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entitled 'Defense Infrastructure: Documentation Lacking to Fully 
Support How DOD Determined Specifications for the Landstuhl 
Replacement Medical Center' which was released on May 25, 2012. 

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United States Government Accountability Office: 
GAO: 

Report to the Subcommittee on Military Construction, Veterans Affairs, 
and Related Agencies, Committee on Appropriations, U.S. Senate: 

May 2012: 

Defense Infrastructure: 

Documentation Lacking to Fully Support How DOD Determined 
Specifications for the Landstuhl Replacement Medical Center: 

GAO-12-622: 

GAO Highlights: 

Highlights of GAO-12-622, a report to the Subcommittee on Military 
Construction, Veterans Affairs, and Related Agencies, Committee on 
Appropriations, U.S. Senate. 

Why GAO Did This Study: 

Landstuhl Regional Medical Center (LRMC) is DOD’s only tertiary 
medical center in Europe that provides specialized care for 
servicemembers, retirees, and their dependents. Wounded servicemembers 
requiring critical care are medically evacuated from overseas 
operations to the 86th Medical Group clinic at Ramstein Air Base to 
receive stabilization care before being transported to LRMC for 
intensive care. According to DOD, both facilities were constructed in 
the 1950s and are undersized to meet current and projected workload 
requirements. DOD plans to consolidate both facilities into a single 
medical center at an estimated cost of $1.2 billion. In this report, 
GAO (1) describes how DOD considered changes in posture and the 
beneficiary population when developing facility requirements, (2) 
assesses DOD’s process for determining facility requirements, and (3) 
reviews DOD’s process to develop the facility’s cost estimate. GAO 
examined posture planning documentation, beneficiary demographic data, 
plans for the replacement medical center, and relevant DOD guidance, 
as well as interviewed relevant DOD officials. 

What GAO Found: 

Department of Defense (DOD) officials considered current beneficiary 
population data, contingency operations, and most of the expected 
changes in troop strength when planning for the replacement medical 
center. However, recently announced posture changes in January 2012 
have yet to be assessed for their impact on the facility. DOD 
estimates that the replacement medical center will provide health care 
for nearly 250,000 beneficiaries. A majority of those who are expected 
to receive health care from the center come from within a 55-mile 
radius of the facility. DOD officials told us that because the 
replacement medical center was designed for peacetime operations-—with 
the capacity to expand to meet the needs of contingency operations—-
reductions in ongoing contingency operations in Afghanistan would not 
have an impact on facility requirements. At the time of this review, 
DOD officials said they were in the process of assessing proposed 
changes in posture to better understand their possible impact on the 
sizing of the replacement medical center. 

DOD officials incorporated patient quality of care standards as well 
as environmentally friendly design elements in determining facility 
requirements for the replacement medical center. DOD also determined 
the size of the facility based on its projected patient workload. 
Internal control standards require the creation and maintenance of 
adequate documentation, which should be clear and readily available 
for examination to inform decision making. However, GAO’s review of 
the documentation DOD provided in support of its facility requirements 
showed (1) inconsistencies in how DOD applied projected patient 
workload data and planning criteria to determine the appropriate size 
for individual medical departments, (2) some areas where the 
documentation did not clearly demonstrate how planners applied 
criteria to generate requirements, and (3) calculation errors 
throughout. Without clear documentation of key analyses—-including 
information on how adjustments to facility requirements were made—-and 
without correct calculations, stakeholders and decision makers lack 
reasonable assurances that the replacement medical center will be 
appropriately sized to meet the needs of the expected beneficiary 
population in Europe. 

DOD’s process for developing the approximately $1.2 billion cost 
estimate for the replacement medical center was substantially 
consistent with many cost estimating best practices, such as cross-
checking major cost elements to confirm similar results. However, DOD 
minimally documented the data sources, calculations, and estimating 
methodologies it used in developing the cost estimate. Additionally, 
DOD anticipates that the new facility will become the hub of a larger 
medical-services-related campus, for which neither cost estimates nor 
time frames have yet been developed. Without a cost estimate for the 
facility that includes detailed documentation, DOD cannot fully 
demonstrate that the proposed replacement medical center will provide 
adequate health care capacity at the current estimated cost. Further, 
DOD and Congress may not have the information they need to make fully 
informed decisions about the facility. 

What GAO Recommends: 

GAO recommends that DOD provide clear and thorough documentation of 
how it determined the facility’s size and cost estimate, correct any 
calculation errors, and update its cost estimate to reflect these 
corrections and recent posture changes. In commenting on a draft of 
this report, DOD concurred with GAO’s recommendations and stated that 
it has conducted a reassessment of the project that will be released 
once approved by the Secretary of Defense. 

View [hyperlink, http://www.gao.gov/products/GAO-11-622]. For more 
information, contact James R. McTigue, Jr. at (202) 512-7968 or 
mctiguej@gao.gov or Debra A. Draper at (202) 512-7114 or 
draperd@gao.gov. 

[End of figure] 

Contents: 

Letter: 

Background: 

DOD Considered Beneficiary Data, Contingency Operations, and Posture 
Changes in Sizing Its Replacement Medical Center but Has Not Assessed 
More Recent Posture Changes: 

DOD Incorporated Quality Standards When Determining Facility 
Requirements, but Inadequate Documentation Makes It Unclear Whether 
DOD Adhered to Its Own Guidance: 

DOD's Cost Estimate Was Not Well Documented, and Cost Elements for 
Associated Facilities Have Yet to Be Developed: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Catchment Area Populations by Beneficiary Category, 
Fiscal Years 2006 through 2011: 

Appendix III: Detailed Information on Each of the Cost Estimating 
Characteristics: 

Appendix IV: Comments from the Department of Defense: 

Appendix V: GAO Contacts and Staff Acknowledgments: 

Tables: 

Table 1: Landstuhl Regional Medical Center (LRMC) Catchment Areas, by 
Beneficiary Category, as of March 2010: 

Table 2: Patient Migration Patterns for the Landstuhl Regional Medical 
Center (LRMC) and the 86th Medical Group (MDG) at Ramstein Air Base in 
Fiscal Year 2009: 

Table 3: Proposed Sizing Requirements for the Replacement Medical 
Center: 

Table 4: Summary Assessment of the Results of DOD Cost Estimating 
Process for the Replacement Medical Center as Compared to Best 
Practices: 

Table 5: Characteristics of High-Quality and Reliable Cost Estimates: 

Figures: 

Figure 1: Overview of DOD Medical Treatment Facilities Requirements 
and Project Costs Process: 

Figure 2: Location of Four Catchment Areas Used to Define Patient 
Migration to Landstuhl Regional Medical Center: 

Figure 3: DOD Military Installations in Europe with Expected Posture 
Changes That May Affect Replacement Medical Center Facility 
Requirements: 

Abbreviations: 

DOD: Department of Defense: 

EUCOM: European Command: 

ICU: intensive-care unit: 

LEED: Leadership in Energy and Environmental Design: 

LRMC: Landstuhl Regional Medical Center: 

MDG: Medical Group: 

MHS: Military Health System: 

OMB: Office of Management and Budget: 

USA: GU.S. Army Garrison: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

May 25, 2012: 

The Honorable Tim Johnson: 
Chairman: 
The Honorable Mark Kirk: 
Ranking Member: 
Subcommittee on Military Construction, Veterans Affairs, and Related 
Agencies: 
Committee on Appropriations: 
United States Senate: 

The Army's Landstuhl Regional Medical Center (LRMC), in Germany, is 
the Department of Defense's (DOD) only tertiary care medical center in 
the European Command (EUCOM) area of responsibility. As a tertiary 
care center, LRMC provides specialized diagnostic and treatment 
services, such as cardiology and neurosurgery, which are not available 
at all medical facilities that provide acute inpatient care, for 
approximately 248,000 beneficiaries, including servicemembers and 
their families as well as retirees and their families. Wounded 
servicemembers requiring critical care are medically evacuated from 
overseas operations--including Afghanistan--to Ramstein Air Base where 
the 86th Medical Group (MDG) provides them immediate stabilization 
care on the flight line and then transports them directly to LRMC for 
definitive care. 

Both of these facilities were initially constructed in the 1950s and 
according to DOD are deficient in meeting the department's life safety 
and force protection requirements, are out of compliance with many 
building codes, have limited room in which to expand or renovate, and 
are undersized to meet current and projected patient workload 
requirements. In 2008, DOD approved plans to renovate and reconstruct 
the two facilities at their existing locations. In 2009, the Senate 
Appropriations Committee directed the department to complete a site 
assessment and conduct a cost-benefit analysis on the proposed 
location for the replacement medical center.[Footnote 1] The Office of 
the Deputy Under Secretary of Defense (Installations and Environment) 
conducted an analysis, which determined that consolidating the two 
facilities at one location, at a total estimated cost of $1.2 billion, 
would be more efficient and cost-effective than renovating both at 
their current locations. In January 2012, DOD completed the initial 
design phase of the replacement medical center. However, in December 
2011, the Consolidated Appropriations Act, 2012, required that among 
other things, the Secretary of Defense recertify to the Appropriations 
Committees in writing that the replacement medical center was properly 
sized and scoped to meet current and projected health care 
requirements.[Footnote 2] During the course of our review, DOD was in 
the process of conducting this recertification. 

DOD is also in the process of reassessing its force structure plans 
for Europe and is planning to reduce the number of brigade combat 
teams and the size of the military service component commands in 
Europe, among other things. Adjustments to DOD posture, in combination 
with the construction of a new medical center, have raised questions 
about the appropriate size for the replacement facility as well as the 
types of services it is to provide. Your subcommittee asked GAO to 
review DOD's plans for the replacement medical center, including how 
DOD determined the appropriate size for the facility and the types of 
services it will need to provide. In response, this report (1) 
describes how DOD officials considered potential changes to DOD's 
posture in Europe--and their possible effect on the beneficiary 
population--when developing facility requirements for the replacement 
medical center, (2) assesses DOD's process for determining facility 
requirements for the replacement medical center to determine to what 
extent it incorporated recently developed quality standards into the 
facility's design and adhered to DOD guidance, and (3) reviews the 
process used to develop the cost estimate for the facility to 
determine to what extent DOD followed established best practices for 
developing its cost estimate. 

To describe how DOD officials considered potential changes to DOD's 
posture in Europe--and their possible effect on the beneficiary 
population--when developing facility requirements for the replacement 
medical center, we obtained available posture planning documentation, 
including population estimates, and compared it with the beneficiary 
population data used in planning assumptions for the replacement 
medical center. We met with officials from the Offices of the 
Assistant Secretary of Defense (Health Affairs) and the Deputy Under 
Secretary of Defense (Installations and Environment), EUCOM, U.S. Army 
Europe, and U.S. Air Forces Europe to gain insight into possible 
scenarios that are being considered for posture changes in Europe. We 
also discussed with these officials the steps they had taken to ensure 
the reasonable accuracy of DOD beneficiary data and determined that 
the data specifically related to the proposed replacement medical 
center were sufficiently reliable for the purposes of this report. 

To assess DOD's process for determining facility requirements for the 
replacement medical center to determine to what extent it incorporated 
quality standards into its design and adhered to DOD guidance, we 
obtained and reviewed documentation used to develop plans for the 
proposed replacement medical center, such as health care requirements 
analyses and facility designs. We also reviewed relevant 
documentation--including checklists--to determine whether DOD included 
quality and environmentally friendly standards. We also identified key 
assumptions used to determine facility requirements for the 
replacement medical center and obtained and reviewed applicable legal 
and departmental guidance, including DOD instructions and directives, 
and compared them with the documented assumptions and methods used to 
develop the facility's requirements. We also met with medical and 
construction planners at the Office of the Assistant Secretary of 
Defense (Health Affairs), the TRICARE Management Activity, U.S. Army 
Medical Command, LRMC, the Air Force Medical Support Agency, and the 
86th MDG to discuss how they determined the size of the replacement 
medical center. 

To review the process used to develop the cost estimate for the 
facility to determine to what extent DOD followed established best 
practices for developing its cost estimate, we obtained and reviewed 
available cost estimates for the proposed replacement medical center, 
as well as supporting documentation. We evaluated this information 
using GAO's standardized methodology of cost estimating best 
practices.[Footnote 3] We determined whether technical baseline 
documentation exists and is reflected in the estimate. We also 
discussed project costs with officials from the Office of the 
Assistant Secretary of Defense (Health Affairs), the TRICARE 
Management Activity, and the U.S. Army Corps of Engineers, among 
others. 

