San Antonio Military Medical Center Integration: A Case Study in Organizational Leadership Design

Military Medicine, Feb 2008 by De Lorenzo, Robert A

ABSTRACT The Defense Base Closure and Realignment Commission law of 2005 established a combined Army-Air Force medical center in San Antonio, Texas. The new facility is named the San Antonio Military Medical Center. This planned integration of two facilities would result in the downsizing of Wilford Hall Medical Center to a clinic and expansion of the nearby Brooke Army Medical Center to encompass all inpatient care. As part of the integration, the emergency services of both hospitals, to include the emergency departments, would merge under single leadership. As part of this case study, the proposed future organizational design is examined. Real and potential barriers to change are also indentified and possible solutions are explored.

INTRODUCTION

This case study will focus on the Department of Defense's (DoD) Base Realignment and Closure (BRAC) plan as it pertains to the integrations of the two military medical centers in San Antonio, Texas. The integration of Brooke Army Medical Center (BAMC) and Wilford Hall Medical Center (WHMC) is just now underway with a completion date of 2011 set by the law. The organizational issues relevant to the integration will be explored with a focus on the emergency services and emergency departments (EDs) of the hospitals.

BRAC BACKGROUND

BRAC is a federal law passed by Congress as part of the fiscal year 2002 Defense Authorization Act.1 It is the fifth such round by Congress and the Executive to downsize the military in the post-Cold War era. The final BRAC law resulted in more than a dozen major and many more minor medical realignments and consolidations.2 Four major teaching hospitals will close, consolidate, or downsize including the Army's Walter Reed and the Air Force's Wilford Hall, Malcolm Grow, and Keesler Medical Centers. Six community hospitals (one Army, two Navy-Marine Corps, and three Air Force) will also close or convert to clinics. Even the venerable Armed Forces Institute of Pathology will close. Notably, these tallies do not include the closure of smaller medical facilities (mostly clinics), many of which are located on bases and posts recommended for complete closure.

One outstanding feature of the BRAC is the creation of six medical research centers of excellence: (a) trauma and battlefield health, San Antonio, Texas, (b) infectious disease, Bethesda, MD, (c) aerospace medicine, Dayton, Ohio, (d) biological defense, Fort Detrick, MD, (e) chemical defense, Aberdeen Proving Ground, MD, and (f) regulated medical product development and acquisition (e.g., vaccines), Fort Detrick, MD. By consolidating related but geographically scattered researchers under one roof, the DoD plans to enhance collaboration and reduce the considerable overhead associated with scientific endeavors. The BRAC plan also establishes a single location for all enlisted medical training. This massive shift of medical technician education will effectively double the size of Fort Sam Houston, Texas (located in San Antonio), and create the world's largest school of allied health.

Another major feature of BRAC is the establishment of two "supercenters" for graduate medical education (GME) in San Antonio, Texas, and Bethesda, MD. The center in Bethesda will be named the Walter Reed National Military Medical Center, the other the San Antonio Military Medical Center (SAMMC). In creating these centers, the current Walter Reed Army Medical Center campus in Washington, DC, will close and Wilford Hall Medical Center at Lackland Air Force Base (located in San Antonio) will downsize to a clinic. Nevertheless, when complete, the centers will be huge by current DoD medical standards.

One result of the BRAC will be the creation of a newly constructed ED at the BAMC campus in San Antonio to replace the existing and separate smaller EDs. Planned and designed for an annual census of 80,000-100,000, it will be large by any standard. The ED will be jointiy manned and requires the full integration of Army and Air Force mihtary and civihan staff, including nearly 85 faculty and resident physicians, > 125 nurses and technicians, and dozens of support and anciUary health care workers. Of note, the merger also requires an integrated approach to leadership and organizational design; this process forms the basis of this case study.

Models of Product Line Leadership and Military Command

BAMC and WHMC are the two organizations implementing the integration. Both medical centers have long worked in close proximity (they are 16 miles apart), cooperate on a range of programs, and occasionally compete directly for the same patients and resources. In me late 1980s, the two institutions merged leadership functions under a single command entitled the Joint Military Medical Command. However, this was ultimately unsuccessful and the two organizations reverted back to military service-specific lines of reporting in the early 1990s.

Although the focus of this analysis is on the future merger of the respective departments of emergency medicine, it is crucial to examine the existing hierarchal structure between both centers (Fig. 1). The most important observation regards the lines of authority; they are separate and do not join except at the highest levels of the DoD. In other words, both medical centers respond to very distinct leadership, maintain separate budgets, and retain control of their own personnel. Sharing only takes place when the general mission of care for service members, thieir families, and other beneficiaries are coincident, convenient, or directed from above. As the managed care component of Tricare matured in the 1990s and early part of this century, the degree of cooperation increased under the multimarket concept established for the San Antonio area.