Microsoft Word - 765-Article Text.edited rev Available online at: http://journals.researchsynergypress.com/index.php/ijmesh International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH) ISSN 2580-0981 (Online) Volume 5 Number 1 (2022): 63-72 Corresponding author tyrone.1975@yahoo.com DOI: https://doi.org/10.31098/ijmesh.v5i1.765 Research Synergy Foundation Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald1 1Trident University International, United States Abstract During pandemic events, we experienced a heavy burden on our medical labor worldwide. This qualitative methodology research study concentrated on the problem of limited medical staff and tackling patient demands while still keeping motivation up within the workforce. The objective of this study aimed to understand concerns and find solutions for 2021 as well as future fiscal years of proposed manpower cuts at the United States Air Force Military Treatment Facilities (USAF MTF). A significant pending proposal would cut a shocking 4,684 USAF medical positions worldwide. This study analyzed data to solicit feedback on employee and stakeholder concerns to provide practical solutions mitigating impacts and maintaining staff productivity, motivation, and job satisfaction. Theory, previous literature, and findings indicated manpower cuts lead to social effects by reducing recognition, open communication, and motivation for provider staff, as well as reducing productivity and quality care. Human Relations (HR) and Herzberg’s Motivation-Hygiene theories were applied to developing data collection instruments in this qualitative study in order to derive solutions for continued quality care and staff motivation in preparation for manpower cuts. The data was gathered from 10 provider staff and 10 USAF consultants and then analyzed to inform a focused solution-driven discussion with 10 MTF leaders. Analysis and conclusions led to focus group findings, which were then concluded to highlight suggestions and recommendations in areas of illustrating manpower, support, resources, innovation, communication, and motivation concerning proposed manpower cuts. Keywords: Air Force Medical Readiness Agency, Air Force Medical Service, Beneficiaries, Career Field Manager, Department of Defense, Dependent, Medical Treatment Facilities, Program Objective Memorandum, Resource Management, TRICARE, United States Air Force This is an open access article under the CC-BY-NC license. INTRODUCTION The current problem linked with this study is the lack of knowledge associated with losing 4,684 USAF medical manpower cuts. More specifically, USAF MTF staff were unsure of how to maintain quality healthcare, provider staff motivation and productivity, job satisfaction, and prioritization of services with pending manpower cuts. The answers to these problems were addressed by collecting and analyzing qualitative data from 30 individuals, including USAF medical provider staff, USAF consultants, and USAF MTF leaders. From previous research, Congressionally proposed manpower cuts were announced that could impact patient care critical to military medicine. In the current environment where we have seen our medical resources spread thin due to the pandemic, this causes great concern. Military medical personnel is also heavily tasked with military deployments depending on the current threats. This increases the trepidation in the situation. The organization in this study was commonly known as the Air Force Medical Readiness Agency (AFMRA) and currently holds over 400 Department of Defense personnel with locations at Falls Church, Virginia, and San Antonio, Texas. International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH), Vol. 5(1), 63-72 Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald 64 Present research indicated social effects were a large factor as seen by events of reduced praise, open communication, and motivation for provider staff leading to reduced motivation. This also led to a lack of recognition, feedback, and open communication between employer and employee. Eventually, the staff became less motivated in productivity. Hertzberg's Motivation-Hygiene theory (Lundberg, 2009) says certain factors in the workplace cause job satisfaction while a separate set of factors cause dissatisfaction. Herzberg (2016) stated that the absence of hygiene factors might cause dissatisfaction, such as work conditions, quality of supervision, and company policies and practices. Looking at our USAF MTF manpower cuts, we anticipated patient care in clinical areas such as Internal Medicine, Family Practice, and other clinical function could overwhelm provider staff and cause job dissatisfaction and decreased job performance. These two named theories emphasized the differences of this study by creating a conceptual framework and deriving our foundation and assisted in building collection instruments. Collection instruments were designed, each having a consent form, a pilot test, and Institution Review Board approval from both our research institution and selected medical facility. The staff interviews were scheduled for approximately 30-60 minutes. It had five demographic