We conducted this performance audit from July 2011 through May 2012 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. Further 
details on our scope and methodology can be found in appendix I. 

Background: 

The Military Health System operated by DOD is large and complex and 
has a dual health care mission--readiness and benefits. The readiness 
mission provides medical services and support to the armed forces 
during contingency operations and involves deploying medical personnel 
and equipment, as needed, around the world to support military forces. 
The benefits mission provides medical services and support to members 
of the armed forces, their family members, and others eligible for DOD 
health care, such as retired servicemembers and their families. 
[Footnote 4] DOD's health care mission is carried out directly through 
military medical centers, hospitals, and clinics throughout the United 
States and overseas, commonly referred to as military treatment 
facilities, as well as by civilian health care providers through 
TRICARE. Military treatment facilities make up DOD's direct care 
system for providing health care to beneficiaries. 

DOD's delivery of health care services includes, among other things, 
inpatient and outpatient care. Inpatient care refers to care for a 
patient who is formally admitted to a hospital or an institution for 
treatment, or care. Outpatient care, also known as ambulatory care, 
refers to health care services for an actual or potential disease, 
injury, or lifestyle-related problem that does not require admission 
to a medical treatment facility for inpatient care. 

The Assistant Secretary of Defense (Health Affairs) is responsible for 
ensuring the effective execution of DOD's health care mission and 
exercises authority, direction, and control over medical personnel 
authorizations and policy, facilities, funding, and other resources 
within DOD.[Footnote 5] The TRICARE Management Activity operates under 
the authority, direction, and control of Health Affairs. 

In 2008, the TRICARE Management Activity approved plans to renovate 
LRMC and the 86th MDG clinic at their existing locations. The initial 
LRMC plans included renovation of the inpatient tower; construction of 
an additional tower for emergency medicine, inpatient nursing units, 
and other clinical and support activities; and demolition of older 
facilities. The initial plans for the 86th MDG clinic included 
construction of a single building to consolidate health care services 
provided at separate facilities that currently make up the 86th MDG 
clinic. In 2009, the Office of the Deputy Under Secretary of Defense 
(Installations and Environment), together with Health Affairs, 
conducted a cost-benefit analysis that included consideration of 
alternative sites as well as consolidation of the two projects into a 
single medical center, and determined that consolidating the aging 
LRMC and 86th MDG clinic into one new facility that provides tertiary 
care in an area adjacent to Ramstein Air Base, known as the Weilerbach 
Storage Area, would be more efficient and cost-effective than pursuing 
two separate renovation or reconstruction projects. The replacement 
medical center will be operated and maintained by the Army, with the 
Air Force to provide clinical services that are currently offered at 
the 86th MDG clinic. 

Facility Requirements Process: 

The version of DOD's guidance governing the planning and acquisition 
of military health facilities (DOD Instruction 6015.17) that was in 
effect when the facility requirements for the replacement medical 
center were determined in 2010 described the procedures to be used by 
the military departments to prepare project proposals for military 
treatment facilities.[Footnote 6] This instruction also identified the 
types of documentation needed to support a project proposal. The 
documentation includes, among other things, the current and projected 
beneficiary population served in a military treatment facility's 
catchment area, as well as current and projected staffing and workload 
data.[Footnote 7] Army Medical Command, with input from the Air Force 
Medical Support Agency, developed a report that summarizes the 
projected health care requirements for Military Health System 
beneficiaries in the areas served by the proposed medical center. 
[Footnote 8] Generally, the combination of workload data and staffing 
requirements are key considerations for determining the size and 
configuration of military treatment facilities. These facility space 
requirements are identified in a Program for Design document, which 
lists square footage requirements per medical department and room. The 
estimated square footage is then used as the basis for developing 
overall project cost estimates as reflected on DD Form 1391 (Military 
Construction Project Data), the standard format used throughout DOD to 
support the planning and execution of military construction projects. 
Figure 1 provides an illustration of the process used in determining 
project costs for the replacement medical center. 

Figure 1: Overview of DOD Medical Treatment Facilities Requirements 
and Project Costs Process: 

[Refer to PDF for image: illustration] 

Staffing requirements; plus: 
Health care requirements/workload: 
DOD space planning guidance shows that among other things, workload 
and staffing are used to size and configure facilities to help ensure 
appropriate facility space. Health care requirements/workload and 
staffing requirements are usually determined and supported by a health 
care requirements analysis.
 
Space planning criteria: 
Staffing and workload are inputs into DOD's space planning criteria 
for health facilities, which is used to help determine the size and 
configuration of facilities.  
 
Facility requirements: 
Facility requirements are based on staffing and health care 
requirements/workload. The facility requirements are provided in the 
program for design.   

Project cost estimate: 
Project costs are based on facility requirements and reflected on the 
DD Form 1391, Military Construction Project Data. 

Source: GAO analysis of DOD information. 

[End of figure] 

DOD Considered Beneficiary Data, Contingency Operations, and Posture 
Changes in Sizing Its Replacement Medical Center but Has Not Assessed 
More Recent Posture Changes: 

In planning for the proposed replacement medical center, DOD officials 
considered beneficiary population data, contingency operations, and 
changes or expected changes in troop strength known at the time. 
However, more recent posture changes, announced in January 2012, are 
currently being assessed by military medical officials for their 
impact on the replacement medical center. DOD used beneficiary 
population data as of March 2010 and data on historical patterns of 
patient migration to identify the areas served by the proposed 
replacement medical center. A majority of the beneficiaries expected 
to receive health care from the replacement medical center are located 
within a 55-mile radius of it. DOD officials told us that because the 
replacement medical center was designed for peacetime operations--with 
the capacity to expand to meet the needs of contingency operations--
reductions in ongoing contingency operations in Afghanistan would not 
have an impact on facility requirements.[Footnote 9] DOD posture in 
Europe has been reduced over the past few years, and DOD had 
previously announced that one of four brigade combat teams currently 
stationed in Europe would be removed by 2015. According to DOD 
officials, this posture change was not expected to have a significant 
impact on the size of the replacement medical center because DOD plans 
to continue to use the facilities at Baumholder, Germany, which will 
be vacated by the brigade combat team, for other DOD personnel. In 
January 2012, DOD announced its decision to remove a second brigade 
combat team currently stationed in Europe, thereby reducing the 
remaining number of brigade combat teams in Europe to two--one 
stationed in Germany and the other in Italy. At the time of our 
review, DOD officials told us that they were in the process of 
assessing these proposed changes in posture to better understand their 
ramifications for DOD's medical facility needs. 

Beneficiary Population Areas Are Defined Using Historical Patterns of 
Patient Migration: 

The replacement medical center will serve as the only tertiary-level 
referral hospital for the EUCOM, Central Command, and Africa Command 
theaters of operation. Because of these unique aspects, according to 
medical planners they did not use typical DOD catchment area 
standards. Military treatment facilities are typically designed to 
offer sufficient health care for active duty beneficiaries and their 
dependents within a 40-mile radius of the military treatment facility. 
In the case of LRMC, medical planners determined that the historical 
patterns of care indicated that this area should be a 55-mile radius. 
Medical planners in the Office of the Secretary of Defense, the Army, 
and the Air Force analyzed historical patterns of patient migration 
and contingency operations at LRMC and the 86th MDG to define four 
catchment areas.[Footnote 10] See figure 2 for the location of these 
four catchment areas. 

Figure 2: Location of Four Catchment Areas Used to Define Patient 
Migration to Landstuhl Regional Medical Center: 

[Refer to PDF for image: illustrated map of Europe] 

Depicted on the map: 

Kaiserlaughtern Military Community; 
Germany; 
Europe Regional medical Command; 
European Command; 
Area within a 55-mile radius of Landstuhl Regional Medical Center. 

Source: GAO analysis of DOD information; Map REsources (map). 

Note: European Command also includes all of Russia, Greenland, and 
Iceland. 

[End of figure] 

The four catchment areas, as defined by military medical planners, are 
based on populations of patients who are enrolled as beneficiaries or 
who are eligible to enroll for the following locations: 

1. The Kaiserslautern Military Community catchment area includes all 
beneficiaries enrolled in LRMC, 86th MDG, and Kleber/Kaiserslautern 
military treatment facilities. This catchment area is approximately 55-
miles in radius surrounding the proposed facility's site. 

2. The Germany-wide catchment area includes all beneficiaries enrolled 
in the Kaiserslautern Military Community catchment area plus 
beneficiaries enrolled in the military treatment facilities in 
Germany. This catchment area definition was essential in determining 
the patterns of enrolled beneficiaries' use of German health care. 
[Footnote 11] 

3. The Europe Regional Medical Command catchment area includes all 
beneficiaries in the Germany-wide catchment area plus beneficiaries 
enrolled in all military treatment facilities in Italy and Belgium. 
This catchment area reflects historical inpatient referral patterns at 
LRMC. 

4. The EUCOM catchment area includes all enrolled beneficiaries and 
eligible beneficiaries in Europe, including all beneficiaries in the 
other three catchment areas. 

Table 1 shows the beneficiary population, by catchment area and 
beneficiary category, as of March 2010. In appendix II we include 
catchment area populations by beneficiary category, for fiscal years 
2006 through 2011. 

Table 1: Landstuhl Regional Medical Center (LRMC) Catchment Areas, by 
Beneficiary Category, as of March 2010: 

Catchment area: Kaiserslautern Military Community (enrolled)[C]; 
Beneficiary population: 
Active duty: 13,713; 
Active duty family members: 16,781; 
Retirees and others[A]: 3,955; 
March 2010 total[B]: 34,449. 

Catchment area: Germany-wide (enrolled); 
Beneficiary population: 
Active duty: 54,460; 
Active duty family members: 59,649; 
Retirees and others[A]: 11,366; 
March 2010 total[B]: 125,475. 

Catchment area: Europe Regional Medical Command (enrolled)[D]; 
Beneficiary population: 
Active duty: 66,068; 
Active duty family members: 73,993; 
Retirees and others[A]: 13,033; 
March 2010 total[B]: 153,094. 

Catchment area: European Command[E] (eligible)f; 
Beneficiary population: 
Active duty: 107,818; 
Active duty family members: 96,746; 
Retirees and others[A]: 43,603; 
March 2010 total[B]: 248,167. 

Source: DOD. 

[A] "Others" includes retiree family members. 

[B] Totals as of March 2010. 

[C] An enrolled beneficiary is defined as a TRICARE beneficiary who 
has elected to receive DOD's managed care options (TRICARE Prime, 
TRICARE Prime Remote, and TRICARE Prime Remote for Active Duty Family 
Members, the US Family Health Plan, TRICARE Prime Overseas, or TRICARE 
Global Remote Overseas) by enrolling in a military treatment facility. 

[D] Europe Regional Medical Command consists of beneficiaries enrolled 
in military treatment facilities located in Germany, Italy, and 
Belgium. According to DOD analysis, this catchment area reflects 
historical inpatient referral patterns at LRMC. 

[E] The European Command catchment area consists of beneficiaries in 
TRICARE's Region 13: "Europe." This region includes beneficiaries in 
both European Command and Central Command. 

[F] Eligible beneficiaries include active duty personnel and their 
dependents, medically eligible Reserve and National Guard personnel 
and their dependents, and retirees and their dependents and survivors. 

[End of table] 

According to DOD officials, the flow of patients from theaters of 
operation, including contingency operations, minimally affects the 
volume of inpatient care at LRMC and outpatient care at both LRMC and 
86th MDG. Table 2 shows that approximately half of all inpatient care 
at LRMC, a little more than 77 percent of outpatient care at LRMC, and 
almost 96 percent of outpatient care at the 86th MDG is provided to 
beneficiaries located within the Kaiserslautern Military Community 
catchment area as well as the Germany-wide catchment area. 

Table 2: Patient Migration Patterns for the Landstuhl Regional Medical 
Center (LRMC) and the 86th Medical Group (MDG) at Ramstein Air Base in 
Fiscal Year 2009: 

LRMC inpatient days of care: 
Germany-wide catchment area[A]: 49.9%; 
Europe Regional Medical Command and European Command catchment 
areas[B]: 39.6%; 
Contingency operations: 10.5%; 
Total: 100%. 

LRMC outpatient encounters;: 
Germany-wide catchment area[A]: 77.3%; 
Europe Regional Medical Command and European Command catchment 
areas[B]: 14.0%; 
Contingency operations: 8.7%; 
Total: 100%. 

