A Thoughtful Second Look

An Independent Review:
Report on CDS Directed Review of Care

for the Ill, Injured and Transitioning
MWO
(RETD) BARRY WESTHOLM, CD
FINAL | V1
A Thoughtful Second Look

Table of Contents
Topic
Page
Introduction
A Thoughtful Second Look
3
A Thoughtful Second Look:

Report on CDS Directed Review of Care for the Ill, Injured and Transitioning
JPSU Sergeant Major (retd) Barry L. Westholm, CD
Intent/Methodology
4
The JPSU Train
5
Key Commentary/Recommendations
7
JPSU Construct:
Strategic Level
Operational Level
Tactical Level
Terminology
Vital Ground
Summary of Key Recommendations
10
Commentary:
Report on CDS Directed Review of Care for the Ill,
Injured and
Transitioning
11
Background
11
Methodology
12
A Natural Inflection Point
14
Development
The Posting Process
19
Stresses
20
Command Philosophy
21
Chain of Command
21
Command and Control Structure
23
Client Management
30
Medical
32
Policies and Processes
33
Support
35
Branding, Culture and Stigma
35
Summary of Key Recommendations
36
Way Ahead
37
Conclusion
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38

Document Summary
38
Date. 28 December, 2015

A THOUGHTFUL SECOND LOOK:
REPORT ON CDS DIRECTED REVIEW OF CARE FOR THE ILL, INJURED AND
TRANSITIONING.
Refs: A. Somalia (Operation (Op) Deliverance, UNOSOM)
B. Rwanda (Op Lance, UNOMUR)
C. France (Operation Jubilee, Dieppe)
D. Report on CDS Directed Review of Care for the Ill, Injured and Transitioning
E. https://openparliament.ca/committees/national-defence/41-2/12/colonelgerry-blais-1/only/
F. France (Battle for Beaumont Hamel)
G. Review Phase Spreadsheet
H. Letter of Resignation (.pdf)
Introduction
1. Over the recent history of the Canadian Armed Forces (CAF), there have
been some regrettable incidents (refs. A, B.) that could have been easily
prevented if proper leadership was in-place and been applied. Further back in
our history we can find other tragic events whose root cause also falls upon
poor planning and leadership (refs. C, F.).
2. The ongoing situation of the Joint Personnel Support Unit (JPSU) is one such
situation that has developed to critical mass; a delicate point where it can be
corrected if the right leadership is applied, or continue on the path of past
regrettable events if it isnt.
3. This document, A Thoughtful Second Look, brings insight to the Report on
the CDS Directed Review of Care for the Ill, Injured and Transitioning (ref. D.)
from a perspective of a former senior member of the JPSU. On reviewing this
Report, the author has found a series of recommendations that encourage a
continuation down the path of regrettable events. It is hoped that upon review
of this document, that path can be changed towards one of success.
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4. This is not to take away from or disrespect the author of the CDSs Report
the JPSU is a labyrinth of unorthodox terminology, nonsensical structure,
civilianization, co-op arrangements, infighting, doctrinal misapplications and a
host of other pitfalls for anyone trying to navigate it. The JPSU in its present
form is eight-years in the un-making starting with a solid concept, its
leadership embarked on a path that initiated a series of investigations, media
reports and unease of unit commanders as the reputation of the struggling unit
became known.
MWO (retd) Barry Westholm, CD

Hm. 613 587 4203
Cell. 613 559 1312
Email. barrylw11@hotmail.com
A Thoughtful Second Look.
5. A Thoughtful Second Look introduces additional commentary and Courses of
Action (COA) to be considered from an independent and knowledgeable
perspective: Master Warrant Officer (MWO) (Retired) Barry Westholm. MWO
Westholm was a founding member of the Joint Personnel Support Unit (JPSU)
and bore witness to the JPSUs development from inception in 2009 to 2013 as
the Regional MWO/Sergeant Major of the JPSUs most populous Region: Eastern
Ontario Region.
6. As the initial inadequacies of the JPSU became apparent, and new challenges
appeared on the horizon, MWO Westholm was a strong voice to take early
corrective measures. However by 2013, the JPSU had descended to a point
where control of the unit and proper support of the injured and ill posted to the
JPSU was impossible.
7. In February 2013, MWO Westholm took the extreme step of resigning from
the CAF in protest of what he saw as a tragedy developing at the JPSU. A
component of his resignation was to allow him freedom to provide personal
insights on the JPSU free from pressures, influence or repercussions of the JPSU
Chain-of-Command (CoC).
8. From 2013 until the present time, MWO (retd) Westholm has taken an
advocacy role for the JPSU and those left stranded in and by the unit. Over that
time he petitioned the CAF, the CAF
Ombudsman, Members of Parliament,
the Canadian Senate, media and others in an attempt to bring attention and
assistance to the JPSU. He also wrote blogs, open letters, conducted radio and
television interviews, all with the sole objective of getting much-needed support
to the JPSU.
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9. In doing so, MWO (retd) Westholm has remained an engaged, independent,