questions to understand the experience, knowledge, and position of the interviewee, and six questions focused on concerns, mitigations, and solutions as they pertained to their satisfaction and motivation in light of manpower cuts. The USAF consultant interviews were scheduled to last 30-60 minutes as well, with five demographic questions indicating experience, position, and duties. The seven main survey questions involved vital career field manning recommendations, prioritization of services, and predicted effects of the cuts. Lastly, the focus group with five MTF leadership members was scheduled for 30-60 minutes; each member introduced himself/herself by stating their position, work location, and experience, then began a focused discussion with the guide of a talking paper derived from the interviews. The objective of this study identified concerns about proposed manpower cuts at USAF MTFs and provided solutions to minimizing the cuts, maintaining provider staff productivity and motivation, job satisfaction, and prioritization of healthcare services. This study looked at HR and Herzberg’s Motivation- Hygiene theories as they related to our noted problems of keeping employee motivation and job satisfaction in the light of limited labor resources. HR theory, explained by Hawthorne Studies (2019), says employees are motivated not only by financial reward but also by a range of social factors (e.g., praise, a sense of belonging, feelings of achievement, and productivity in one's work). Hertzberg’s Motivation- Hygiene theory aligned because it addressed how a lack of motivation could potentially affect provider staff and beneficiaries at USAF MTF. LITERATURE REVIEW/BACKGROUND The HR and Herzberg’s motivation-hygiene theories relate to this study as they examine both motivation and productivity. These theories were used to explore more deeply how proposed manpower cuts can negatively influence MTF staff. The original purpose of the Hawthorne studies on HR was to examine how different aspects of the work environment affected worker productivity. Furthermore, this study focused on perceptions of the work environment related to proposed manpower cuts from provider staff, USAF consultants, and MTF leadership perspectives. The Herzberg motivation-hygiene theory states there are certain factors in the workplace that cause job satisfaction while a separate set of factors cause dissatisfaction. This theory relates to the study by International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH), Vol. 5(1), 63-72 Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald 65 focusing on factors such as manpower cuts that will potentially cause dissatisfaction among provider staff, USAF consultants, and MTF leadership. The two-factor theory implies that managers must guarantee the adequacy of the Herzberg hygiene factors to avoid employee dissatisfaction. Also, managers must make sure the work environment is stimulating and rewarding so that the employees are motivated to work and perform effectively. Additional assumptions about this project predicted that MTFs might not be able to receive patients for pediatric and obstetrics/gynecology care. Also, laboratory and pharmacy services, along with radiology, will be minimized. Furthermore, TRICARE Prime retirees will be forced to re-enroll from MTFs into the civilian networks, resulting in them being charged with new and higher co-payments (Beasley, 2019). These predictions will happen with 17,000 proposed positions being reduced in healthcare business organizations. If Congress approves the military manpower cuts, these actions will take effect in future fiscal years. After in-depth research, more than 17,000 medical military authorizations are being cut and repurposed as warfighters to increase the lethality and size of operational units. The manpower cuts would decrease healthcare manpower by 13 percent and impact access to care standards for beneficiaries by reducing the number of provider visits. With a reduction in manpower, this will result in patients being referred off- base, and the MTF providers' workload will decrease drastically. These actions will lead to providers retiring, separating, and a decrease in patient workload, which impacts maintaining their skills. The USAF stands to lose approximately $60,000 to $103,320 and experience for each provider authorization that is cut (Rege, 2019). With these manpower deficits, MTFs could experience limited civilian staff and be unable to backfill with reserve medical personnel as well as civilian contracts. The lack of providers delivering care on base will force over 500,000 beneficiaries off-base and onto TRICARE provider networks (Philpott, 2019). Beasley (2019) stated that replacing military manpower with civilians is not a reliable strategy. In fact, obtaining private-sector medical professionals to take jobs at military facilities may not be realistic or feasible. The impact of these actions will result in beneficiaries seeking care in civilian networks rather than going to MTFs for care. By utilizing off-base healthcare sectors, beneficiaries will be exposed to expensive charges and co-payments to