The rewrite process is almost completed–thanks to all who have helped. The latest draft was presented in July at the SAS training for comments/corrections. Please see Col Louis Perino’s excellent edits below. These have all been incorporated. They are presented below so you can see his attention to detail. Thanks to Col Louis Perino,
Explanation of changes for 2013 Revised ANGI 40-102 State Air Surgeon.
This series of notes provides insight for the changes that have been proposed and will follow the order of the changes in the ANGI. I hope that this will supply the reader with background and the thought process. If you have any comments or questions, please let me know—WWP firstname.lastname@example.org or (260) 602-5167
–At the top of the ANGI, on the first page, the logo needs to be changed to the current NGB logo. The one currently shown is from 2008.
–Add the following paragraph as para 2.4 and renumber current para 2.4-2.12.
“2.4 Maintain at least an active Top Secret security clearance. If this level of clearance is not already possessed, as soon as the SAS is selected, he/she shall be processed for the appropriate clearance.”
Comment: During discussions of RPA support and such, it occurred to me that there is no guidance on security clearance in the current ANGI. I pulled the above suggested paragraph verbatim from AFI 48-101 220.127.116.11. for SGP qualifications. It seems to me that for the SAS to support the State’s SGP(s), he/she would need at least the same level of security clearance. We may not win this fight, but our gun will be empty if we don’t have any formal guidance to take to our States to request the TS.
The remainder of my comments are style/typo considerations.
–Last sentence of opening para from:
“This Air National Guard Instruction (ANGI) prescribes the qualifications, duties, responsibilities, and both wartime and peacetime contingency requirements of the State Air Surgeon.”
“This Air National Guard Instruction (ANGI) prescribes the qualifications, duties, responsibilities, and both wartime and peacetime contingency requirements of the SAS.”
Comment: this abbreviation has already been defined in the first sentence of this paragraph, so full SAS title is not needed.
–Last sentence of para 1 from:
“To qualify for and maintain the position of SAS, the SAS must hold valid credentials and waiver/certification approval authority granted by the Air National Guard Surgeon General (ANG/SG).”
“To qualify for and maintain the position of SAS, the SAS must hold valid credentials and waiver/certification approval authority granted by the NGB/SG.”
Comment: This is the only place in the entire ANGI where the Air Surgeon is referred to as ANG/SG. In all other places, the Air Surgeon is referred to as NGB/SG. I am OK either way — we just need to be internally consistent.
“3.1. Within ninety (90) days of appointment, State Air Surgeon shall supply all information necessary for the ANG/SG to establish a Provider Credential File (PCF).”
“3.1. Within ninety (90) days of appointment, SAS shall supply all information necessary for the ANG/SG to establish a Provider Credential File (PCF).”
Comment: this abbreviation has already been defined, so full SAS title is not needed.
“18.104.22.168. The SAS after coordination with the Assistant Adjutant General – Air (AAG) will assign a host Medical Group (MDG) to all Geographically Separated Units (GSUs) within the State.”
“22.214.171.124. The SAS, after coordination with the Assistant Adjutant General – Air (AAG), will assign a host Medical Group (MDG) to all Geographically Separated Units (GSUs) within the State.”
Comment: Missing commas.
“4.1.6. Ensures that support agreements are formally established between the host MDG and the squadron medical element or other unique operational groups or squadrons that have medical providers in accordance with AFI 48-149, Flight and Operational Medicine Programs, and AFI 25-201, Support Agreements Procedures.”
4.1.6. Ensures that support agreements are formally established between the host MDG and the squadron medical element or other unique operational groups or squadrons that have medical personnel in accordance with AFI 48-149, Flight and Operational Medicine Programs, and AFI 25-201, Support Agreements Procedures.”
Comment: Need to expand coverage of this paragraph to include all medical personnel in SME, HRF/CERF, and other operational groups or squadrons.
–4.2.1. first sentence from:
“4.2.1. SASs will assist in the identification and resolution of problems, conflicts or other factors potentially limiting an organization’s mission readiness.”
“4.2.1. SAS will assist in the identification and resolution of problems, conflicts or other factors potentially limiting an organization’s mission readiness.”
Comment: Type extra “s” after SAS.
“4.4.1 SAS will act as PHEO liaison between the TAG, NGB/SGP (who functions as the ANG PHEO) and governmental agencies such as Federal Emergency Management Agency (FEMA); SAS will not be required to uphold all PHEO requirements as described in AFI 10-2603, Emergency Health Powers on AF Installations.”
“4.4.1 SAS will act as PHEO liaison between the TAG, NGB/SGP (who functions as the ANG PHEO) and governmental agencies such as FEMA; SAS will not be required to uphold all PHEO requirements as described in AFI 10-2603, Emergency Health Powers on AF Installations.”
Comment: FEMA has been previously defined in the ANGI, so full name is not needed.