86th MDG outpatient encounters: 
Germany-wide catchment area[A]: 95.7%; 
Europe Regional Medical Command and European Command catchment 
areas[B]: 2.7%; 
Contingency operations: 1.6%; 
Total: 100%. 

Source: DOD. 

[A] The Germany-wide catchment area includes those beneficiaries in 
the Kaiserslautern Military Community catchment area. 

[B] Percentage of inpatient days of care and outpatient encounters for 
the European Command and Europe Regional Medical Command catchment 
areas do not include those days of care and encounters from the 
Germany-wide catchment area. 

[End of table] 

Replacement Medical Center Is Designed for Peacetime Operations, with 
Flexible Capacity to Accommodate Contingency Operations: 

According to DOD officials, the replacement medical center is being 
sized for peacetime operations, not for contingency operations. 
However, these officials told us that the replacement medical center 
is being designed with the flexibility to expand capacity during 
surges to be able to handle casualties that result from contingency 
operations.[Footnote 12] 

DOD officials determined that the replacement medical center should be 
able to accommodate contingency operations' medical needs similar to 
those experienced in Fallujah, Iraq, during November 2004, in which 
the United States sustained about 100 casualties and 600 wounded over 
a 2-month period. For this reason, the new medical center is designed 
to be able to nearly double its medical/surgical bed capacity if 
needed to support contingency operations. 

According to Army officials, to mitigate the increase in patient 
workload resulting from surges caused by contingency operations, the 
new medical center will follow the procedures currently in use at 
LRMC. These procedures require that priority be given to active duty 
servicemembers, and therefore, other beneficiaries normally treated at 
LRMC would be directed to German health care facilities during a time 
when surge capability is needed (and capacity is constrained) and then 
redirected back to LRMC when the workload from contingency operations 
lessens. 

Earlier Posture Reduction Decisions Not Expected to Affect Replacement 
Medical Center Size, but More Recent Posture Changes Have Yet to Be 
Evaluated: 

DOD has been reducing its military posture in Europe since German 
reunification in 1990. At its peak, the United States had 
approximately 350,000 active duty servicemembers stationed in EUCOM's 
area of responsibility. The size of DOD's military posture in EUCOM's 
area of responsibility is currently estimated at about 78,000 active 
duty servicemembers. DOD has been reducing its medical treatment 
capacity over time to correspond to the reduction in the number of 
military servicemembers stationed in Europe. Today, LRMC is DOD's only 
remaining tertiary care medical center in Europe. Furthermore, it is 
the only medical center in Europe, Asia, or Africa that serves 
beneficiaries from the EUCOM, Central Command, Africa Command, and 
Special Operations Command areas of responsibility. 

In 2004, DOD announced its plans for an overseas basing strategy that 
called for reducing the number of Army brigade combat teams stationed 
in Europe from four to two. However, in the February 2010 Quadrennial 
Defense Review, DOD decided that it would retain all four Army brigade 
combat teams in Europe, rather than returning two to the United States 
as originally planned. Moreover, in April 2011, based on several 
factors, including consultations with allies and the findings of the 
North Atlantic Treaty Organization's new Strategic Concept, DOD 
announced that it planned to remove by 2015 only a single brigade 
combat team from Europe. According to DOD officials, the brigade they 
anticipated removing from Europe was stationed at U.S. Army Garrison 
(USAG) Baumholder, Germany, initially leaving brigades at USAG 
Grafenwoehr and USAG Vilseck, which are located close to one another 
in Germany and at USAG Vicenza, Italy. There are also elements of the 
Grafenwoehr brigade at USAG Schweinfurt, Germany. DOD also has plans 
to eventually close four Army locations in Germany--Heidelberg, 
Mannheim, Bamberg, and Schweinfurt. As a result of these closures, the 
elements of the Grafenwoehr brigade at Schweinfurt were expected to 
move to Grafenwoehr when Schweinfurt closed. As of the date of this 
report, the four brigade combat teams are still assigned at their 
original locations in EUCOM. The April 2011 announcement also included 
a DOD decision to station four Aegis Cruisers in Spain, a change that 
would increase the military beneficiary population in Europe. Figure 3 
shows the locations of DOD military installations in Europe where 
posture changes are expected to take place that could affect the 
facility requirements for the replacement medical center. 

Figure 3: DOD Military Installations in Europe with Expected Posture 
Changes That May Affect Replacement Medical Center Facility 
Requirements: 

[Refer to PDF for image: illustrated map of Europe] 

Military Installations depicted on the map: 

Landstuhl Regional Medical Center; 

Increasing personnel: 
Grafenwoehr/Vilseck (Germany) Army; 
Kaiserslautern (Germany) Army; 
Rota (Spain) Navy; 

Decreasing personnel: 
Baumholder (Germany) Army. 

Closing: 
Bamberg (Germany) Army; 
Heidelberg (Germany) Army; 
Mannheim (Germany) Army; 
Schweinfurt (Germany) Army. 

Ramstein (Air Force). 

Source: GAO analysis of DOD information; Map Resources (map). 

[End of figure] 

The brigade combat team currently located at Baumholder is within the 
Kaiserslautern Military Community catchment area and is expected to 
reduce the beneficiary population when it leaves.[Footnote 13] 
According to Army officials, the brigade consists of approximately 
4,200 soldiers, who are accompanied by about 6,300 
dependents.[Footnote 14] However, according to DOD officials, when 
this brigade leaves Baumholder other DOD personnel will be restationed 
there because Baumholder is considered an enduring installation with 
accessible joint military training facilities nearby.[Footnote 15] 
Army officials also told us that because some of the housing at 
Baumholder is substandard, they expect only 2,300 to 3,500 
servicemembers to move to Baumholder. Using the Army ratio of 1.5 
dependents to each military member indicates that as approximately 
10,500 servicemembers and their dependents who are medical 
beneficiaries of LRMC leave the catchment area, they will be replaced 
by 5,750 to 8,750 new servicemembers and their dependents--an overall 
reduction in the Kaiserslautern Military Community catchment area of 
from 4,750 to 1,750 beneficiaries. 

DOD officials told us that even though the beneficiary population at 
Baumholder will be reduced, they expect this change to have little 
impact on the workload and sizing requirements for the replacement 
medical center. In October 2009, DOD hired an independent contractor, 
Noblis, to perform a sensitivity analysis that would provide an order 
of magnitude estimate of potential changes to the beneficiary 
population that would need to occur to affect the size of the 
facility.[Footnote 16] This sensitivity analysis was further refined 
and updated in 2010. It specifically assessed the type of population 
changes that would require the addition or subtraction of intensive-
care unit (ICU) and medical/surgical beds, as well as specialty care 
exam rooms for outpatients. The analysis concluded that the planned 
capacities for the replacement medical center would be resilient to 
sizable changes in the population served. 

* A population change of up to 70,000 beneficiaries--a change in the 
total EUCOM beneficiary population of about 29 percent--would 
necessitate resizing of the requirements for ICU or medical/surgical 
beds by the addition or subtraction of a 20-bed module.[Footnote 17] 

* A population change of 25,000 to 31,000 beneficiaries--a change in 
the total EUCOM beneficiary population of between 10 percent and 13 
percent would necessitate re-sizing requirements for specialty care 
exam rooms by the addition or subtraction of an 8 to 10 exam room 
module.[Footnote 18] 

DOD officials told us that changes in the beneficiary population are 
expected to occur in the EUCOM catchment area through 2015. Although 
some of these changes will increase the population in certain 
locations, the overall change will be a reduction in the overall 
number of beneficiaries in EUCOM's area of responsibility. The 
following beneficiary changes are expected: 

* The Army expects a reduction in the Europe Regional Medical 
Command's active duty servicemembers and their dependents' population 
of about 21,000--a reduction in the total EUCOM beneficiary population 
by about 8 percent--by fiscal year 2015, according to the Updated 
(FY10) Health Care Requirements Analysis.[Footnote 19] However, it 
does not expect a significant change to the beneficiary population in 
the immediate Kaiserslautern Military Community catchment area. 

* The Air Force does not expect a change in its beneficiary population 
through fiscal year 2015. 

* The Navy expects to gain about 1,200 sailors from the stationing of 
the Aegis Cruisers in Rota, Spain, along with about 1,300 additional 
dependents--for a total increase of about 2,500 beneficiaries, or a 1 
percent gain in the total EUCOM beneficiary population. 

Based on the results of DOD's 2009 sensitivity analysis, the expected 
changes would not necessitate a change in the number of ICU beds, 
medical/surgical beds, or outpatient exam rooms. 

In January 2012, however, DOD announced new posture decisions that 
will further reduce EUCOM's troop strength. According to DOD, these 
posture decisions are part of a deficit reduction package based on the 
Budget Control Act of 2011[Footnote 20] requirement to reduce the 
department's future expenditures by approximately $487 billion 
[Footnote 21] over the next decade. EUCOM data indicate that by 2015 
approximately 71,500 active duty military servicemembers will remain 
in Europe following the latest changes to DOD's European posture. 

According to the January 2012 DOD publication Defense Budget 
Priorities and Choices, DOD has updated its April 2011 plans for its 
European basing strategy and has stated that it intends to now remove 
two brigade combat teams from Europe.[Footnote 22] These two brigades 
are currently located at Baumholder and Grafenwoehr with elements of 
the brigade in Grafenwoehr located in Schweinfurt. As a result, the 
elements in Schweinfurt will not relocate to Grafenwoehr as previously 
planned. 

DOD's decision to remove two brigades from Europe and how this shift 
in troop numbers will affect health care requirements in the EUCOM 
area of responsibility have yet to be fully determined. However, DOD 
officials noted that they did not believe the removal of a second 
brigade combat team would affect the beneficiary population of the 
replacement medical center because the second brigade is currently 
stationed outside the immediate Kaiserslautern Military Community 
catchment area. DOD officials told us that they have started a review 
to confirm that the shift in DOD posture will not affect the 
requirements for the proposed replacement medical center. They noted 
that recent troop reductions are being studied to determine what 
impact, if any, they will have on the proposed size of the replacement 
medical center. They also noted that they are developing a sensitivity 
analysis to accommodate the information and will include it as part of 
DOD's statutorily required recertification of the facility. As of the 
date of this report, they had not completed the study because along 
with the recertification, DOD must also submit a plan for implementing 
GAO's recommendations with respect to the LRMC facility. 

DOD Incorporated Quality Standards When Determining Facility 
Requirements, but Inadequate Documentation Makes It Unclear Whether 
DOD Adhered to Its Own Guidance: 

When developing facility requirements for the replacement medical 
center, DOD officials incorporated many patient quality of care and 
environmentally friendly design standards. However, our review of the 
documentation DOD provided in support of these facility requirements 
revealed gaps, inconsistencies, and calculation errors that required 
extensive explanation by DOD officials to understand the deviations 
and decisions made to develop the requirements. Without clear 
documentation that explains how the analyses were performed and any 
adjustments made, stakeholders and decision makers lack reasonable 
assurance that the proposed replacement medical center will be 
appropriately sized to meet the needs of the expected beneficiary 
population in Europe. 

DOD Incorporated Quality of Care and Environmentally Friendly Design 
Standards in Determining Facility Requirements: 

DOD officials used checklists and discussions with external health 
care providers to incorporate updated patient quality of care 
standards into the facility requirements for the replacement medical 
center; they also incorporated environmentally friendly design 
standards. They used DOD's military hospital construction checklists 
to ensure that they incorporated updated patient quality of care 
standards, such as evidence-based design[Footnote 23] and world-class 
standards,[Footnote 24] when determining the size of the replacement 
medical center. For example, DOD officials told us they used the 
Evidence Based Design Checklist--which DOD created in August 2007 and 
updated in 2009--to incorporate design concepts into health care 
construction projects that have impacts on patient-centered care. 
Examples of evidence-based design include single-patient instead of 
multiple-patient rooms to better accommodate family involvement in the 
provision of care and to better control infections, and studying 
layouts and workspace ergonomics to maximize work pattern efficiency. 
Additionally, DOD officials and the architectural and engineering firm 
contracted for the design of the replacement medical center used DOD's 
Military Health Service World-Class Checklist to ensure that world-
class standards were integrated into the facility's design. The 
checklist identifies areas for DOD officials to research to help 
ensure that world-class standards are systematically developed, 
validated, and communicated with project teams. The completed 
checklist described examples of how world-class standards--which 
encompass many of the evidence-based designs from the Evidence Based 
Design Checklist--were integrated into the facility's design. Some of 
the world-class standards incorporated into the facility requirements 
were (1) optimizing the size and position of the patient windows to 
provide exterior views for the patient from the bed, (2) providing 
patient and family control over the environment in the patient room 
(e.g., heating and cooling), and (3) providing full height walls with 
higher noise transmission ratings (a higher noise transmission rating 
blocks more noise from transmitting through a wall) in spaces where 
patients would be asked to disclose personal information. DOD 
officials told us they also met with officials from Department of 
Veterans Affairs' hospitals, private sector hospitals, and German 
hospitals to obtain information on evidence-based practices for 
providing health care that could be applied to the replacement medical 
center's design. 