receive healthcare. With reduced medical staffing, the uniformed Army medical staff will fall by almost 7,300. The Navy's medical personnel will be reduced by almost 5,300 and the USAF by just over 5,300. This will spread across a combined medical force of 130,000, both active-duty, guard, and reserve. Moreover, the planned cuts would lower uniformed medical strength by roughly 13 percent, a drop steep enough to alarm some healthcare leaders as well as advocates for military personnel and their beneficiaries. Additional archived quantitative data from Headquarters USAF suggested if Congress approved the cuts, to be presented billet by billet, the reductions would begin to take effect in Fiscal Year (FY) 2020 or later. Preliminary Navy documents show uniformed staff at Walter Reed National Military Medical Center falling by 534 personnel. For example, 82 were taken from the director of clinical support, including 28 of 39 corpsmen, 5 of 12 radiological diagnosticians, 4 of 7 pharmacists, 8 of 19 pharmacy technicians, and 9 of 45 medical laboratory technicians. With these manpower deficits, MTFs will have robust civilian staff and be able to backfill with reserve medical personnel as well as civilian contracts. International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH), Vol. 5(1), 63-72 Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald 66 In today's healthcare, off-base care for beneficiaries seems to be increasing due to more referrals to the network (Policy Lab, 2019). Military families covered by TRICARE, the health care program for uniformed service members and their families, report lower access to care and satisfaction with the quality of care than civilian families who have private or public coverage for their kids. Using a national data set from 2007-2015, researchers analyzed families' reported experiences with TRICARE coverage for nearly 85,000 youth ages 0-17. TRICARE-covered families were less likely than families with private insurance to report accessible care (35% vs. 50%) or responsive care (47% vs. 54%) for their children. A few companies were experimenting with more effective ways to handle their changing workforce needs. In 2013, AT&T company leaders concluded that 100,000 of its 240,000 employees were working in jobs that would no longer be relevant in a decade. The workforce changes included manpower reductions sparking job dissatisfaction. Instead of letting these employees go and hiring new talent, AT&T decided to retrain all 100,000 workers by 2020 (King, 2017). The company understood concerns of workforce change and keeping its employees motivated. By doing this, AT&T would not lose the knowledge their employees had developed and would not undermine the trust in senior management that was necessary for engagement, innovation, and performance. John Donovan, Chief Executive Officer of AT&T Communications, noted that 18 months after the program's inception, the company had decreased its product development cycle time by 40 percent and accelerated its time to revenue by 32 percent (King, 2017). Since 2013, its revenue has increased by 27 percent, and in 2017 AT&T even made Fortune’s 100 Best Companies to Work For list for the first time. Leaders of Nigerian International Oil Companies were facing challenges in developing efficient strategies for motivating employees with reduced manpower (Onyebuenyi, 2016). Findings from the study indicated approximately 78 percent to 82 percent of respondents recognized that a lack of job satisfaction was a critical challenge facing employee productivity in the Nigerian oil industry. The lack of resources resulted in low productivity in the Nigerian oil industry. Empirical evidence suggested low job satisfaction combined with reduced manpower increased the rate of abnormal attrition in many organizations. Employees were non-productive, uncreative, and not adaptive when dissatisfied with their jobs. In Silver City, New Mexico, the small Gila Regional Medical Center sliced more than a dozen jobs from the payroll. The hospital no longer employs a chief operating officer. Hennepin County Medical Center, a public hospital in Minneapolis, is cutting about 130 jobs, or 2 percent of its full-time staff. Administrators stated they might need to double the job reductions by the end of the year (Ross, 2017). The hospital lost about $11 million in 2016 because it served a large number of uninsured and low-income patients. Memorial Care Health System in Long Beach, California, laid off 131 employees, citing a huge increase in Medicare and Medicaid patients and declining reimbursements from those programs. The MTFs learned that manpower reductions could eliminate key positions and impact revenue generated from treating uninsured patients. With the abrupt termination of the military space program in 1969, research at Brooks focused on clinical aviation medicine and support of advanced military aircraft while continuing close cooperation in support of orbital spaceflight and the journey to the Moon. Reorganization in the 1990s assigned all research functions at Brooks to the Human Systems Division and its successors, leaving missions related to