–Para 5, second sentence from:
“As such all medical issues that may impact medical readiness of the unit should be brought to the attention of the SAS.”
“As such, all medical issues that may impact medical readiness of the unit should be brought to the attention of the SAS.”
Comment: missing comma.
–Para 5, third sentence from:
“In addition, the SAS must mentor the younger/less experienced medical officers in the State.”
“In addition, the SAS must mentor the less experienced medical officers in the State.”
Comment: I think “experience” of the medical officer is the issue, not “age” of the medical officer.
— 5.1.3. from:
“5.1.3. Brief the TAG/State Headquarters as needed on medical issues.”
“5.1.3. Brief the TAG/State Headquarters as needed on medical issues.”
Comment: There is an extra line break in the sentence.
–5.4. first sentence from:
“5.4. Act as the Waiver Authority for cases, including enlistment physicals accomplished at MEPS, where the SAS has been delegated Waiver Authority by NGB/SG.”
“5.4. Act as the Waiver Authority for cases where the SAS has been delegated Waiver Authority by NGB/SG.”
Comment: Based on the most recent AFIs, local GMU are out of the MEPS business, which is as it should be…so I assume the SAS is also. The revised sentence is broad enough to cover any SAS waiver authority duties.
Thanks so much to:
Scott McPherson for keen editorial eye.
Brad Eisenbrey for raising the issue of the SAS relationship with the GSUs.
Louis Perino for a thorough critique with excellent editing suggestions by providing location, old wording and new wording, e.g. “Para 2.1., from “the aeronautical rate of” to “the aeronautical rating of”.
Col Perino’s critique and suggestions were several pages long and they have all been incorporated. I bet he was dynamite in English class.
Brett Wyrick for emphasizing and clarifying the importance of the ANG/SG in maintaining quality and uniformity in SAS credentialing, waiver approval/certification process and training.
Dana Rawl in pointing out that an ANG Assistant may be the most senior medical officer in the state or that there might be a more senior flight surgeon at the unit; nonetheless the SAS should be the most senior physician who is able to fulfill the responsibilities of the office.
John McGoff and Lisa Snyder for their suggestions which have been incorporated.
“Groucho” Chappuis for wit and encouragement.
Robert Desko and Melinda Sutton for many, many substantive comments and suggestions.
“Mighty” Mike Daggett, Recruiting and Retention Superintendent, for suggestions regarding MEPS physical waiver improvement and delegation authority to SAS in certain cases.
Stuart Christian to assure coverage of all medical units in the state, even those that are unique and only a few of which exist nationally.
To the lively SAS discussion that resulted in specific inclusion of SAS interaction with the WDPH in Para 4.6
Sid Jackson for enhancement of the conflict of interest section, CERFP credentials, unique operational groups, templates
And to the many who have offered to assist in generating templates, guides, and SAS training materials.
In the heading, the dates have been updated to 2014 and the OPR as Col Mark P. Gaul.
a. Thanks to Dana Rawl for the suggestion that the SAS should be, rather than must be, the highest ranking medical officer in the state because the ANG Assistants are still attached to their respective states or because sometimes a less senior physician is appointed to the position of SAS; nonetheless, the SAS fills the roles and meets the requirements as delineated in ANGI 40-102.
b. The relationship between the ANG/SG and JFHQ staff has been clarified. The State Air Surgeon is a member of the State Joint Force Headquarters and in that chain of command while the ANG/SG is responsible for granting credentials and waiver/certification approval authority, both of which are necessary to function in the position. Thanks to Col Wyrick for his sage counsel in noting that occasionally the state appointing authority may not have a full understanding of the position and qualifications of the SAS and may appoint a physician without the requisite qualfications. Consequently, the ANG/SG is tasked with assuring uniform nationwide qualifications of those in the SAS position. The result is that if a member is not granted credentials or certification/waiver authority by the ANG/SG, the member cannot hold the position. (In a similar manner, the Medical Licensing Board does not determine what physicians may be appointed to a hospital staff; however failure to acquire or maintain licensure by the MLB disqualifies the physician from his position.)
c. Specifically omitted was the statement requiring concurrence of the NGB/SG for the appointment of the SAS. The ANG/SG is not in the chain of command any more than the SAS being in the chain of command for the Medical Group Commander. Again, by way of example, the SAS approves credentials for the MDG commander and may make recommendations to the Wing Commander regarding the appointment, but the SAS does not have the authority to disapprove an applicant; however, if the provider is not credentialed, he/she cannot hold the position.
d. From a practical standpoint it is best for ANG to exercise control at the credential level after examination of the credentialing package, rather than before appointment because, if concurrence by the ANG/SG is required by regulation for the appointment of the SAS, then there must be generated a specific legal framework with specifics such as format, timeframe, criteria, appeal process, etc. Best just to delete the words requiring concurrence and use the process as delineated above.
