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Support Operations: Lessons Learned in a Multifunctional Medical Battalion

As part of the greater transformation effort conducted by the Army in the last decade, the Army Medical Department (AMEDD) created a new unit called the multifunctional medical battalion (MMB), which includes a support operations (SPO) section. We think that the MMB’s SPO organization is a poorly understood and often underused staff section. A literature review has found only two articles that discuss the MMB SPO section. Neither article is dedicated to this new staff section; they only briefly mention the SPO section and its capabilities. In this article, we will attempt to explain the roles and functions of the new MMB SPO section and discuss the lessons we learned while leading a SPO section in garrison and during a deployment.

Replacing Stovepiped Units


The MMB comprises portions of the former area support, evacuation, medical logistics, dental, and veterinary battalions. The MMB concept was adopted from the multifunctional logistics battalions formerly found in divisions and brigade combat teams: the forward support battalion and the main support battalion.

Previously, the stovepiped medical department battalions operated the same way as the old logistics battalions. In garrison, the battalions were functionally aligned, but a medical task force was normally created during a deployment. The MMB was developed to make this ad hoc deployment task force organization permanent, just as the innovative forward support and main support battalions did. This approach helps foster stronger relationships among the specialties and ensures that the battalion headquarters personnel will be experienced enough to properly command and control subordinate units, regardless of their specialty.

The MMB does not have a set modification table of organization and equipment (MTOE) other than that of the headquarters and headquarters detachment. The MMB has no lettered subordinate units. All units assigned to it are stand-alone, numbered companies and detachments that are assigned to the MMB in a tailored package for a specific deployment mission.

The key to commanding and controlling the diverse number and types of medical companies and detachments assigned to the battalion is a staff section that also was originally developed in multifunctional logistics units—the SPO section.

SPO Section Organization

The SPO section has the same mission in either a multifunctional logistics or multifunctional medical battalion: to plan, coordinate, and enable the external support provided by the battalion’s subordinate units. The traditional S-shop staffs focus on internal personnel, supply, maintenance, training, and operations issues for the battalion. The SPO section and the S-shops have distinct, separate functions and focuses, though they require considerable coordination.

The MMB S-shops answer to the battalion executive officer (a medical service corps major), whereas the SPO section reports to the SPO officer (also a medical service corps major). Traditionally, battalions have an executive officer (a major) and an S–3 operations officer (a major), who both report directly to the battalion commander. The executive officer handles all administrative matters for the battalion while the S–3 handles training and planning.

SPO Staffing

The SPO section was added to logistics units to coordinate the external support that the battalion provided. Because of the importance of this section, the S–3 position was downgraded to a captain and the SPO officer-in-charge (OIC) was made a major. This same rank structure was built into the MMBs, with each major answering directly to the battalion commander.

The MMB SPO section (with 29 of the 77 authorized headquarters and headquarters detachment positions) was allotted a sergeant major as the section’s noncommissioned officer-in-charge (NCOIC). Previously, operations sergeants major were only authorized at the brigade level, so this is a very significant addition to a battalion staff. The rank provides an experienced noncommissioned officer (NCO) who has great authority to help oversee the diverse and critical SPO section.

The SPO section is structured to have an assortment of subject-matter experts capable of providing oversight for any medical company, detachment, or team that could be assigned to the MMB. These experts’ specialties include medical maintenance, medical supply, behavioral health, veterinary services, patient administration, optical fabrication, laboratory services, preventive medicine, dentistry, medical operations and planning, evacuation, and practical nursing.

The rank structure is set up to ensure that experienced personnel are assigned to the SPO section. The most junior authorized rank for SPO NCOs is staff sergeant, and most of the NCO slots are sergeant first class. All of the officer slots are authorized at captain or chief warrant officer 3. This structure provides the requisite expertise to properly plan and manage the support provided by subordinate units. It also gives the staff officers and NCOs a high level of authority when providing guidance and enforcing standards. This high rank structure has proven critical to the SPO section’s success.

Naming the Section

Unit leaders debated about what to call the SPO section after our unit, the 421st Evacuation Battalion, was redesignated as the 421st MMB in June 2007 at Wiesbaden Army Airfield, Germany. The MTOE refers to the section as force health protection (FHP). Field Manual Interim (FMI) 4–02.121, Multifunctional Medical Battalion, uses FHP to describe the overall mission of the MMB: “The FHP system encompasses the promotion of wellness and preventive, curative, and rehabilitative medical services. . . [and] is a continuum from point of injury or wounding through successive levels of care.” The FMI does not call the section the FHP, but uses the term “medical support operations.”