DOD has also incorporated additional environmental and efficiency 
features into the design of the replacement medical center and expects 
to exceed the U.S. Green Building Council's Leadership in Energy and 
Environmental Design (LEED) green building standards, which have been 
adopted by several federal agencies.[Footnote 25] The LEED system 
awards points for meeting a variety of standards and certifies 
buildings as silver, gold, or platinum. The replacement medical 
center's current design will likely qualify for a "silver" 
certification. However, the facility's extensive energy efficiency and 
renewable energy features indicate that it may qualify for a "gold" 
certification once it has met the more stringent German design 
requirements. For example, the project will use low water plumbing 
fixtures and commercial kitchen equipment available in Germany to 
reduce water use and achieve higher efficiency. 

Inconsistencies, Gaps, and Calculation Errors in Planning 
Documentation Make It Unclear Whether DOD Adhered to Its Own Guidance 
for Determining Facility Requirements: 

DOD sized the replacement medical center based on projected patient 
workload data. However, our review of the planning documentation DOD 
provided in support of its facility requirements showed that there 
were (1) inconsistencies in how DOD projected patient workload and 
applied the planning criteria, (2) some areas where the planning 
documentation did not clearly show how DOD officials had applied the 
formulas provided in the criteria to generate requirements, and (3) 
calculation errors throughout. DOD guidance in effect when the 
facility was designed[Footnote 26] provided that when designing 
medical facilities, planners should develop patient workload 
factors[Footnote 27]--both current and projected--and use these 
factors to determine the sizing requirements for the facility. While 
DOD officials acknowledged that inconsistencies, gaps in 
documentation, and calculation errors existed in the requirements 
documentation, they did not think the identified issues alone would 
necessitate a revision of the facility requirements. However, because 
DOD has not yet determined the effects of the newly proposed posture 
changes on projected patient workload--which in turn drives the 
requirement for the facility size--it is not known if the 
inconsistencies, gaps, and calculation errors coupled with the posture 
change will require DOD to revise its facility requirements. DOD 
officials plan to examine these concerns in their recertification 
process. 

The Updated (FY10) Health Care Requirements Analysis report for LRMC 
captures some of these data and steps DOD used to determine the sizing 
requirements for the replacement medical center (see table 3 for the 
sizing requirements that DOD developed, by medical center department). 
[Footnote 28] 

Table 3: Proposed Sizing Requirements for the Replacement Medical 
Center: 

Department: Inpatient beds; 
Number of beds: [Empty]; 
Number of rooms: [Empty]. 

Department: Intensive care unit; 
Number of beds: 18; 
Number of rooms: [Empty]. 

Department: Newborn intensive care unit; 
Number of beds: 8; 
Number of rooms: [Empty]. 

Department: Medical/surgical; 
Number of beds: 60[A]; 
Number of rooms: [Empty]. 

Department: Obstetrician-postpartum; 
Number of beds: 14; 
Number of rooms: [Empty]. 

Department: Behavioral health; 
Number of beds: 30; 
Number of rooms: [Empty]. 

Department: Total number of inpatient beds; 
Number of beds: 130; 
Number of rooms: [Empty]. 

Department: Operating rooms; 
Number of beds: [Empty]; 
Number of rooms: 9. 

Department: Labor and delivery rooms; 
Number of beds: [Empty]; 
Number of rooms: 6. 

Department: Outpatient exam rooms; 
Number of beds: [Empty]; 
Number of rooms: 198. 

Sources: GAO (analysis); DOD (data). 

[A] Fifty of the 60 single-patient medical/surgical inpatient beds 
have the capability to become semiprivate patient rooms if needed for 
surge capacity, which would bring the total number of beds to 180 if 
all 50 were placed in service. 

[End of table] 

Inconsistencies in projecting workload and applying criteria. To 
project most inpatient and outpatient workload for the replacement 
medical center, DOD officials used fiscal year 2010 estimated patient 
workload data as a baseline.[Footnote 29] However, they used different 
baseline data in different parts of the analysis. For example, in 
determining the number of labor and delivery rooms, DOD officials did 
not use workload data from fiscal year 2010 as the baseline. According 
to DOD officials, the obstetrician workload has historically been 
relatively stable. Therefore, they used the labor and delivery room 
workload data from the Health Care Requirements Analysis, which had 
been conducted in fiscal year 2008 to support the original plan for 
renovating and reconstructing LRMC and determined that the data were 
accurate enough for their purposes. 

Once DOD officials determined what projected workload data to use in 
their calculations for the new facility, they were to use the criteria 
in DOD Space Planning Criteria for Health Facilities to calculate the 
facility's requirements, for example, the appropriate number of 
inpatient beds and outpatient exam rooms.[Footnote 30] DOD officials 
generally used the formulas provided in this document, but they 
applied them inconsistently when determining the appropriate size for 
individual departments within the facility. For example, the space 
planning criteria direct DOD officials to divide an inpatient 
department's projected workload--in this case, the average daily 
census--by a particular occupancy rate to determine the number of 
inpatient beds that would be required.[Footnote 31] The criteria 
specify that certain inpatient beds should be designed in modules of 
4, 6, or 8 beds. DOD generally followed these criteria in calculating 
the number of nursing unit medical/surgical beds, a type of inpatient 
bed. The criteria specify an occupancy rate of 85 percent for 
inpatient medical/surgical beds. Following this formula, DOD officials 
divided the projected average daily census (48.7 patients) by 0.85. 
This calculation resulted in a requirement for 57.3 beds. To conform 
to the modular grouping criteria, DOD officials rounded to 60 beds. 

However, in determining the number of inpatient behavioral health beds 
DOD officials deviated from these criteria. The projected average 
daily census for behavioral health was 24 patients. The space planning 
criteria specify a 70 percent occupancy rate for psychiatric (i.e., 
behavioral health) beds when the average daily census is fewer than 25 
patients, instead of the 85 percent occupancy rate specified for 
nursing unit medical/surgical beds. Nevertheless, DOD officials used 
an 85 percent occupancy rate to calculate the requirement for 
behavioral health beds. This resulted in a requirement for 28.2 beds--
rounded to 30 beds to conform to the modular grouping criteria. 
According to DOD officials, they chose to use a different occupancy 
rate factor because they reasoned that since space planning criteria 
had not been updated to reflect the shift to single occupancy rooms, 
the 70 percent rate would likely result in a requirement for a higher 
number of beds. Following the space planning criteria's guidance would 
have produced a requirement for 34.3 beds, which would have been 
rounded to 36 beds to account for the modular grouping criteria. As a 
result, the need for behavioral health beds may actually be higher 
than DOD officials determined. The documentation did not clearly 
convey the reasons for the deviations or adjustments DOD officials 
made when applying the criteria, and as a result, decision makers may 
lack reasonable assurances that the number of beds required would be 
sufficient to meet the needs of the expected beneficiary population in 
Europe. Although these deviations or adjustments may not adversely 
affect the size of the replacement medical center, their effect when 
combined with the yet to be assessed posture changes remains unknown. 

Inadequate documentation of how facility requirements were estimated. 
DOD's documentation of its processes for determining the replacement 
medical center's sizing requirements did not always clearly indicate 
how DOD officials had generated these requirements and omitted details 
that would have helped demonstrate how DOD officials had determined 
the size of the replacement medical center. For example, DOD's 
planning documentation reported contradictory methods for projecting 
patient workload. According to the Updated (FY10) Health Care 
Requirements Analysis, DOD used three different scenarios to project 
the facility's workload, resulting in a low, a midrange, and a high 
projection; all three scenarios used estimated patient workload data 
from fiscal year 2010 as the baseline: 

* Scenario A excluded the workload attributable to the conflicts in 
Iraq and Afghanistan, and assumed that the change in patient workload 
would continue to follow the trend set over the previous 5 years. 
[Footnote 32] 

* Scenario B adjusted for potential future decreases in beneficiary 
population, and assumed that the change in patient workload would 
continue to follow the trend set over the previous 5 years.[Footnote 
33] 

* Scenario C assumed that the change in patient workload would 
continue to follow the trend set over the previous 5 years and made no 
exclusions or adjustments. 

The Updated (FY10) Health Care Requirements Analysis first reported 
using Scenario B--the scenario that resulted in midrange projections--
to project inpatient and outpatient workload for the replacement 
facility. However, later sections of the document report the use of 
different methods to project patient workload. DOD officials confirmed 
that they had used a combination of methods to project inpatient and 
outpatient workload, and that they had used Scenario B only to 
validate these projections after they had calculated them. These 
officials acknowledged that the Updated (FY10) Health Care 
Requirements Analysis could have better documented how these 
projections were developed. The lack of clear documentation makes it 
difficult to understand the processes used without extensive 
explanation by DOD officials. 

In addition, the Updated (FY10) Health Care Requirements Analysis 
omitted details on how DOD officials developed certain data. For 
example, the document does not show how DOD officials projected 
inpatient workload for behavioral health beds, only noting that the 
projected average daily census was 24 patients. Although the Updated 
(FY10) Health Care Requirements Analysis did not document how the 
average daily census was calculated, DOD officials told us that the 
historical data on inpatient behavioral health workload were not 
sufficient for projecting workload because LRMC's behavioral health 
inpatient capacity was such that any beneficiaries other than active 
duty servicemembers were referred to the German economy for treatment. 
Therefore, the officials said they used another method (Scenario C) to 
project workload, so that the facility would have the inpatient 
behavioral health capacity to treat additional patients. The planning 
documentation also does not show how DOD officials projected the 
number of providers required for outpatient ambulatory departments. 
[Footnote 34] The Updated (FY10) Health Care Requirements Analysis 
contains a table with the number of outpatient ambulatory providers 
but does not show how or whether projected outpatient workload data 
for the replacement medical center were used to determine the number 
of outpatient providers that would be required. These gaps in 
documentation make it unclear whether the size of the replacement 
medical center will be adequate to meet the needs of the beneficiary 
population, and when combined with potential posture changes and 
previously discussed deviations or adjustments, the extent to which 
they may affect the size of the facility is unknown. 

Calculation errors in the planning documentation. We also found 
several calculation errors within the Updated (FY10) Health Care 
Requirements Analysis report. One table in the report that shows 
historical (5-year average), baseline, and projected workload for 
inpatient and outpatient care had errors in the 5-year average column 
for inpatient dispositions[Footnote 35] and bed days of care. When we 
spoke with DOD officials, we pointed out these errors. DOD officials 
acknowledged the errors and noted that the correct numbers could be 
found in a separate table in the report's appendix--although the 
appendix table was not listed as a reference to support the historical 
workload numbers. Additionally, a table in the report's appendix, 
which illustrated the different projected inpatient and outpatient 
workload data, calculated using the three different scenarios, had 
many calculation errors in the projected outpatient workload columns. 
Specifically, in calculating projected workload using Scenarios A and 
B, DOD incorrectly used the 5-year average--instead of the fiscal year 
2010 data--as a baseline, and when using Scenario C, DOD adjusted for 
potential decreases in the beneficiary population, although this 
scenario did not call for such an adjustment. As a result, outpatient 
workload data using Scenario B, for example, was calculated to be 
288,534 encounters instead of 328,944 (a 14 percent difference). The 
projected data derived by incorrectly applying Scenario B were then 
used in another table in the report's appendix to verify that the 
projected outpatient provider staffing would be sufficient to treat 
the projected number of outpatients. DOD officials acknowledged the 
error and provided us with correct data. According to DOD officials, 
even though there was a 14 percent difference in the projected 
outpatient workload data, the outpatient provider staffing levels 
would still be sufficient. Although these calculation errors may not 
adversely affect the size of the replacement medical center, it 
remains unknown to what extent this error will affect facility 
requirements when combined with the yet to be assessed posture 
changes, previously discussed deviations or adjustments, and gaps in 
documentation. 