2. Nomination and appointment was reworded to make it more complete and flowing.
a. Examples of Appointment Letters, Templates, etc. were initially suggested to be added as Attachments; however the consensus seems to be that these would best be located in a central repository such as the ANG/SG SharePoint and the www.aangfs.com website. The utilization and location of such templates would then be covered in the ANG/SG training. This caching of templates in a central repository would permit quicker modifications and updating of different versions of the documents along with contact information for the originator of the document. It is much easier to modify the documents in SharePoint and the Alliance website than in the ANGI. The ANGI makes the requirement; these template documents are suggestions to make work easier and lend uniformity.
b. The original suggested appointment letter required the TAG to attest to the fact that the candidate had read and agreed to the responsibilities of the office—probably not the TAG’s job since this acknowledgement is covered in the acknowledgment letter signed by the SAS Appointee.
c. The original suggestions used the passive voice to say that “the letters must be sent” without specifying who is responsible. The loop has now been closed with a responsible party; the applicant is probably the most motivated and the closest to having read the regulation so that is why the responsibility is delegated to the SAS Appointee.
d. Para 2.4 has been added to require reappointment after 4 years. This does not necessarily preclude reappointment, but it does require evaluation by the JFHQ staff of not only qualifications, but of force structure, career progression and manning.
3. Qualification and Re-Qualification Training;
a. These sections from the prior version of ANGI 40-102 were merged into the same section since they cover the same subjections,
b. Timeframes were added whereby the SAS must provide Credential information and attend the one week orientation training so there are clear deadlines.
c. The periodic training requirements are new and should be given consideration and consideration by those reviewing this version of the ANGI. Due to the ongoing changes in the Air National Guard Medical Service and the volumes of information, many have felt that the SAS should attend an ANG/SG approved in-person training for a week at least every other year. This in effect becomes part of the required Annual Training for the SAS and therefore warrants allocation of days and funds. Although some updating of skills and information may be accomplished by video/teleconferencing and electronic means, certain skills and working information must be done on site and in person at the ANGRC.
d. A new section requires a passing a test of SAS knowledge of the SAS duties, responsibilities and requirements. SAS input from the field for the test questions would be appreciated.
4. Duties and Responsibilities remain relatively unchanged.
a. Para 4.1.6. Support and evaluation of the Geographically Separated Units is given specific clarification, such as specifying that the SAS in coordination with the Assistant Adjutant General – Air assigns the host MDG for GSUs. The GSU/host loop is also closed by specifying that a copy of the letter be forwarded to the ANG/SGP who then maintains a file of the agreements and if no yearly update occurs, then the ANG/SGP queries the SAS as to the status of the relationship. . (“4.1.6. Ensures that support agreements are formally established between the host MDG and the squadron medical element or other unique operational groups or squadrons that have medical providers in accordance with AFI 48-149, Flight and Operational Medicine Programs, and AFI 25-201, Support Agreements Procedures.”)
b. Para 4.1.9 is a new section that involves that Medical Readiness Reporting. This has become a high visibility issue item. The SAS, due to experience and ties to the units in the state, is probably the best qualified person to review such reporting and to convey such information and comment upon it to the state HQ.
c. Performing aggregate annual capability gap analysis on data and forwarding to regional SAS rep on Human Weapons System Council (Para 126.96.36.199 in the 2008 ANGI 40-102) has not occurred so the section has been removed.
d. Since visit to GSU, SME, MDG requires documentation; there should be a concise, easy to use template that does not duplicate information contained in other reports. SAS input from the field regarding the template would be helpful.
e. The awareness of funds and the Regional Readiness Response was left unchanged even though its purpose and function remain unclear to most so if anyone has insight into the purpose for and the working of this requirement, please clarify this for us.
f. Luis Perino has rightly pointed out that in some states such as his with 9 units requiring inspection, Para 4.2.1 may not be feasible if done in person, consequently electronic and telephonic means for the annual inspection may be utilized in a manner deemed most appropriate by the SAS.
g. Para 4.2.5. regarding the inspection process has become more broad and thanks again to Louis Perino for the rewording. Management Internal Control Toolset (MICT) will probably be used instead of Self Inspection Database SID, but these inspection tools seem to keep changing, so the requirement is now more broadly worded to simply require SAS involvement in the MDG self inspection process. Once again, there needs to be a good template for the SAS annual report and a location needs to be made available that can be accessed by the Traditional Guardsmen, such as the www.aangfs.com. The Community of Practice is gone and SharePoint is still not able to be accessed by most from a non military computer.
h. Para 4.2.6. shares templates in a central repository, but does not specify the type, since this again may change before the next rewrite of the SAS ANGI. (“When infor¬mal methods are utilized, the SAS will prepare an annual report, which may be facilitated by utilizing templates supplied by the ANG/SG and which may be located in a central repository.”)