The term “force health protection” is confusing since it was commonly used in the past to describe preventive medicine efforts; outside units did not understand our capabilities and thought we were solely focused on preventive medicine. The term used in the FMI was adopted, but the word “medical” was dropped for convenience as well as to align us with the section in the brigade support battalions that coordinates external support—support operations. The section OIC is known as the SPO and the NCOIC as the SPO sergeant major.

The MTOE and FMI are also different in what they name the SPO subsections. The MTOE lists medical logistics, medical operations, preventive medicine, and mental health subsections, while the FMI lists medical logistics, medical operations, and clinical operations as subsections.

The section personnel listed in the MTOE and the FMI also differ. For example, the MTOE lists the military occupational specialty (MOS) 68WM6, practical nurse, in medical operations, but in the FMI, the position is listed in clinical operations. The 421st MMB decided to use the FMI structure of three subsections—medical operations, clinical operations, and medical logistics—with a captain OIC and a master sergeant NCOIC for each.

MTOE Deficiencies

The MMB should be authorized a Professional Filler System (PROFIS) battalion surgeon (preferably
a lieutenant colonel) for the special staff. Some missions will not require this position to be filled; others will. Having this authorization on the MTOE would enable the battalion commander to request a fill without having to justify the need to the Army Forces Command and Army Medical Command (as was required for the deployment to Iraq). It has been suggested that a nurse and a pharmacist should also be listed as PROFIS. These officers certainly could make contributions, but with the sergeant first class pharmacy technician and master sergeant practical nurse to team with a PROFIS battalion surgeon, the battalion would have the expertise needed to accomplish its mission.

The MTOE has no authorized tentage, light sets, or other items needed in field operations for the 29 SPO Soldiers. It authorizes only six 9-millimeter pistols for the entire headquarters detachment, with only one available in the SPO section. The SPO, SPO sergeant major, and chief warrant officer 3 should be provided pistols. It is also advisable to provide each of the three subsection OICs and NCOICs with a pistol because of their rank and responsibility in order to align them better with their counterparts in the S-shops.

Transportation is another issue. Currently, only two high-mobility multipurpose wheeled vehicles and two 2½-ton trucks are authorized. Even with the ideal configuration and types of vehicles, the SPO section could only transport half of its personnel at one time—a difficult situation if the battalion is maneuvering during a campaign.

Developing SPO’s Role in the Battalion

The addition of the SPO section to the MMB was a step forward in planning and oversight, but the transformation was not completed at the higher levels of command. Logistics battalion SPO sections coordinate with similarly structured sections in the sustainment brigade. This is not the case with the MMB SPO section; no SPO section exists in any medical brigade or medical command. When the MMB SPO section needs to coordinate efforts with the medical brigade or medical command, it has to work with three separate sections: G–3, G–4, and clinical operations. This leads to many challenges in consistency of guidance and coordination of efforts.

Because subordinate units and higher headquarters are more familiar with the S-shops than they are with the SPO section, many SPO-related issues are referred to and worked by the S-shops. The FMI actually contributes to this confusion. It states that the SPO section needs to work with the S-shops because the S–1 will provide personnel casualty estimates, the S–2/3 will gather medical intelligence and provide clinical input for FHP estimates and plans, and the S–4 will provide support for all class VIII (medical materiel) requirements.

Combining the SPO section with the S-shops divides the responsibility for planning, coordination, and oversight of the external support provided by the subordinate units between the SPO section and the S-shops and only leads to confusion. The entire reason for creating the SPO section was to unify the coordination of external support under one section where clinical, logistics, and operational requirements can be planned and tracked. Having it any other way nullifies the need for the SPO section.

The 421st MMB SPO section performed all of the functions mentioned above. It found that creating clear and distinct lines of responsibility was necessary. All internal administrative, training, and operational matters, such as awards, evaluation reports, ranges, convoys, unit status reports, property book, and ground maintenance, are the responsibility of the S-shops. All external support provided and planned for, such as borrowed military manpower memorandums of agreement, expert field medical badge training, MOS 68W (healthcare specialist) sustainment, medical maintenance oversight, medical taskings, medical support planning, workload data collection, subject-matter expert guidance, and medical maintenance, is the responsibility of the SPO section. In short, anything that deals specifically with a medical function or capability is the SPO section’s concern; everything else is worked by the S-shops.

In garrison, the SPO section needs to actively seek out projects to keep exercising its planning and coordinating skills. In the garrison environment, the S-shops naturally become the focus of the headquarters’ efforts. Personnel and property administration, equipment maintenance, and Soldier training need to be consistently executed to ensure that subordinate units are ready to operate properly when in the field. But the SPO section cannot become merely a personnel mine for NCOs and officers to conduct additional duties and taskings because, in the field, the SPO section becomes the focus of the headquarters efforts and must be prepared to meet those responsibilities.