clinical work and teaching. In 2002, the USAF and the city of San Antonio implemented a shared operation of Brooks as a City-Base in the hope of deflecting threatened closure. Nevertheless, under continuing International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH), Vol. 5(1), 63-72 Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald 67 pressure to consolidate MTFs in the United States, the 2005 Base Closure and Realignment Commission ordered Brooks closed by 2011, with its aerospace medicine functions relocated to new facilities at Wright-Patterson AF Base in Dayton, Ohio (Webb, 2011). RESEARCH METHODOLOGY The nature of this study was a qualitative descriptive nature aimed to better understand USAF MTF staff concerns about manpower cuts, but also how these concerns tied to solutions by lessening the impact of these proposed manpower cuts. Furthermore, the qualitative approach pertained to this study by providing an in-depth understanding of concerns and solutions toward labor cuts through 20 independent interviews and two solution-focus groups. These participants had first-hand knowledge and awareness about the topic. In addition, the participants were subject matter experts concerning this topic and were engaged on a daily basis with the proposed manpower reductions at USAF MTF. The first step in the process was solicitation. Ten members volunteered to participate in a staff member interview from a total population of over 11,000 members in general, using the first-come, first-served process. Next, 10 volunteer participants were returned from a bank of 34 consultants, also on a first-come, first-served basis. During steps one and two, the provider staff and USAF consultants were provided with questions by the researcher orally via teleconference or in-person. Questions asked were regarding concerns and suggestions for mitigating negative impacts related to proposed manpower cuts in patient care areas and on how to increase productivity, motivation, and job satisfaction for provider staff. USAF consultants were interviewed next in the same fashion, but the topics addressed prioritization of services and manning while still meeting the needs of beneficiaries. After conducting interviews with provider staff and USAF consultants, the researcher analyzed the data responses (80-page transcriptions) from staff and (100 pages) from consultants using a 6-step thematic process by Braun and Clarke (2006). Then went on to present this information to a USAF MTF 5-member leadership solution-based focus group (90 pages of transcripts), highlighting emerging concerns, ideas for solutions, and suggestions for prioritization and rationale. The purpose of this was to understand better how to implement these solutions by mitigating these effects. Validity is the degree to which the instrument in the research study truly measures what its purpose is to measure (Roberts, 2010). For validity, the researcher consulted with the AFMRA Legal Office and Data Collection Process Officer to ensure interview and focus group instruments were designed effectively for data collection. Reliability is the degree to which the instrument in the research study is consistent from one time to another time (Roberts, 2010). The researcher thoroughly reviewed the instruments for reliability in consultation with MTF staff. The validity and reliability of these data collection instruments were strengthened through pilot testing prior to the research study being conducted. These actions acknowledged the questions were subjective in nature, and responses could vary within validity as well as reliability due to the nature and perception of individuals when participating in such research. FINDINGS AND DISCUSSION From the analysis came 22 codes and 8 important themes that then led to deriving findings and suggestions. Theme 1 specified how proposed manpower cuts could have an impact resulting in low motivation and productivity from provider staff at USAF MTF. The participants stated challenges could affect motivation and productivity because the reduction of patient services would lead to less healthcare in the USAF MTF. Due to increased off-base referrals, the proposed cuts could ultimately generate more healthcare in the civilian network. Furthermore, provider staff in clinical areas would be less motivated International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH), Vol. 5(1), 63-72 Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald 68 because active-duty billets would be potentially reduced and backfilled with civilian and/or contractor positions. Practical clinical skills could be at risk causing enlisted medical technicians to revert to non- clinical skills that move them away from patient care, such as front-desk duties, appointment lines, etc. Theme 2 indicated how motivation, job satisfaction, and productivity might be affected if the proposed manpower cuts are implemented. Reduced manpower in clinical areas could present a decreased patient workload resulting in fewer patients to treat, contributing to low job satisfaction. Provider staff could start to lose enjoyment with their passion for treating patients