Standards for internal controls include, among other things, control 
activities.[Footnote 36] Control activities include policies, 
procedures, techniques, and mechanisms that enforce management's 
directives. They can include a wide range of activities--such as 
authorizations, verifications, and documentation--that should be 
readily available for examination. Detailed and appropriate 
documentation is a key component of internal controls. Without clear 
documentation of key analyses, and of how adjustments to facility 
requirements were made, stakeholders lack reasonable assurances that 
the proposed replacement medical center will be able to provide the 
appropriate health care capacity to meet the needs of the beneficiary 
population it is expected to serve. 

DOD's Cost Estimate Was Not Well Documented and Cost Elements for 
Associated Facilities Have Yet to Be Developed: 

In developing the cost estimate for the replacement facility, DOD 
followed many of the best practices in developing estimates of capital 
projects, but DOD minimally documented the data sources, calculations, 
and estimating methodologies used in developing the cost estimate. 
Further, it is anticipated that the replacement medical center will 
become the hub of a larger medical-services-related campus, for which 
neither cost estimates nor time frames have yet been developed. 

DOD's Cost Estimation Methodology Substantially Met Best Practice 
Criteria but Was Not Well Documented: 

The GAO Cost Estimating and Assessment Guide contains cost estimating 
best practices that have been identified by GAO and cost experts 
within organizations throughout the federal government and 
industry.[Footnote 37] These best practices can be grouped into four 
general characteristics of sound cost estimating: 

1. "Accurate" refers to being unbiased and ensuring that the cost 
estimating is not overly conservative or overly optimistic and is 
based on an assessment of most likely costs. 

2. "Credible" refers to discussing any limitations of the analysis 
because of uncertainty or bias surrounding data or assumptions used in 
the cost estimating process. 

3. "Comprehensive" refers to ensuring that cost elements are neither 
omitted nor double counted, and all cost-influencing ground rules and 
assumptions are detailed. 

4. "Well documented" refers to thoroughly documenting the process, 
including source data and significance, clearly detailed calculations 
and results, and explanations of why particular methods and references 
were chosen. 

See appendix III for detailed information on each of these cost 
estimating characteristics. 

In addition, Office of Management and Budget (OMB) best practices note 
that programs should maintain current and well-documented estimates of 
program costs, and that these estimates should encompass the full life 
cycle of the program.[Footnote 38] 

The characteristics of sound cost estimating are divided into 
individual criteria, which we used to assess DOD's process for 
developing its cost estimate. Our process for evaluating the cost 
estimate consisted of assigning an assessment rating for the various 
criteria evaluated on a 1 to 5 scale: not met = 1, minimally met = 2, 
partially met = 3, substantially met = 4, and met = 5. Then, we took 
the average of the individual assessment ratings to determine an 
overall rating for each of the overarching characteristics: accurate, 
credible, comprehensive, and well documented. Criteria assessed as not 
applicable were not given a score and were not included in our 
calculation of the overall assessment. Furthermore, our review of 
DOD's process for developing the cost estimate does not reflect an 
assessment of how facility requirements were developed or their 
quality, but only a determination of whether they are described in 
technical documentation and reflected in the estimate.[Footnote 39] 
However, as discussed previously in this report, during our assessment 
of DOD's process for determining facility requirements for the 
replacement medical center, we found some calculation errors in the 
facility requirements. 

Table 4 provides a summary of our assessment of DOD's cost estimating 
process. 

Table 4: Summary Assessment of the Results of DOD Cost Estimating 
Process for the Replacement Medical Center as Compared to Best 
Practices: 

Characteristic: Accurate; 

Overall assessment[A]: Substantially met; 
Best practice: The cost estimate results are unbiased, not overly 
conservative or optimistic, and based on an assessment of the most 
likely costs; 
Individual assessment: Minimally met. 

Best practice: The estimate has been adjusted properly for inflation; 
Individual assessment: Partially met. 

Best practice: The estimate contains few, if any, minor mistakes; 
Individual assessment: Met. 

Best practice: The cost estimate is regularly updated to reflect 
significant changes in the program so that it always reflects current 
status; 
Individual assessment: Met. 

Best practice: Variances between planned and actual costs are 
documented, explained, and reviewed; 
Individual assessment: Not applicable. 

Best practice: The estimate is based on a historical record of cost 
estimating and actual experiences from other comparable programs; 
Individual assessment: Substantially met. 

Characteristic: Credible; 

Overall assessment[A]: Substantially met; 
Best practice: The cost estimate includes a sensitivity analysis that 
identifies a range of possible costs based on varying major 
assumptions, parameters, and data inputs; 
Individual assessment: Partially met. 

Best practice: A risk and uncertainty analysis has been conducted that 
quantified the imperfectly understood risks and identified the effects 
of changing key cost driver assumptions and factors; 
Individual assessment: Partially met. 

Best practice: Major cost elements have been cross-checked to see 
whether results were similar; 
Individual assessment: Met. 

Best practice: An independent cost estimate has been conducted by a 
group outside the acquiring organization to determine whether other 
estimating methods produce similar results; 
Individual assessment: Met. 

Characteristic: Comprehensive; 

Overall assessment[A]: Substantially met; 
Best practice: The cost estimate includes all life cycle costs; 
Individual assessment: Minimally met. 

Best practice: The cost estimate completely defines the program, 
reflects the current schedule, and is technically reasonable; 
Individual assessment: Substantially met. 

Best practice: The cost estimate work breakdown structure is product 
oriented, traceable to the statement of work/objective, and at an 
appropriate level of detail to ensure that cost elements are neither 
omitted nor double counted.[B]; 
Individual assessment: Met. 

Best practice: The estimate documents all cost-influencing ground 
rules and assumptions; 
Individual assessment: [Empty]. 

Characteristic: Well documented; 
Overall assessment[A]: Minimally met; 

Best practice: The documentation captures the source data used, the 
reliability of the data, and how the data were normalized; 
Individual assessment: Minimally met. 

Best practice: The documentation describes in sufficient detail the 
calculations performed and the estimating methodology used to derive 
each element's cost; 
Individual assessment: Minimally met. 

Best practice: The documentation describes step-by-step how the 
estimate was developed, so that a cost analyst unfamiliar with the 
program would be able to understand what had been done and replicate 
it; 
Individual assessment: Minimally met. 

Best practice: The documentation discusses the technical baseline 
description and the data in the baseline are consistent with the 
estimate; 
Individual assessment: Minimally met. 

Best practice: The documentation provides evidence that the cost 
estimate has been reviewed and accepted by management; 
Individual assessment: Partially met. 

Source: GAO analysis of DOD data. 

[A] Assessments are defined as follows: not met means that DOD 
provided no evidence that satisfies the criterion; minimally met means 
that DOD provided evidence that satisfies a small portion of the 
criterion, but overall, did not include sufficient support for 
stakeholders to reasonably conclude that the cost estimate is 
reliable; partially met means that DOD provided evidence that 
satisfies about half of the criterion; substantially met means that 
DOD provided evidence that satisfies a large portion of the criterion; 
and met means that DOD provided complete evidence that satisfies the 
entire criterion. 

[B] A work breakdown defines in detail the work necessary to 
accomplish a program's objectives. It deconstructs a program's end 
product into successive levels with smaller specific elements until 
the work is subdivided to a level suitable for management control. It 
is also a valuable communication tool between management and 
stakeholders because it provides a clear picture of what needs to be 
accomplished and how the work will be done. In addition, it provides a 
consistent framework for planning and assigning responsibility for the 
work. Initially set up when the program is established, the work 
breakdown structure becomes more detailed over time, as more 
information becomes known about the program. 

[End of table] 

DOD's Cost Estimating Methodology for the Replacement Medical Center 
Substantially Met Best Practice Criteria for Accuracy: 

We determined that the cost estimate for the replacement medical 
center had been updated as project requirements were better defined. 
The overall cost estimate was broken down into costs per square foot, 
which were based on historical records of costs and actual experiences 
from other comparable programs. Although the DD Form 1391 does not 
include documentation regarding how inflation was factored into the 
estimated costs for the replacement medical center, DOD officials told 
us that costs on the DD Form 1391 have been adjusted for inflation 
using departmental guidance. 

We found no evidence indicating that the cost estimate is biased. 
However, it is not possible to fully assess the accuracy and 
reliability of a cost estimate without conducting a risk analysis that 
indicates the confidence level associated with the project's estimated 
cost. Yet, the independent estimate and estimate validation that are 
further described below are sufficient to meet the requirements of 
this criterion. 

DOD's Cost Estimating Methodology for the Replacement Medical Center 
Substantially Met Best Practice Criteria for Credibility Overall, but 
Lacked Sensitivity and Risk Analyses of Some Key Cost Elements: 

DOD hired an architecture and engineering firm to validate the cost 
estimate using a cross-check of major cost elements to determine 
whether alternative methods would have produced similar results. 
[Footnote 40] The contractor concluded that the cost estimate was 
valid. It also developed an independent cost estimate and determined 
that the design of the facility was within 1 percent of the size 
listed on the DD Form 1391, and that the resulting cost was also 
within 1 percent of DOD's cost estimate.[Footnote 41] 

DOD officials told us that they also hired a separate firm to develop 
sensitivity and risk analyses that were designed to meet GAO cost 
estimating standards as published in the Cost Estimating and 
Assessment Guide.[Footnote 42] However, we found some limitations in 
these analyses. The only cost drivers evaluated were the exchange 
rate, German inflation, the cost of various raw materials, and a 
composite labor rate. The analyses did not evaluate the potential cost 
impact of variations in the beneficiary population, catchment area, 
level of care provided, or amount of battle-related injuries. 
Moreover, the analyses did not evaluate the cost impact of varying the 
square footage requirements documented in the Program for Design. 
[Footnote 43] To determine whether an estimate is credible, key cost 
elements should be tested for sensitivity, and other cost estimating 
techniques should be used to cross-check the reasonableness of the 
ground rules and assumptions. It is also important to determine how 
sensitive the final results are to changes in key assumptions and 
parameters. 

DOD's Cost Estimating Methodology for the Replacement Medical Center 
Substantially Met Best Practice Criteria for Comprehensiveness 
Overall, but Lacked Recurring Life Cycle Costs: 

DOD's cost estimating methodology for the replacement medical center 
substantially met best practice criteria for overall 
comprehensiveness, but some costs and assumptions were not included in 
the individual criteria that make up the comprehensive cost estimating 
characteristic. The cost estimate generally includes categories of 
costs for the design, construction, and outfitting of the replacement 
medical center. Additionally, DOD provided an appropriate work 
breakdown structure for the facility to help ensure that cost elements 
were neither omitted nor double counted. 

DOD also provided us with technical baseline documentation, including 
the Updated (FY10) Health Care Requirements Analysis report and the 
Program for Design, which defines the technical and programmatic 
requirements of the project. DOD officials told us that technical 
baseline documentation was developed by qualified personnel--including 
a multidisciplinary team of health care planners, architects, and 
engineers--and has been updated as the project has evolved. We found 
no instances in which any costs for design, construction, and 
outfitting of the replacement medical center were omitted. 

Although DOD provided us with some cost information as well as 
technical baseline documentation, additional recurring life cycle 
costs were, for the most part, not available, resulting in this 
subcategory criterion for comprehensiveness being rated as minimally 
met. The cost estimate does not include any facility sustainment 
costs, costs for supporting infrastructure, or any operation and 
maintenance costs for personnel or equipment required to operate the 
facility. In addition, the cost estimate does not include costs 
associated with the disposition or retirement of proposed medical 
center facilities at the end of their life cycles, such as demolition 
or renovation costs. In addition, DOD officials said costs associated 
with the disposition of the current LRMC or 86th MDG are not included 
in the cost estimate. Army officials told us that the facilities that 
make up the current LRMC will remain under the auspices of the Army. 
These officials noted that following completion of the replacement 
medical center, ownership of the current LRMC facilities will transfer 
to Army Installation and Management Command. Under this arrangement, 
these facilities will no longer be classified as part of the Military 
Health System. Therefore, Army officials told us that any costs 
associated with their disposition should not be included in the 
overall estimate for the replacement medical center. The 86th MDG 
clinic consists of 13 separate buildings. The remaining components 
that make up the current 86th MDG clinic will be transferred to 
Ramstein Air Base. According to 86th MDG officials, some of these 
buildings will remain in use following completion of the replacement 
medical center, while others will be demolished. However, it has not 
been decided how the remaining clinic buildings will be used; the 
officials said that this decision will be made by the installation 
commander at Ramstein Air Base. Since demolition or continued use of 
the remaining facilities will require DOD funding, these costs should 
be captured; they will help to show the full cost impact of the 
replacement medical center project. Further, the cost estimate 
contains minimal documentation of cost-influencing ground rules and 
assumptions. DOD officials noted that some of the ground rules and 
assumptions have been included in the technical baseline 
documentation. However, we could not find a documented reference or 
link in the technical baseline documentation we examined to specific 
cost elements in the DD Form 1391. We also found no evidence of 
documentation of the risks associated with assumptions, which should 
be traced to specific cost elements. 