It is important to seek out events to plan and coordinate, such as planning and executing an expert field medical badge training event, conducting MOS 68W sustainment training, or conducting a combat lifesaver class. For example, while the 421st MMB subordinate units were still going through transformation in Germany, the SPO section was the lead for planning the rebasing, inactivation, or transition to TDA (table of distribution and allowances) missions for medical logistics, preventive medicine, veterinary, and optometry units.

The SPO section should also be the planners, main trainers, and evaluators for subordinate units going through mission readiness exercises or reset evaluations. The ability of subordinate units to conduct their medical missions, which involve all aspects of field craft and medical skills, is naturally the responsibility of the SPO section with its large number of senior subject-matter experts.

Coordinating the subordinate units’ efforts was a challenge in the months following the 421st’s conversion to an MMB. In fact, the battalion’s deployment mission readiness exercise was the first time the SPO section planned and coordinated functions for subordinate units in the field. With the 421st MMB commander’s support, the efforts of the SPO officers and NCOs at the mission readiness exercise displayed the full capabilities of this robust staff section.

Preparing for Deployment

The new SPO and SPO sergeant major were assigned to the section in the summer of 2007. With a deployment planned for 2008, filling the authorized SPO personnel slots was critical. The SPO and battalion leaders filled these slots through frequent communication with personnel managers at the brigade, regional medical command, and Army Human Resources Command.

Filling the low-density MOS positions was a particular challenge since these positions are for senior NCOs and this was a new type of unit with which they were unfamiliar. But these experts were deemed critical to the mission that the unit would inherit in Iraq. In particular, the optical fabrication technician, pharmacy technician, and practical nurse positions were “must fills” for the deployment. By the mission readiness exercise in August 2008, most of the positions were filled, though several Soldiers arrived during the predeployment block leave.

The 44th Medical Command allotted the 421st MMB a slot on its Iraq predeployment site survey team. The SPO was selected to fill this slot. The trip gave him firsthand knowledge of the exact nature of the MMB’s upcoming mission. The visits to health, optometry, and dental clinics; ground ambulance squads; and the battalion headquarters were valuable. The discussions with the 261st MMB SPO and S-shop sections regarding their training advice and concerns enabled the 421st MMB to tailor its predeployment training plan to match the mission it would execute.

The 421st MMB Headquarters and Headquarters Detachment deployed to Balad, Iraq, in the fall of 2008. The SPO OIC and the NCOIC of the medical operations section were in the advance party to help ensure the handoff from the 261st MMB was well coordinated from the start.

421st MMB Mission in Iraq

Several rotations earlier, the two MMBs in Iraq had aligned their missions functionally. Instead of having subordinate units assigned for all of the specialties, each MMB was assigned all of the units of a limited number of specialties, thus enabling the MMB staff to focus its efforts. This practice continued during the 421st MMB deployment. The mission of the 421st MMB was to command and control five area support medical companies, two dental companies, two ground ambulance companies, four optometry detachments, and one head and neck surgical team. (Our sister battalion, the 111th MMB, was responsible for the medical logistics, veterinary, combat operational stress control, and preventive medicine missions.)

The 421st MMB’s units were scattered from Mosul in the north to Basra in the south and from Baghdad to Al Asad in the west at a total of 30 sites. Although the mission of each subordinate unit was important, the primary focus of the 421st MMB was level II medical, dental, and optometry clinics.

Tactics, Techniques, and Procedures

With the SPO section being such a new organization for AMEDD, no two deployed MMB SPO sections have been structured the same. Each has been tailored to the mission based on the available personnel and the comfort level of the battalion commander and the SPO. In the 421st MMB, we used the FMI structure of three subordinate sections—medical operations, clinical operations, and medical logistics—as had the battalion we replaced.

Medical operations. The 421st MMB varied from its predecessors by ensuring that the medical operations section was not integrated into the S–3, where these two sections could not be distinguished from each other. The 421st medical operations section was kept separate to ensure the responsibility for planning and tasking for medical missions was maintained in the SPO section.

However, the S–3 shop issued all orders coming from the headquarters. Within the SPO section, all orders came to the medical operations section for review and, once approved by the SPO and SPO sergeant major, were passed to the S–3 for format review and issue.

The preventive medicine officer and NCO were placed in the medical operations section. Since the 421st MMB mission did not include theater preventive medicine, these personnel were only involved part time in preventive medicine issues. The rest of their time was spent assisting with medical operations functions and battalion extra duties, such as the safety officer.