and seek employment in the civilian sector earning more money. In addition, proposed manpower cuts could result in low productivity among staff which creates a bad work environment with fear of the unknown. Participants concurred that motivation, job satisfaction, and productivity could be affected by pending manpower cuts. The reason was that productivity and patient workload could be decreased if proposed manpower cuts took effect. Appointments such as sports physicals could be decreased, impacting kids seeking quality healthcare for football, basketball, and soccer. Then affects a member's quality of life standards in their employer. Additionally, participants discussed factors such as timeliness of access to care standards that could have an impact on provider staff job satisfaction and work environment conditions. Theme 3 discussed how job satisfaction and quality healthcare could be affected by proposed manpower cuts forcing disruptive innovation. Enlisted medical technicians could be replaced with advanced technology such as check-in kiosks. These check-in kiosks would serve as a substitute to execute duties such as vital signs, height, weight, etc. USAF MTF is allocated disruptive allocation funds to help support clinical initiatives if proposed labor cuts become a reality. Proposed manpower cuts could present challenges such as patient treatment delays and longer wait times. This includes medical appointments going beyond access to care standards of 1 week for routine, 2 weeks for a follow-up, and 30 days for specialty care, which is well below the baseline standard. Theme 4 indicated that inpatient MTFs need to be prioritized highly because they serve as a foundation of healthcare. Without inpatient services, this could potentially decrease the ability of USAF MTF to hospitalize patients. Reorganization initiatives such as Healthcare Operations Squadron and Operational Medical Readiness Squadron could be required if certain healthcare services are removed. It was discovered that if services were removed, referral leakage for a health system could possibly average anywhere from 55-65 percent. With missing healthcare services, MTF could lose between 821 to 971 thousand dollars on average per physician per year. Moreover, urgent care centers, surgical services, and inpatient units are the most important services to retain, which are key to healthcare, whether in-garrison or deployed. Theme 5 indicated that recommendations on mitigating the effects of career field manning shortages, lack of training opportunities, and readiness currency should the manpower cuts take place consisted of several factors. There could be fewer deployment opportunities and training deficiencies due to provider vacancies. Additional recommendations included taking cuts in later fiscal years and permanently removing the cuts altogether. It was also mentioned that mitigation includes voicing concerns to senior leadership and addressing potential impacts of the cuts are implemented. Further suggestions included that training deficiencies could be avoided if the cuts were permanently removed and stopped in the medical field. Moreover, it addressed mitigation of career field manning shortages, including advocating International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH), Vol. 5(1), 63-72 Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald 69 to move then cuts to later fiscal years. In addition, completely leaving the medical field absent of the cuts due to the recent pandemic concerns and focusing on non-patient care areas moving forward and beyond. Theme 6 provided comments concerning recommendations for the prioritization of healthcare services at USAF MTF. Additionally, participants with more years of experience expressed that non-clinical services versus clinical services could be prioritized lower due to the availability of civilian hiring. The participants with less experience suggested maintaining all healthcare services and seeking to delay proposed labor cuts until Corona Virus efforts are improved. Also, participants mentioned that communication should be conducted monthly through email and teleconferences concerning proposed manpower cuts. Furthermore, annual senior leadership workshops should use this as a forum to spread the information to the mass public. Theme 7 indicated feedback from the USAF consultants and provider staff and recommended short-term mitigation such as focusing on targeted manpower cuts in non-clinical areas such as the release of information, kiosk desks, etc. This included long-term mitigation, suggesting taking cuts in future fiscal years and substituting personnel with disruptive innovation ideas such as check-in self-help desks instead of front-desk staff. Participants concurred that motivation, job satisfaction, and productivity are key qualities in operating clinical areas at USAF MTF. Lack of motivation, job satisfaction, and productivity may produce errors in patient care with the uncertainty of future stability. Furthermore, thinking outside of the box is critical if active billets are to be removed. USAF MTF will have to adapt and learn how to maintain