A life cycle cost estimate should encompass all past (or sunk), 
present, and future costs for every aspect of the program, regardless 
of funding source, including all government and contractor costs. 
Without a full accounting of life cycle costs, management will have 
difficulty successfully planning program resource requirements and 
making wise decisions about where to allocate resources. Cost 
estimates are typically based on limited information and therefore 
need to be bound by the constraints that make estimating possible. 
These constraints are usually defined by ground rules and assumptions. 
However, because such assumptions are best guesses, the risks 
associated with a change to any of these assumptions must be 
identified and assessed. Many assumptions profoundly influence cost; 
the subsequent rejection of even a single assumption could invalidate 
many aspects of the cost estimate. Unless ground rules and assumptions 
are clearly documented, a cost estimate will not provide a basis for 
developing resolutions concerning areas of potential risk. 
Furthermore, it will not be possible to reconstruct the estimate when 
the original estimators are no longer available. 

DOD's Cost Estimating Methodology for the Replacement Medical Center 
Minimally Met Best Practice Criteria for Well Documented: 

A well-documented cost estimate is essential if an effective 
independent review is to ensure that it is valid. However, the 
documentation DOD provided in support of its cost estimate did not 
clearly demonstrate how facility requirements had been factored into 
cost elements. 

DOD's cost estimate lacked documentation that described, in detail, 
the calculations performed and the estimating methodology used to 
derive the cost for each element of the replacement medical center. 
None of the documents provided to us included detailed documentation 
of how DOD developed and refined the cost estimate. A complete 
documentation of source data would include, for each line item in the 
cost estimate, a reference to a specific data source or sources 
(including the document and page number) used as the basis for each 
square footage and unit cost amount. For example, the cost estimate 
contains line item estimates for electricity, water/sewer/gas, 
steam/chilled water distribution, and storm drainage. However, from 
the documentation provided, it is not possible to determine how these 
requirements were used to develop cost estimates. 

The technical baseline description and data in the technical baseline 
documentation are spread across several documents, including the 
Updated (FY10) Health Care Requirements Analysis report, Program for 
Design, and a Planning Charrette Discussion.[Footnote 44] However, 
only the Planning Charrette Discussion is referenced in the cost 
estimate on the DD Form 1391. Moreover, we found minor differences 
between the square footage requirements in the Program for Design and 
the cost estimate as described on the DD Form 1391. For example, the 
Program for Design reports a total gross square footage requirement of 
1,293,409 and the cost estimate reports a total requirement of 
1,340,731 square feet. It was not possible to compare square footage 
amounts for various components of the facility because of the 
differing levels of detail in the Program for Design and the cost 
estimate. The difference in square footage numbers between the Program 
for Design and the DD Form 1391 is not documented; therefore, the 
reasons for the difference are unclear. Since the technical baseline 
is intended to serve as the basis for developing a cost estimate, it 
should be discussed in the cost estimate documentation. 

Cost estimators should provide a briefing to management about how the 
estimate was constructed--including specific details about the 
program's technical characteristics, assumptions, data, cost 
estimating methodologies, sensitivity, risk, and uncertainty--so 
management can gain confidence that the estimate is accurate, 
complete, and high in quality. However, we found no documentation of a 
detailed review and approval that included the estimate's technical 
foundation, ground rules and assumptions, estimating methods, data 
sources, sensitivity analysis, risks and uncertainty, cost drivers, 
cost phasing, contingency reserves, or affordability. 

DOD officials confirmed our conclusion that their cost estimating 
process was not fully documented. They told us that they had developed 
supporting facility costs using expert opinion and parametric models; 
however, these were not listed in the cost estimate.[Footnote 45] 
According to DOD officials, DOD guidance does not require detailed 
documentation as part of the DD Form 1391 cost estimate. Under DOD's 
cost methodology, as the project design matures, so does the level of 
cost analysis. DOD officials asserted that the current cost estimate 
is appropriate for the current level of design. DOD officials 
acknowledged that better documentation would have provided more 
support and information to the various decision makers in the process 
and would be a good practice to follow. 

If the cost estimate for the replacement medical center does not 
include detailed documentation, stakeholders cannot reasonably 
conclude that it is reliable. In addition, DOD and Congress may not 
have the information they need to make fully informed decisions about 
the facility. If a cost estimate does not fully account for life cycle 
costs, management will have difficulty successfully planning program 
resource requirements and making wise decisions. Poorly documented 
cost estimates can cause a program's credibility to suffer, because 
the documentation cannot explain the rationale of the methodology or 
the calculations underlying the cost elements. Further, without clear 
technical baseline documentation, the cost estimate will not be based 
on a comprehensive program description and will lack specific 
information regarding technical and program risks. Unless the cost 
estimate is fully documented, it cannot be reconciled with an 
independent cost estimate. 

Replacement Medical Center Expected to Be Part of Medical Campus, but 
Additional Cost Elements Have Yet to Be Determined: 

DOD officials told us that the replacement medical center will be a 
fully functioning military treatment facility and not require any 
additional support facilities to fulfill its mission of providing 
inpatient and outpatient care. However, in the Strategic Concept of 
Operations section of the Updated (FY10) Health Care Requirements 
Analysis report for the replacement medical center, the center is 
described as being the hub of a medical-services-related campus at 
Weilerbach Storage Area.[Footnote 46] The medical campus is expected 
to be an integrated health care campus that would include hospital and 
ancillary components as well as outpatient, administrative, and 
educational components. The other facilities that DOD expects to 
develop for this campus under separate military projects include 
warrior transition unit facilities, medical transition detachment 
housing, and possibly medical troop barracks, among other facilities. 

At this time, DOD has not determined the additional costs for these 
facilities, nor has it developed a time frame for their construction. 
However, Army officials told us that plans for the campus concept are 
still predecisional and that certain facilities would only be 
replicated at Weilerbach Storage Area following the expiration of 
their useful life. For instance, the child care center near the 
current LRMC will remain there until it requires renovation or 
reconstruction. At that point, a similar facility would be constructed 
at Weilerbach Storage Area to replace it, so that staff working at the 
replacement medical center would not have to leave the area for day 
care services for their children. 

Conclusions: 

The need to replace the outdated LRMC and the 86th MDG clinic to 
ensure that military servicemembers and their families receive the 
care they deserve is widely recognized. A critical step toward meeting 
this goal is the development of a credible and comprehensive 
assessment of the facility requirements and the cost of the 
replacement medical center. DOD's evolving posture in Europe will 
likely have an impact on the size of the beneficiary population served 
by the replacement medical center. However, DOD's current needs 
assessment contains inconsistencies and errors in how it used patient 
workload and staffing data to determine facility requirements, such as 
facility size. In several situations, DOD officials adjusted the 
criteria being used but failed to document their rationale or need for 
taking these steps. Moreover, the documentation used to support the 
determination of the facility requirements does not clearly describe 
the methodology or calculations used to develop the requirements, and 
these requirements provided the basis for the cost estimate. DOD 
officials have indicated that the issues GAO has identified may not 
have a substantial impact on the size of the replacement medical 
center, but they have not yet taken specific action to determine what 
the individual or cumulative effects would be. DOD's cost estimating 
methodology substantially met many best practices criteria but was 
only minimally documented. Congress has required the Secretary of 
Defense recertify to the Appropriations Committees in writing that the 
replacement medical center is properly sized and scoped to meet 
current and projected health care requirements. With this 
recertification, DOD has an opportunity to determine the impact the 
proposed posture changes will have on the proposed facility 
requirements and revise its documentation to provide clear support for 
how it developed its facility requirements. Without clear 
documentation of how key requirements were developed and how they 
factored into the development of facility requirements and cost, DOD 
cannot fully demonstrate that the proposed replacement medical center 
will provide adequate health care capacity at the current estimated 
cost. 

Recommendations for Executive Action: 

To ensure that the replacement medical center is appropriately sized 
to meet the health care needs of beneficiaries in a cost-effective 
manner, we recommend that as part of the facility's recertification 
process, the Secretary of Defense direct the Assistant Secretary of 
Defense (Health Affairs) to take the following two actions: 

* provide sufficient and clear documentation on how medical planners 
applied DOD criteria to determine the facility's requirements, 
including how and why medical planners made adjustments to the 
criteria, and: 

* correct any calculation errors and show what impact, if any, these 
errors had on the sizing of the facility. 

Furthermore, in light of recently announced posture changes and 
potential adjustments that may need to be made in facility 
requirements based on correcting identified calculation errors in the 
original documentation, we recommend that the Secretary of Defense 
direct the Assistant Secretary of Defense (Health Affairs) to revise 
the cost estimate for the center, incorporating the best practices 
outlined in the GAO Cost Estimating and Assessment Guide to: 

* reflect these potential posture changes, 

* update it with the revised calculations as part of the 
recertification process, and: 

* more thoroughly document the data, assumptions, calculations, and 
methodology used to develop specific cost elements. 

Agency Comments and Our Evaluation: 

In written comments to a draft of this report, DOD agreed with our 
conclusions and each of our recommendations. DOD stated that it 
recently conducted a reassessment of the original $1.2 billion project 
submitted in the Fiscal Year 2012 President's Budget request that 
responds to GAO's recommendations by utilizing the most current data, 
including recently announced force structure changes, and providing a 
documented audit trail of how the size, scope, and cost of the 
alternatives were developed. Although we are encouraged that DOD has 
performed a reassessment, DOD did not make it available for our 
review. DOD's comments noted that the reassessment will be provided 
once approved by the Secretary of Defense. As a result, we are unable 
to confirm at this time that these actions have been taken. Therefore, 
we believe our recommendations are still appropriate until the 
reassessment is released and documentation made available. 

DOD also provided technical and clarifying comments, which we 
incorporated as appropriate into this report. DOD's comments are 
reprinted in their entirety in appendix IV. 

We are sending copies of this report to the interested congressional 
committees, Secretary of Defense; the Secretaries of the Army and the 
Air Force; and the Director of the Office of Management and Budget. In 
addition, the report is available at no charge on the GAO website at 
[hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact us at (202) 512-7968 or mctiguej@gao.gov or (202) 512-7114 or 
draperd@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. GAO staff who made key contributions to this report are listed 
in appendix V. 

Signed by: 

James R. McTigue, Jr. 
Director, Defense Capabilities and Management: 

Signed by: 

Debra A. Draper: 
Director, Health Care: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

To describe how DOD officials considered potential changes to DOD's 
posture in Europe--and their possible effect on the beneficiary 
population--when developing facility requirements for the replacement 
medical center, we obtained available posture planning documentation, 
including population estimates, and compared it with the beneficiary 
population data used in planning assumptions for the replacement 
medical center. We also obtained and reviewed Health Care Requirements 
Analysis documentation containing beneficiary population information 
and requested and reviewed more recent updates of this information. We 
met with officials from the Offices of the Assistant Secretary of 
Defense (Health Affairs) and the Deputy Under Secretary of Defense 
(Installations and Environment), U.S. European Command, U.S. Army 
Europe, and U.S. Air Forces Europe to gain insight into possible 
scenarios that are being considered for posture changes in Europe. In 
addition we talked with some of the above individuals and met with 
officials with the U.S. Army Corps of Engineers Europe and with the 
U.S. Army Installation Command Europe to discuss how the location for 
the replacement medical center was selected. We also discussed with 
some of the officials above the steps they had taken to ensure 
reasonable accuracy of DOD beneficiary data and determined that the 
data specifically related to the proposed replacement medical center 
were sufficiently reliable for the purposes of this report. 