An addition to the medical operations mission was civil-military operations (CMO). Since all of the training support coordinated for the Iraqis by the 421st was medical in nature (we were not involved in any medical humanitarian assistance efforts), CMO was brought into the SPO section. Since the 421st MMB had no air evacuation planning mission, the evacuation pilot of the medical operations section was made the battalion CMO officer. He worked closely with the civilian, contracted cultural expert, who was an Iraqi-American physician. The efforts of these individuals made the CMO mission a success, particularly in building a partnership with the Iraqi Ground Forces Command surgeon’s cell. They met the goal of organizing two medical CMO training events each month.

Clinical operations. The clinical operations section was the medical administration section of the battalion. It collected daily workload statistics; updated and wrote standing operating procedures on such diverse topics as patient safety, laboratory controls, and infection control; and wrote fragmentary orders that the staff drafted in their areas of expertise. This section also worked very closely with the battalion surgeon in the battalion’s effort to standardize care across the battlefield, a never-ending task as units came and went in the theater.

Medical logistics. The medical logistics section was responsible for medical supply, pharmacy, and medical maintenance oversight. Medical supply personnel assisted with researching required items and drafting letters of justification for equipment, assisted with Defense Medical Logistics Standard Support Customer Assistance Module (DCAM) ordering issues, and reviewed the monthly reconciliation reports. The pharmacy technician managed and set the standards for the pharmacy technicians working in the clinics. The surgeon and this NCO interacted frequently to ensure that the proper procedures for narcotics storage and issue were being followed.

Medical maintenance personnel reviewed medical equipment purchase requests, arranged for operational float equipment, scheduled services, and standardized equipment models across the battlefield to make maintenance simpler. This section also oversaw clinic renovation and construction by assisting the base mayor’s cells with letters of justification, having floor plans drawn, and validating and arranging for furniture and equipment purchases.

SPO Battle Brief

The SPO section previously had no forum for presenting information to the battalion commander regarding the medical support provided by subordinate units. A biweekly SPO battle update brief was developed to present plans, taskings, subject-matter expert issues, and workloads to the battalion commander and the subordinate unit commanders through an online Adobe Breeze session. This proved to be a critical improvement for the battalion. Previously, only general administrative issues, such as officer efficiency ratings, awards, and the property book, were discussed at battalion command and staff meetings. With the SPO battle update brief, information on medical support efforts was shared, and the important medical missions of the battalion and the subordinate units were better understood by all, which greatly helped with planning and decisionmaking.

During the deployment, great strides were made in standardizing healthcare throughout the task force’s area of operations. Quarterly staff assistance visits, new standing operating procedures, an enhanced peer review program, and the SPO battle update briefing were the most powerful tools used to raise the quality of care and enforce standardization in the clinics.

Overall, Task Force 421st MMB successfully conducted 170,000 primary care and 54,000 dental visits and 43,000 optometry examinations; completed 6,000 radiology studies and 28,000 lab procedures; fabricated 36,000 pairs of glasses; filled 87,000 prescriptions; provided medical support for 720 logistics convoys; and executed 22 CMO training events. This was certainly a team effort in which all the staff sections and subordinate units contributed, but the SPO section played a significant role in each of these achievements.

The SPO section has proven its worth to the MMB in garrison and at war. The expertise contained in the section makes it flexible and experienced enough to meet the diverse challenges that an MMB may face. The SPO section’s variety of tasks and requirements is greater than in any other staff section in an AMEDD field unit. The success or failure of the battalion is largely determined by the performance of the SPO section.

The SPO section positions (such as medical operations officer, medical logistics officer, and clinical operations NCOIC) should be as valued and sought after in the future as the traditional S-shop positions are now. The SPO section needs to be better understood, supported, and valued in AMEDD. This greater understanding will foster more capable and better integrated SPO sections in all of the MMBs.

Lieutenant Colonel Douglas H. Galuszka was the support operations officer for the 421st Multifunctional Medical Battalion while stationed at Wiesbaden Army Airfield, Germany, and deployed to Joint Base Balad, Iraq. He holds a B.A. degree in history from Michigan State University, an M.A. degree in public administration from the University of Maryland-Europe, an M.H.A. degree from Baylor University, and M.M.A.S. degrees in military history and theater operations from the Army Command and General Staff College. He is a Fellow of the American College of Healthcare Executives and is a graduate of the AMEDD Basic Course, the Combined Logistics Officers Advanced Course, the Army Command and General Staff College, and the School of Advanced Military Studies.

Sergeant Major David Franco is the support operations sergeant major for the 421st Multifunctional Medical Battalion stationed at Wiesbaden Army Airfield, Germany, and cowrote this article while deployed to Joint Base Balad, Iraq. He holds a B.S. degree in business management from the University of Maryland-University College and has been inducted into the Order of Military Medical Merit.He is a graduate of the First Sergeant’s Course and the Sergeants Major Academy.

 
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