan 20032003

20042004

20042004

20042004

20042004

20042004

20042004 2005200520032003 20062006

20052005 20062006

20052005 20062006

Slide 6

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Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected] 7

Facility Project

Scope and Cost

Data Collection

Mission

Market Assessment

Business Plan

Population (RAPS)

Workload (MEPRS/CHCS)

Staffing (TDA)

Capital Investment

Proposal (CIP)

Prioritization/

Submission

Constraints & Opportunities

Existing Program Capacities

Photographs

Site and Accessibility Info

Infrastructure Assessment

Architectural

Engineering Systems

Equipment

AT/FP

Facilities

Data

Space Utilization

Capacity Analysis

Architectural CADD Drawings

Site Drawings

List of Current Projects

Historical Background

Cost Option Studies

Provider Requirements

Volume Thresholds

Optimization

Functional Alignment

Planning

Scenarios

Enrollment (MCFAS)

Utilization (M2)

Capacity Analysis

Space Program

Functional Options

Health Care

Requirements Analysis

Site/Facility/

Capacity Analysis

Mission

Business Plan

Bio-Safety Levels

Research Population

Animal Population

Research Focus

Equipment-driven Space

Researcher Requirements

Phasing

Optimization

Functional Alignment

Animal Models

Utilization

Throughputs

Protocol Durations

Capacity Analysis

Space Program

Functional Options

Research

Market Analysis

Space

Requirements

Forecast

Site

Assessment

Demand

Analysis

Planning

Scenarios

Army Medical Construction Planning Process

*See back-up slides for Health Care

Requirements Analysis process

resulting in staffing leading to space

leading to cost.

Page 8: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Decision Making Process

• Define the problem

• Gather the facts and state assumptions

– Physical plant assessment, understanding the health care

system, health care requirements analysis

• Develop evaluation criteria necessary to solve the problem

• Develop various courses of action (status quo is always a

course of action)

• Eliminate courses of action due to inability to execute

• Weight criteria for evaluating courses of action

• Decision matrix analyzing various courses of action. Each

course of action must address every criteria.

• Make recommendation based on the analysis

Slide 8

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Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Facility Solutions Supporting a Health Care System

• Political situation affecting ability to provide health care

• Health care system

– Is it affiliated with a larger facility or University? Is it a NGO or PVO organization?

– Who funds the facility? Payment system?

• Scope of Services

– What type of medical services are provided by this organization? Primary care, sub-

specialty care, OR, ICU, med-surg wards, CMS, procedures

– Ancillary: lab, radiology, pharmacy, immunizations, blood products

– Administrative: logistics/ supply, patient administration/ processing, medical records,

nutrition care, information management, security, safety, quality assurance, bio-

medical equipment maintenance / management, environmental services

– Other: Patient education, preventive medicine services, emergency services. public

health services, dental

• Health care organization staffing

– Number, Type of, and minimal educational level:

– Are there required levels of formal training for each profession?

– Is continuing education conducted/required for each profession?

– How involved are family members in the care of patients?

Slide 9

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Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Facility Solutions Supporting a Health Care System -

Physical Plant Assessment

• Structural / Architectural: exterior envelope (roof, walls, foundation, etc),

structural integrity

• Electrical: demand versus source and reliability of supply, back-up systems,

critical systems

• Medical gases: Source and distribution

• HVAC: Heating, Ventilation, Air Conditioning including positive and negative

pressure requirements

• Plumbing: water supply, sewer, steam / hot water, sterilization

• Life Safety: Fire safety, egress requirements

• Interior finishes

• Communications / network

• Accessibility: exterior and interior of building, access to the site (mode of

transportation and limitations), emergency vehicles

• Building maintenance program

• Waste disposal: hazardous materials, regulated medical waste

Slide 10

Page 11: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Facility Solutions Supporting a Health Care System –

Health Care Requirements Analysis

• Population served including demographics

• Current utilization of services, i.e. outpatient visits per person per

month/year by demographic by service

• Current workload by provider / full time equivalent

• Provider available time in clinic

• Surgeon procedures by type

• Number of procedures and utilization of ORs

• Inpatient by type of ward: Average length of stay, admission rate,

occupancy rates, acuity measures driving staffing, nursing staff levels

• Staff interviews to validate analysis and understand clinic concept of

operations.