To assess DOD's process for determining facility requirements for the 
replacement medical center to determine to what extent it incorporated 
quality standards into its design and adhered to DOD guidance, we 
obtained and reviewed documents detailing the process and any data 
used in the development of the requirements for the replacement 
facility. Specifically, we obtained and reviewed documentation used to 
develop plans for the proposed replacement medical center, such as 
health care requirements analyses and facility designs. We also 
reviewed relevant documentation--including checklists--to determine 
whether DOD included quality and environmentally friendly standards, 
such as world-class standards and Leadership in Energy and 
Environmental Design (LEED) green building standards.[Footnote 47] We 
also identified key assumptions used to determine facility 
requirements for the replacement medical center and obtained and 
reviewed applicable legal and departmental guidance, including DOD 
instructions and directives, and compared them with the documented 
assumptions and methods used to develop the facility's requirements. 
Additionally, we reviewed their facility requirements documentation 
for calculation errors and attempted to duplicate their results. We 
also met with medical and construction planners with the Office of the 
Assistant Secretary of Defense (Health Affairs), the TRICARE 
Management Activity, U.S. Army Medical Command, the Landstuhl Regional 
Medical Center (LRMC), the Air Force Medical Support Agency, and the 
86th Medical Group (MDG) to discuss how they determined the size of 
the replacement medical center. 

To review the process used to develop the cost estimate for the 
facility to determine to what extent DOD followed established best 
practices for developing its cost estimate, we obtained and reviewed 
available cost estimates for the proposed replacement medical center 
as well as supporting documentation that was used to determine overall 
costs. We evaluated this information using GAO's standardized 
methodology of cost estimating best practices. For our reporting 
needs, we collapsed these best practices into four general 
characteristics for sound cost estimating: accurate, credible, 
comprehensive, and well documented. We determined the overall 
assessment by rating whether DOD followed best practices that make up 
each of the four characteristics. We assigned a number to our ratings: 
not met = 1, minimally met = 2, partially met =3, substantially met = 
4, and met = 5. We took the average of the individual assessment 
ratings to determine the overall rating for each of the four 
characteristics. Criteria assessed as not applicable were not given a 
score and not included in the overall assessment calculation. We met 
with officials from the Office of the Assistant Secretary of Defense 
(Health Affairs), the TRICARE Management Activity, Army Medical 
Command, the Air Force Medical Support Agency, and the U.S. Army Corps 
of Engineers prior to our evaluation to explain our approach for 
reviewing DOD's cost estimating process and to discuss project costs. 
We also met with these officials to discuss the results of our 
evaluation. To determine the overall costs of the replacement medical 
center, we obtained and reviewed planning documents. We also met with 
officials from LRMC and 86th MDG to discuss what the future plans are 
for the current facilities following construction of the replacement 
medical center. 

We conducted this performance audit from July 2011 through May 2012 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Catchment Area Populations by Beneficiary Category, 
Fiscal Years 2006 through 2011: 

Kaiserlautern Military Community enrolled: 

Beneficiaries: Active duty enrolled; 
2006: 13,614; 
2007: 12,828; 
2008: 13,365; 
2009: 13,970; 
2010: 13,452; 
2011: 13,833.
    
Beneficiaries: Active duty family member; 
2006: 16,453; 
2007: 15,749; 
2008: 16,218; 
2009: 16,695; 
2010: 16,576; 
2011: 17,338. 

Beneficiaries: Retiree; 
2006: 1,551; 
2007: 1,636; 
2008: 1,687; 
2009: 1,603; 
2010: 1,837; 
2011: 1,976. 

Beneficiaries: Other; 
2006: 1,922; 
2007: 2,079; 
2008: 2,128; 
2009: 2,038; 
2010: 2,340; 
2011: 2,599. 

Beneficiaries: Total; 
2006: 33,540; 
2007: 32,292; 
2008: 33,398; 
2009: 34,306; 
2010: 34,205; 
2011: 35,746. 

German enrolled: 

Beneficiaries: Active duty; 
2006: 65,966; 
2007: 59,247; 
2008: 55,758; 
2009: 56,074; 
2010: 54,633; 
2011: 54,982. 

Beneficiaries: Active duty family member; 
2006: 68,299; 
2007: 62,505; 
2008: 60,204; 
2009: 60,081; 
2010: 58,872; 
2011: 59,512. 

Beneficiaries: Retiree; 
2006: 5,280; 
2007: 5,439; 
2008: 5,321; 
2009: 4,791; 
2010: 5,038; 
2011: 5,110. 

Beneficiaries: Other; 
2006: 6,946; 
2007: 7,229; 
2008: 7,124; 
2009: 6,283; 
2010: 6,488; 
2011: 6,579. 

Beneficiaries: Total; 
2006: 146,491; 
2007: 134,420; 
2008: 128,407; 
2009: 127,229; 
2010: 125,031; 
2011: 126,183. 

Europe Regional Medical Command: 

Beneficiaries: Active duty enrolled; 
2006: 78,390; 
2007: 71,166;
2008: 67,380; 
2009: 67,578; 
2010: 66,275; 
2011: 66,609. 

Beneficiaries: Active duty family member; 
2006: 82,795; 
2007: 76,807; 
2008: 74,522; 
2009: 74,471; 
2010: 72,548; 
2011: 73,030. 

Beneficiaries: Retiree; 
2006: 5,807; 
2007: 6,006; 
2008: 5,892; 
2009: 5,411; 
2010: 5,708; 
2011: 5,767. 

Beneficiaries: Other; 
2006: 7,743; 
2007: 8,076; 
2008: 7,989; 
2009: 7,238; 
2010: 7,491; 
2011: 7,555. 

Beneficiaries: Total; 
2006: 174,735; 
2007: 162,055; 
2008: 155,783; 
2009: 154,698; 
2010: 152,022; 
2011: 152,961. 

European Command eligible: 

Beneficiaries: Active duty; 
2006: 103,383; 
2007: 95,436; 
2008: 90,713; 
2009: 115,516; 
2010: 110,568; 
2011: 112,031. 

Beneficiaries: Active duty family member; 
2006: 108,889; 
2007: 101,188; 
2008: 98,445; 
2009: 97,507; 
2010: 94,911; 
2011: 92,037. 

Beneficiaries: Retiree; 
2006: 14,294; 
2007: 14,435; 
2008: 14,343; 
2009: 14,703; 
2010: 14,498; 
2011: 14,447. 

Beneficiaries: Other; 
2006: 28,160; 
2007: 27,597; 
2008: 26,827; 
2009: 27,593; 
2010: 28,449; 
2011: 28,444. 

Beneficiaries: Total; 
2006: 254,726; 
2007: 238,656; 
2008: 230,328; 
2009: 255,319; 
2010: 248,426; 
2011: 246,959. 

Source: GAO analysis of DOD information. 

[End of figure] 

[End of section] 

Appendix III: Detailed Information on Each of the Cost Estimating 
Characteristics: 

The GAO Cost Estimating and Assessment Guide contains cost estimating 
best practices that have been identified by GAO and cost experts 
within organizations throughout the federal government and 
industry.[Footnote 48] For our reporting needs, we collapsed these 
best practices into four general characteristics of sound cost 
estimating: accuracy, credibility, comprehensiveness, and well 
documented. Table 5 provides detailed information on each of these 
cost estimating characteristics. 

Table 5: Characteristics of High-Quality and Reliable Cost Estimates: 

Characteristic: Accurate; 
Description: The cost estimate should provide for results that are 
unbiased, and it should not be overly conservative or optimistic. An 
estimate is accurate when it is based on an assessment of most likely 
costs, adjusted properly for inflation, and contains few, if any, 
minor mistakes. In addition, a cost estimate should be updated 
regularly to reflect significant changes in the program, such as when 
schedules or other assumptions change, and actual costs, so that it is 
always reflecting current status. During the update process, variances 
between planned and actual costs should be documented, explained, and 
reviewed. Among other things, the estimate should be grounded in a 
historical record of cost estimating and actual experiences on other 
comparable programs. 

Characteristic: Credible; 
Description: The cost estimate should discuss any limitations of the 
analysis because of uncertainty or biases surrounding data or 
assumptions. Major assumptions should be varied, and other outcomes 
recomputed to determine how sensitive they are to changes in the 
assumptions. Risk and uncertainty analysis should be performed to 
determine the level of risk associated with the estimate. Further, the 
estimate's cost drivers should be cross-checked, and an independent 
cost estimate conducted by a group outside the acquiring organization 
should be developed to determine whether other estimating methods 
produce similar results. 

Characteristic: Comprehensive; 
Description: The cost estimate should include both government and 
contractor costs of the program over its full life cycle, from 
inception of the program through design, development, deployment, and 
operation and maintenance to retirement of the program. The cost 
estimate should also completely define the program, reflect the 
current schedule, and be technically reasonable. Comprehensive cost 
estimates should be structured in sufficient detail to ensure that 
cost elements are neither omitted nor double counted. Specifically, 
the cost estimate should be based on a product-oriented work breakdown 
structure that allows a program to track cost and schedule by defined 
deliverables, such as hardware or software components.[A] Finally, 
where information is limited and judgments must be made, the cost 
estimate should document all cost-influencing ground rules and 
assumptions. 

Characteristic: Well documented; 
Description: A good cost estimate, while taking the form of a single 
number, is supported by detailed documentation that describes how it 
was derived and how the expected funding will be spent in order to 
achieve a given objective. Therefore, the documentation should capture 
in writing such things as the source data used, the calculations 
performed and their results, and the estimating methodology used to 
derive each work breakdown structure element's cost. Moreover, this 
information should be captured in such a way that the data used to 
derive the estimate can be traced back to and verified against their 
sources so that the estimate can be easily replicated and updated. The 
documentation should also discuss the program requirements and scope 
and how the data were normalized. Finally, the documentation should 
include evidence that the cost estimate was reviewed and accepted by 
management. 

Source: GAO. 

[A] A work breakdown defines in detail the work necessary to 
accomplish a program's objectives. It deconstructs a program's end 
product into successive levels with smaller specific elements until 
the work is subdivided to a level suitable for management control. It 
is also a valuable communication tool between management and 
stakeholders because it provides a clear picture of what needs to be 
accomplished and how the work will be done. In addition, it provides a 
consistent framework for planning and assigning responsibility for the 
work. Initially set up when the program is established, the work 
breakdown structure becomes more detailed over time, as more 
information becomes known about the program. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
Health Affairs: 
1200 Defense Pentagon: 
Washington, DC 20301-1200: 

Mr. James R. McTigue, Jr.
Acting Director, Defense Capabilities and Management: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Mr. McTigue: 

This is the Department of Defense's (DoD) response to the Government 
Accountability Office (GAO) Draft Report, GAO-12-622, "Defense 
Infrastructure: Documentation Lacking to Fully Support How DoD 
Determined Specifications for the Landstuhl Replacement Medical 
Center," dated April 20, 2012, (GAO Code 35163). Thank you for the 
opportunity to review the Draft Report and offer comments. 

Overall, I concur with the Draft Report and its conclusions. However, 
as you know, the Department recently conducted a reassessment of the 
original $1.2 billion project submitted in the Fiscal Year 2012 
President's Budget request. This new analysis was conducted in a 
manner separate and independent of the analysis reviewed by GAO. It 
responds to GAO's recommendations by utilizing the most current data, 
including recently announced force structure changes, and providing a 
documented audit trail of how the size, scope, and cost of the
alternatives were developed. It does not attempt to adjust or re-
interpret previous planning documentation. The final DoD Reassessment 
Report will be provided once approved by the Secretary of Defense. 

Thank you again for the opportunity to review and provide a response. 
The points of contact on this issue are Mr. John Becker (Functional) 
and Mr. Gunther Zimmerman (Audit Liaison). Mr. Becker may be reached 
at (703) 681-4368, and Mr. Zimmerman may be reached at (703) 681-4360. 

Thank you for your interest in the health and well-being of our 
Service members, veterans, and their families. 

Sincerely, 

Signed by: 

[Illegible] for: 
Jonathan Woodson, M.D. 

[End of letter] 

GAO Draft Report Dated April 20, 2012: 
GAO-12-622 (GAO Code 351630): 

"Defense Infrastructure: Documentation Lacking To Fully Support How 
DOD Determined Specification For The Landstuhl Replacement Medical 
Center" 

Department Of Defense Comments To The GAO Recommendations: 

Recommendation 1: The GAO recommends that the Secretary of Defense 
direct the Assistant Secretary of Defense (Health Affairs) to provide 
sufficient and clear documentation on how medical planners applied DoD 
criteria to determine the facility's requirements, including how and 
why medical planners made adjustments to the criteria. (See page 
42/GAO Draft Report.) 