i. Par 4.2.8. has been added, but it might be best to have the SAS review rather than be required to approve. It would be good to have a senior physician to add weight to recommendations to augment the CERF-P formulary. (“4.2.8. The SAS will review all “augmented” formulary items identified to fulfill unique state requirements in the CERF-P.)
j. This is a significant rewrite of Para 4.3. Credentials which deals with the Interfacility Credentials Transfer Brief (IFCTB). Whenever the SAS works a medical facility whether in the state or out of state, there must be an IFCTB on file. One suggestion was not to require an IFCTB if within the state, but it is probably best to require an IFCTB to assure all providers are appropriately credentialed including the SAS; however the IFCTB would be valid for the entire credentialing period of the SAS.
k. Para 4.3.2 brings up a valid point to assure that all providers are credentialed. If the CERF-P is under the Admin control of the MDG, it should fall under the credentialing auspices of the MDG and not require SAS intervention, However, in order to assure that nothing slips through the cracks the section has been reworded to allow the SAS to credential the senior provider at any medical organization that has not been otherwise credentialed. (“In the event that the senior physician of a CERF-P, Contingency Response Group, Special Tactics Squadron is not credentialed through a Medical Group, the SAS will award clinical privileges to the senior physician of such group.”)
l. Para 4.4 PHEO is a new section.
m. Para 4.5 provides for a more orderly transition upon transition or retirement of the SASs by allowing a 6 month overlap. Or this could be accomplished by appointing the incoming SAS as Deputy.
n. Para 4.5 now allows SAS to act as resource for WDPH and to report quality measures (but not patient specific information.)
5. Medical Review, Certification and Waiver Authority.
a. Para 5.4 now specifically addresses SG delegated waiver authority to include SAS ability to waive specific conditions from MEPS physicals. Note that ANG/SG is permitted, but not required to delegate waiver authority. (This is similar to the authority granted to the State Director of Staff in ANGI36-2002 to waive disqualification due to certain minor legal offenses as specifically delineated) Scenario of how this would work:
i. SAS completes training & maintains competence for ANG/SG delegated waiver authority,
ii. ANG/SG develops list of top 10-15 conditions that are waiverable by SAS.
iii. MEPS completes physical that requires waiver
iv. Before submitting MEPS package to ANG/SG for waiver, state recruiter sends email to SAS inquiring whether condition may be waived by SAS.
v. If yes, package sent to SAS and approved if appropriate.
vi. SAS can only qualify, but not disqualify for waiver.
vii. If SAS does not approve waiver or has any questions, package is sent to ANG/SG for consideration as is currently done.
b. Para 5.4.1. and 5.4.2 in the 2008 version were deleted. Per AFI 10-203 and AFI 48-123, SAS no longer has a role in determining or waiving members to attend UTA.
c. Sid’s reasoning makes sense regarding transfers, including those from AF AD. There are other reasons that the SAS may wish to review transfers besides different standards, reasons such as quality assurance. (“5.5. Review and certify medical examinations for transfers of all individuals of Air Force and non-AF compo¬nent military transfers. Cases with disqualifying/potentially disqualifying conditions must be sent to NGB/SGPA for Waiver consideration.”) AD AF does not stratify folks on SSRIs or Axis I diagnoses necessarily. Need to catch these folks up front.
d. Para 5.6 in the 2008 version dealt with reviews of MEBs conducted at the MDG. This has been removed.
e. Para 5.6 now deals with conflict of interest and is a new section. The conflict of interest suggestion has been incorporated into 5.7 and includes the Deputy SAS. (“5.7.1 SAS or Deputy SAS many not certify physical or waiver of spouse, sibling or any other family member, nor shall the SAS or Deputy SAS act as the privileging authority for spouse, child or other family member.”)
6. Support for the Duties and Responsibilities of the SAS clarifies the roll of Assistant versus Deputy SAS
a. Para 6.2.1. At the discretion of the SAS and with the concurrence of the TAG, States are authorized a Deputy SAS. The consensus of the committee was to let the states decide based upon workload, deployments, retiring SAS, etc.
b. The Assistant for the SAS is an additional duty, may be an officer or enlisted, and assists in most tasks except those pertaining to credentials, privileges, certifications, waivers and actions requiring a privileged provider.
c. The Deputy SAS is to assist the SAS in states with large medical contingents. The Deputy SAS acts in the same manner as the SAS or in his/her absence, so the Deputy must have the same training and appointment requirements.
These have been left unchanged from the prior version of ANGI 40-102 and may be utilized for background, but probably should be checked to make sure that there are no updated versions or additional references that should be incorporated.
Q. What did Dana Rawl say about the rewrite?
A: I believe you all have subdued a very slick eel with all the legs of a cunning octopus!! Nicely done!