Slide 11

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Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Level I: Basic care

Ivory Coast – Bahoulifia Maternity Clinic

• Response to Europe Command (EUCOM) HAP Mission. Provide objective,

practical health facility assessments (Maternity Clinic one of several facilities

assessed in different locations). Determine deficiencies and prioritize. Direct

use of committed HAP Funds.

Slide 12

Page 13: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Ivory Coast – Bahoulifia Maternity Clinic

• Background:

– Provides OB/GYN services to the local population.

– The clinic is staffed by a nurse and a midwife.

– Average 40 deliveries per month

• Assessment:

– A small highly productive rural clinic

– The clinic is a single story building approximately 1,000 square feet

– Lacks water (dry well), State of disrepair, Insufficient Light

– Recent (locked) latrines constructed by Peace Corps Volunteers

• Recommendations ($25k):

– Dig a well in the vicinity of the clinic. The new well should include a hand pump and a

5 cubic meter holding tank.

– Replace the roof, Repair the ceiling.

– Install fluorescent lighting fixtures and bulbs throughout facility.

– Paint interior walls of maternity clinic.

– Install shelves.

Slide 13

Page 14: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Level II+ Hospital

US Army Kwajalein Atoll, Republic of the Marshall

Islands

• Mission: Analyze health requirements on Kwajalein Atoll; Develop

staffing and space needs based on health requirements; Develop and

compare facility alternatives; Recommend changes to the medical/dental

component of the GOCO Performance Work Statement; Briefly examine

the health system and status of a hospital construction project on the

neighboring island of Ebeye.

• Problem: Current facilities deteriorating. Unclear scope of clinical

services and subsequent facility to support that scope.

• Facts and Assumptions: Enduring military mission. Reliance on

local population and contractors.

– Population served, demographics, and corresponding health care demand

– Defined scope of services and staffing requirements to meet demand

– Using DoD space planning criteria developed a Program For Design defining

space based on workload demand and staffing

Slide 14

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Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

US Army Kwajalein Atoll

Republic of the Marshall Islands

• Evaluation criteria: Cost, Clinical operations impact, NFPA life safety code

compliance, Building infrastructure improvement,

• Courses of Action: Total replacement, Complete renovation, Partial

addition / alteration, Status quo / short-term fixes

• Recommendation: Course of Action 2, “Total Renovation.” Based on the decision matrix

analysis, a complete renovation of the existing facility would best meet the needs of improving

clinical operations, meeting National Fire Protection Agency (NFPA) life safety codes, and

improving the building infrastructure while minimizing the overall project cost.

Slide 15

CRITERIA COST $M Clinical Ops Life Safety Building Infrastructure TOTAL

COA / Weight 2 1 1 1

1: Total Replacement $33M

2: Complete

Renovation

$6.5M; Score=2; Wt

Score=43.5 3 3 13.5

3: Partial Addition /

Alteration

$0.70M; Score=3.5; Wt

Score = 72 2 1.5 12.5

4: Status Quo /

Immediate fixes

$0.30M; Score=3.5; Wt

Score=71 2 1.5 11.5

Page 16: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected] 16

QUESTIONS?

Page 17: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Back-up Slides

Page 18: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

The Process for Space Planning

Space

Requirements

Problem ID Demand

Analysis

Scenarios:Staffing

Page 19: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Space Planning Process

1. What’s the problem versus the symptom?

– Not enough space in the waiting room

– Not enough exam rooms

2. Data collection and Demand Analysis

– Distribution of demand (unique characteristics of clinic)

• Sick call TMC

– Distribution of the supply (provider staffing and template mgt)

• Permanent providers and support staff

– Roadblocks to increased productivity

• Maximize provider time

– Support staff

– Two exam rooms per provider

• Ancillary support: Lab, Xray, Pharmacy

Page 20: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Space Planning Process (cont’d)

3. Planning Scenarios

• Targeting increased enrollment

• Driving demand through appointing

• Number of providers in clinic based on above demand

• Number of support staff in clinic based on above demand

4. Space Requirements

– Based on staffing, use space planning criteria to generate

space requirement

– Prioritize space requirements

– Compare to existing space

Page 21: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Space Planning Process