DoD Response: Concur. DoD acknowledges that there are some 
deficiencies in the documentation of the HCRA, including deviations 
from published criteria. While the planning team may have had 
legitimate reasons for making adjustments, assumptions and data used 
to draw conclusions about facility sizing are not always clearly 
documented. DoD believes that the recently completed re-assessment 
addresses these issues. The assumptions that serve as the basis for 
sizing three courses of action (COA) are clearly stated. Data trails 
are explicit and when there are deviations from existing criteria, a 
rationale is provided. 

Recommendation 2: The GAO recommends that the Secretary of Defense 
direct the Assistant Secretary of Defense (Health Affairs) to correct 
any calculation errors and show what impact, if any, these errors had 
on the sizing of the facility. (See page 42/GAO Draft Report.) 

DoD Response. Concur. DoD acknowledges that the HCRA contained some 
calculation errors. However, their characterization as "errors 
throughout" may not accurately reflect their actual frequency. All 
calculations have since been re-computed as part of the recently 
completed re-assessment and efforts have been made to ensure their 
accuracy and consistency. Accordingly, the likelihood of similar 
calculation errors in the re-assessment is extremely low. Sizing of 
the COAs in the re-assessment are based on a series of calculations 
that can be readily duplicated and confirmed. 

Recommendation 3: The GAO recommends that the Secretary of Defense 
direct the Assistant Secretary of Defense (Health Affairs) to revise 
the cost estimate for the center, incorporating the best practices 
outlined in the GAO's Cost Estimating and Assessment Guide to: reflect 
these potential posture changes; update it with the revised 
calculations as part of the recertification process; and more 
thoroughly document the data, assumptions, calculations, and 
methodology used to develop specific cost elements (See page 42/GAO 
Draft Report.) 

DoD Response: Concur. The facility acquisition and life cycle costs 
have been revised to reflect force structure changes known as of 1 May 
2012. Sizing is based on revised calculations that accurately reflect 
projected population and workload. The impact of these changes on 
space requirements have been addressed and reflected in the COAs. Data 
assumptions, calculations, and methodology have been documented in a 
manner more consistent with the GAO Cost Estimating and Assessment 
Guide. It should be noted that DoD was unaware of this guidance until 
August of 2011, long after the cost estimate was developed for the 
current project submitted in the FY 2012 President's Budget. 

[End of section] 

Appendix V: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

James R. McTigue, Jr., (202) 512-7968 or mctiguej@gao.gov Debra A. 
Draper, (202) 512-7114 or draperd@gao.gov: 

Staff Acknowledgments: 

In addition to the contacts named above, Laura Durland, Assistant 
Director; Marcia Mann, Assistant Director; Josh Margraf; Jeff Mayhew; 
and Richard Meeks made key contributions to this report. Joanne 
Landesman assisted in the message and report development, Amie Steele 
assisted in developing the report's tables and graphics, Jennifer 
Echard and Dave Brown provided methodological support, and Michael 
Willems provided legal support. 

[End of section] 

Footnotes: 

[1] S. Rep. No. 111-40, at 20-21 (2009). The committee noted that 
Ramstein Air Base, adjacent to Landstuhl, is the transport hub for 
combat casualties and could potentially accommodate the new medical 
center, and directed DOD to conduct a cost-benefit analysis of 
locating the replacement medical center at its current location or on 
Ramstein Air Base. 

[2] Pub. L. No. 112-74, 125 Stat. 1138 (2011). 

[3] GAO, GAO Cost Estimating and Assessment Guide: Best Practices for 
Developing and Managing Capital Program Costs, [hyperlink, 
http://www.gao.gov/products/GAO-09-3SP] (Washington, D.C.: March 2009). 

[4] Eligible beneficiaries include active duty personnel and their 
dependents, medically eligible Reserve and National Guard personnel 
and their dependents, and retirees and their dependents and survivors. 
TRICARE is the health care program serving active duty servicemembers, 
National Guard and Reserve members, retirees, their families, 
survivors, and certain former spouses worldwide. As a major component 
of the Military Health System, TRICARE brings together the health care 
resources of the uniformed services and supplements them with networks 
of civilian health care professionals, institutions, pharmacies, and 
suppliers to provide access to health care services while also 
maintaining the capability to support military operations. 

[5] For purposes of this report, the Office of the Assistant Secretary 
of Defense (Health Affairs) will be referred to as Health Affairs. 

[6] DOD Instruction 6015.17, Planning and Acquisition of Military 
Health Facilities (Mar. 17, 1983) (canceled by DOD Instruction 
6015.17, Military Health System (MHS) Facility Portfolio Management 
(Jan. 13, 2012)). 

[7] Catchment areas are geographic areas determined by the Assistant 
Secretary of Defense for Health Affairs that are usually within an 
approximately 40-mile radius of military treatment facilities with 
inpatient care. 

[8] U.S. Army Medical Command, Updated (FY10) Health Care Requirements 
Analysis (Washington, D.C.: December 2010). The health care 
requirements analysis report serves as the basis for the planning and 
programming of the replacement medical center. 

[9] The United States ended combat operations in Iraq in August 2010 
and completed the removal of most of its troops in December 2011. 

[10] Medical planners are from the TRICARE Management Activity, 
Portfolio Planning and Management Division; the Army Medical Command, 
Assistant Chief of Staff for Facilities, Programming and Planning 
Division; and the Air Force Health Facilities Division. 

[11] Military beneficiaries are frequently sent to the German health 
care system because there is not sufficient capacity at LRMC to treat 
all requirements. This is especially true when there are surges from 
contingency operations. 

[12] The replacement medical center is designed with 60 single-patient 
medical/surgical inpatient rooms, 50 of which have the flexibility to 
expand to accept two beds for surge capacity. We provide a more 
comprehensive discussion of the medical center's sizing requirements 
in a later section. 

[13] USAG Baumholder is approximately 17 miles north and west of LRMC, 
and falls within the Kaiserslautern Military Community catchment area 
that extends about 55 miles from the facility. 

[14] Army officials noted that the Army uses a ratio of 1.5 dependents 
to each military member to estimate the number of dependents that will 
be leaving the area. 

[15] An enduring installation is one that is permanent and lasting. 

[16] Noblis, Landstuhl Regional Medical Center (LRMC) Sensitivity 
Analysis (Oct.29, 2009; updated Aug. 12, 2010). 

[17] According to the Noblis analysis, ICU and medical/surgical beds 
are typically designed in 20 to 30 bed increments. 

[18] According to the Noblis sensitivity analysis, modern health care 
design calls for modules of 8 to 10 exam rooms. 

[19] U.S. Army Medical Command, Updated (FY10) Health Care 
Requirements Analysis. The health care requirements analysis report 
states that the EUCOM beneficiary population will be reduced by about 
10,300 active duty servicemembers and about 10,600 family members. 

[20] Pub. L. No. 112-25 (2011). 

[21] This number reflects DOD's reported approximation of the 
reductions required by the Budget Control Act of 2011. 

[22] DOD, Defense Budget Priorities and Choices (Washington, D.C.: 
January 2012). 

[23] Evidence-based design represents an emerging body of science that 
links elements of a facility's design with patient, staff, and 
resource outcomes. The goal of evidence-based design is to create a 
healing environment--one that is safe and comfortable and that 
supports the patient, the patient's family, and the staff. See Noblis, 
Evidence-Based Design: Application in the MHS (Washington, D.C.: Aug. 
1, 2007). 

[24] In May 2009, the National Capital Region Base Realignment and 
Closure Health Systems Advisory Subcommittee of the Defense Health 
Board defined characteristics of a "world-class medical facility" in 
their report Achieving World Class. For example, a world-class 
facility, among other things, applies evidence-based health care 
principles and practices, along with the latest advances in the 
biomedical, informatics, and engineering sciences and organizes its 
clinical services so that they are integrated and seamless between and 
among services in the facility. These principles and practices are 
known as world-class standards. 

[25] LEED is a third-party certification program and the nationally 
accepted benchmark for the design, construction, and operation of high-
performance green buildings, according to the nonprofit U.S. Green 
Building Council. 

[26] DOD Instruction 6015.17, Planning and Acquisition of Military 
Health Facilities (Mar. 17, 1983) (canceled by DOD Instruction 
6015.17, Military Health System (MHS) Facility Portfolio Management 
(Jan. 13, 2012)). 

[27] Workload factors include the workload for inpatient and 
outpatient care. For example, the average daily census can be used to 
measure workload for inpatient care, and the number of outpatient 
encounters can be used to measure workload for outpatient care. 

[28] The Updated (FY10) Health Care Requirements Analysis describes 
the analyses conducted to determine the requirements for the 
replacement medical center. 

[29] DOD developed the fiscal year 2010 baseline for both the 
inpatient and outpatient care workload by annualizing the actual 
workload from the first 6 months of fiscal year 2010--the most recent 
available at the time. 

[30] The guidance shows that among other things, workload and staffing 
are used to size and configure facilities to help ensure appropriate 
facility space. Specifically, the guidance provides formulas for 
determining the appropriate size of patient care departments, such as 
the required number of medical/surgical beds or behavioral health 
beds, using the projected workload data for the facility. 

[31] The average daily census identifies the "average" number of 
patients occupying beds at a specific hospital site as determined by 
the inpatient census at midnight but does not specify the actual 
number of beds to be planned to ensure that a bed is available on any 
given day. This requires the application of a planned occupancy rate. 
Occupancy rates are stated as a percentage (e.g., 80 percent or 0.80). 

[32] The health care requirements analysis report notes that 
approximately 10.5 percent of inpatient care and 8.7 percent of 
outpatient care provided at the current facilities was based on 
conflicts in Iraq and Afghanistan. 

[33] In July 2010, the Army projected a decrease of approximately 
21,000 beneficiaries, or 8 percent of the population. 

[34] Unlike inpatient bed requirements, which are based on projected 
patient workload data, outpatient exam room requirements are based on 
the number of providers needed to treat the projected outpatient 
workload. 

[35] The number of inpatient dispositions, also known as inpatient 
encounters, is a measurement of inpatient workload. 

[36] GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] 
(Washington, D.C.: November 1999). 

[37] [hyperlink, http://www.gao.gov/products/GAO-09-3SP]. The guide 
establishes a consistent methodology that is based on best practices 
and can be used across the federal government for developing, 
managing, and evaluating capital program cost estimates. 

[38] OMB, Capital Programming Guide: Supplement to Circular A-11, Part 
7, Preparation, Submission, and Execution of the Budget (Washington, 
D.C.: June 2006). 

[39] Technical documentation refers to documents used to define 
technical and programmatic requirements for the replacement medical 
center, such as beneficiary population estimates, health care demand, 
staffing requirements, and square footage requirements. 

[40] HOK, Kaiserslautern Military Community Medical Center Charrette 
Report (March 2011). 

[41] HOK, Kaiserslautern Military Community Medical Center Charrette 
Report. 

[42] United States Army Corps of Engineers Europe District and Booz 
Allen Hamilton, Sensitivity Analysis and Cost/Schedule Probability 
Report for Kaiserslautern Military Community Medical Center (January 
2012). 

[43] The Program for Design is a document used by DOD when determining 
facility requirements for military treatment facilities that lists 
footage requirements per medical department and room. 

[44] The Planning Charrette Discussion is a document that summarizes 
information from a series of meetings that DOD planners held from May 
10 through 12, 2010, to adjust preliminary programming and facility 
scoping for the replacement medical center in order to address the on-
the-ground situation and any previously unforeseen issues. 

[45] Parametric models typically consist of several interrelated cost 
estimates and are often computerized. They may involve extensive use 
of cost-to-noncost cost estimating relationships, multiple independent 
variables related to a single cost effect, or independent variables 
defined in terms of design characteristics rather than more discrete 
material requirements or production processes. Parametric models are 
always useful for cross-checking the reasonableness of a cost estimate 
that is derived by other means. As a primary estimating method, 
parametric models are most appropriate during the engineering concept 
phase when requirements are still somewhat unclear and no bill of 
materials exists. 

[46] U.S. Army Medical Command, Updated (FY10) Health Care 
Requirements Analysis. 

[47] LEED is a third-party certification program and the nationally 
accepted benchmark for the design, construction, and operation of high-
performance green buildings, according to the nonprofit U.S. Green 
Building Council. 

[48] [hyperlink, http://www.gao.gov/products/GAO-09-3SP]. The guide 
establishes a consistent methodology that is based on best practices 
and can be used across the federal government for developing, 
managing, and evaluating capital program cost estimates. 

[End of section] 

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