operations with reduced personnel in non-clinical and clinical areas. Theme 8 indicated a plan of action to address fear as well as anxiety in the organization. Participants agreed that providing updated information and communicating with the field will help reduce anxiety and well fair concerns of its staff. Weekly staff meetings with the higher headquarters addressing the proposed cuts could help. Furthermore, providing more communication through monthly newsletters, Commander’s Call, USAF Medical Service Council, and monthly personnel reduction briefings could also contribute to mitigating fear and anxiety in the organizations. From these themes, the researcher derived findings and solutions. One finding indicated labor cuts could undoubtedly affect job satisfaction resulting in more off-base referrals and a lack of recognition of employees for their hard work. One solution would be to negotiate the manpower cuts to span slower over a period of years which would include FY2022, FY2023, and FY2024, to avoid losing experienced provider staff within six months. Another finding was low morale and productivity in clinical areas could lead to provider staff pursuing more advantageous employment in the civilian sector. One solution for this would be to improve constant feedback for employees to look at benefits so that leadership could provide better motivation to their employees. Additional findings were job satisfaction, and quality healthcare could be affected by proposed manpower cuts forcing disruptive innovation. Recommendations for this would be for leaders to encourage and promote innovation down to the lowest levels in order to find more efficient ways of doing things. Lack of job satisfaction and quality healthcare can present challenges such as patient treatment delays and longer wait times. Prioritizing the critical services that make a member deployment-ready is a must for the military. International Journal of Management, Entrepreneurship, Social Science and Humanities (IJMESH), Vol. 5(1), 63-72 Proposed Manpower Cuts at the United States Air Force Military Treatment Facilities Tyrone Anthony McDougald 70 Manning shortages also place an even bigger burden on those who are balancing the effects of the pandemic and deployment taskings. Cutting services that are not essential needs would need to happen. Handling minor services via online methods would be a great solution. Long-term mitigation included taking cuts later and substituting removed active-duty personnel with disruptive innovation ideas. Short- term mitigation included completely eliminating the cuts for the medical field, thinking outside of the box, and more focused effort on non-clinical functions first and then clinical functions second. CONCLUSION AND FURTHER RESEARCH This study addressed concerns and provided practical solutions toward mitigating impacts, maintaining provider staff productivity and motivation, job satisfaction, and prioritization of the current healthcare services. Key implications for businesses and practitioners found that manpower cuts may be inherent to the business, and we need to adapt and overcome them. This research found communications, prioritization, and innovation as good solutions to mitigating some of the effects a business may experience. Future research should address the barriers to implementing these ideas, a new normal way of life including more online services and their implications, and a better understanding of how outsourcing care affects military members and their families. Additional recommendations for further research include showing consultancy capability as an expert. This would be providing specific, measurable, achievable, relevant, and time-based goals. The goal would be for all employees to understand how proposed manpower cuts may have negative impacts and affect productivity. The researcher would illustrate how proposed manpower cuts have affected select businesses, which resulted in declined performance, satisfaction, and employee motivation. Communication and morale initiatives such as emails, status updates, quizzes with rewards, and monthly newsletters would be shared with employees during initial inquiries of proposed manpower cuts. Also, the researcher would ensure all employees are informed by having briefings and focus groups on discussing the latest updates and document acknowledgment of proposed actions. Finally, the researcher would update executive leadership weekly with relevant employee feedback to address concerns, solutions, mitigations, fears, and anxieties of proposed manpower cuts and how they may impact the work environment. In addition, it is recommended that businesses explore the possibility of ensuring employees understand the potential negative impacts of manpower cuts. Integrating effective communication within businesses to better understand practical solutions for mitigating impacts, maintaining provider staff productivity and motivation, job satisfaction, and prioritization of services is very beneficial. This benefits all managers and employees involved in a business experiencing manpower cuts. 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