1. What’s the problem versus the symptom?

– Lack of available appts

2. Data collection and Demand Analysis

– Distribution of demand

Avail Wks/Yr * Days/Wk

Avail

Hrs/Day Clinic Hrs/Yr

Aver

Visits/Hr

Provider

Visits/Yr (b)

Family Medicine (A) 44 X 5.0 X 7.0 = 1,540 x 2.9 = 4,404

Family Medicine (B) 44 X 5.0 X 6.0 = 1,320 X 2.9 = 3,775

Avg Visits per

year (c )

(c ) / ( b) =

provider FTE

required

Acutal

provider

FTE

Family Medicine (A) 35,443 8.0 8.0

Family Medicine (B) 35,443 9.4 8.0

Page 22: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Distribution of Supply

Weeks/ Yr Hrs / Yr

Annual Compensated Time 52 2080

Time away from Work Center

Annual Leave 4 160

Sick Leave 2 80

Civilian Holidays 2 80

Professional / Cont. Ed. 1 40

Military Tng. / Ed. 1 40

Training Holidays 0.8 32

Available Time in Work Center 41.2 1,648

Less Admin. / Conference 206

Available Time for Direct Patient Care 1,442

Avail Clinic Average Provider

Admin Clinic Clinic Procedures Wks / Yr Hrs / Yr Visits / Hr Visits / Yr

Primary Care 1.0 7.0 5.0 0.0 41.2 1,442 3.0 4,326

Avail Hrs / Day Days / Week

Page 23: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Avail Wks/Yr * Days/Wk

Avail

Hrs/Day Clinic Hrs/Yr

Aver

Visits/Hr

Provider

Visits/Yr (b)

Family Medicine (A) 44 X 5.0 X 7.0 = 1,540 x 2.9 = 4,404

Family Medicine (B) 44 X 5.0 X 6.0 = 1,320 X 2.9 = 3,775

Avg Visits per

year (c )

(c ) / ( b) =

provider FTE

required

Acutal

provider

FTE

Family Medicine (A) 35,443 8.0 8.0

Family Medicine (B) 35,443 9.4 8.0

3. Planning Scenarios• Targeting increased enrollment

• Driving demand through appointing

• Number of providers in clinic based on above demand

• Number of support staff in clinic based on above demand

Page 24: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Space Planning Process (cont’d)

4. Space Requirements

– Based on staffing, use space planning criteria to generate

space requirement

– Prioritize space requirements

– Compare to existing space

Page 25: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Space Requirement

Family Practice & Wellness

Room Description Staff Clinic Clinic w /SDS/MB

Qty. NSF Total

Direct Care Space

Exam Rooms 42 100 4200

Isolation Room 2 100 200

Isolation Toilet 2 60 120

Procedure Rooms 4 150 600

Colposcopy Room 150 0

Flex Sig Room 150 0

Toilet 60 0

TPR w eights and measures 2 200 400

Vascetomy Room 150 0

ENT Exam Area 0 100 0

Behavioral Science 0 100 0

Immunization Room 1 200 200

Holding Area 1 200 200

Patient Toilet 4 60 240Patient Resource Center 1 140 140

Sub-Total - Net Square Feet 15,188

Department Circulation 30% 4,556

Net-to-Gross 10% 1,974

TOTAL DEPT GROSS SQUARE FT 21,719

Page 26: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Space Requirements

• Required Space

– DoD Space Planning Criteria (space allocation)

– Guideplates (layout)

• Patient Flow

• Room Adjacencies

• Factors to Consider

• Prioritize Requirements

• Overlay over existing layout

Page 27: US Army Health Facilities Assessmentsenergytoolbox.org/library/infra2010/presentations/...Disaster Relief Humanitarian Assistance Peacekeeping/Mil Spt. Peace Enforcement Low Intensity

Medical Facilities Life Cycle Management

UNCLASSIFIEDCOL Guy Kiyokawa / MCFA /(703) 681-8221(DSN761) / [email protected]

Cost

• Gross Square Feet x costing factors

• DoD uses specific factors based on type of building,

location, size, etc.

• Incorporate Info Mgt, Force Protection, built-in medical

equipment, oversight / management

• Initial Outfitting with medical equipment and transition from

existing operations