informed and largely critical observer of the CAFs management of this
important unit. In the past seven-years, MWO (retd) Westholm submitted
dozens of reports and recommendations attempting to prevent the situation
that now faces the JPSU, its staff and posted-in members from ever happening.
10. MWO (retd) Westholm welcomes the recent interest of the CDS in the JPSU
and Gen. Andersons Report on CDS Directed Review of Care for the Ill, Injured
and Transitioning. He also appreciates the prolonged interest the CAF
Ombudsmans Office and media has taken in the JPSU and the time they have
taken in communicating with him.
11. A Thoughtful Second Look provides informed and independent commentary
of Gen. Andersons Report on CDS Directed Review of Care for the Ill, Injured
and Transitioning from the perspective of one who knows the JPSU intimately
and cares for its success.
Intent
12. The intent of this document is to add some clarity to Gen. Andersons
review to be used in conjunction with the accompanying spreadsheet. The
commentary provides an educated unbiased perspective uninfluenced by, or
obligated to, any of the parties affected by this issue. With this it provides an
additional tool to make corrective decisions/input to address/discuss this
regrettable situation before it worsens or becomes something we try to justify in
hindsight (ref. C.).
Methodology
13. The Report on CDS Directed Review of Care for the Ill, Injured and
Transitioning was carefully read and compared with the authors experiences as
a senior member of the JPSU, Eastern Ontario Region.
14. Upon finding irregularities in the Report, the author supplied several
historical JPSU emails to the Chief of Defence Staff (CDS) and Ombudsmans
Office in advance of this document to provide a source for the following
commentary. These emails are referenced in the accompanying spreadsheet.
15. Gen Andersons findings were transferred to this document and are
italicized in Times New Roman, font 10. The text may be annotated with a
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highlighted number (1) or bolded and will have a corresponding number and
comment following. An example of both follows:
11. The JPSU structure was established (originally as a project) in 2008 to
(1) care for the influx of ill and injured from operations in Afghanistan that
was overwhelming the Rear Parties of parent units
16. The italicized text from the CDS Directed Review of Care for the Ill, Injured
and Transitioning was then annotated with paragraph-by-paragraph
commentary starting at Methodology.
17. A Thoughtful Second Looks commentary will be in Calibri Body, font 11
format as below:
Para 11. Commentary:
(1) The first posted-in members of the JPSU were from
the former support system the Service Personnel
Holding List (SPHL). Upon transferring these injured
members, the JPSU became fully-tasked almost instantly.
There were no transfers from rear-parties at that time,
they came later.
18. This format is maintained throughout the Report and is similar to that
employed the attached Phase spreadsheet (ref. G.) which has a column
dedicated to additional commentary in a different font.
The Joint Personnel Support Unit (JPSU) Train.
19. According to Gen Andersons Report, the JPSU Train jumped the CAF
Doctrinal rails almost as soon as it left the station:
This violates a fundamental tenet of military command doctrine that states
line and staff functions must be clearly delineated. Furthermore, a
distinct and unambiguous chain of command that coherently integrates
strategic, operational, and tactical headquarters and elements needs to be
in place.
20. The JPSU Train was a new concept at departure, not refined or equipped for
the long-journey on which it embarked, but once started the only time it slowed
was to pick up military injured and ill. Since 2009 the JPSU Train has been
bumping along its own rails, making up its own rules, language, structure,
communications, operations and CoC along the way. It went unimpeded until a
series of investigations, complaints and reviews caught up with it. It was a
rough ride for all involved and now it sits mired, a great concept but still
unrefined, far off CAF Doctrinal Rails.
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21. Now that the JPSU train has stopped, a series of Courses of Action (COAs)
can be considered to salvage it and the situation. Gen. Andersons COAs make
the best of where the train lies mired, accepting, and even expanding, on its
unique characteristics. This COA may have consequences that negatively affect
the success, or even acceptance of the JPSU by military commanders.
22. The JPSU/IPSCs civilianize military terms and replaces them a unique
language of its own. For example, Ive crafted the below statement using
terminology from Gen. Andersons Report:
From the desk of the DCSM Rep and JPSU/IPSC lead: Service Manager Bob Dixon: The Service
Providers of the Joint Personnel Support Unit (JPSU), Integrated Personnel Support Centre (IPSC),
now located in the Black Bear Soldier Support Building, will be relocating to the new Vimy House
at the Pembroke Mall.
This move is deemed necessary as 5% of the clients associated with our Military Customer-Base have
issues attending the present on-Base location. (Were also considering a new civilian dress policy for
our in-house Military Service Providers to compliment the move to the Mall).
Given the increased distance of Vimy House from CFB Petawawa there will be an equitable increase
on the Client Tax Rate to our Military Customers. Our new rotation of In-House Military Service
Providers are struggling with the present In-House Client work-load and have requested an increase
on the Military Customers Client Tax as well, something Im now considering.
Our current JPSU/IPSC Service Providers serve 300 in-house Military Clients from our Military
Customer-Base, 60 walk-in Military Clients, 20 Retire-Based Clients and 12 Family-Based Clients
from our Non-Military Customer-Base per-day. On a positive note, Ive just learned through the
DCSM Services Manager Network that Services Managers now have Tactical Level oversight of the
largest military unit in Canada!
23. While the above takes place with the JPSU Train sitting mired a full eightyears off the CAF Doctrinal Rails in its own JPSU/DCSM made wilderness, CAF
Commanders remain firmly on those Doctrinal Rails observing it. And as the
CAF Commanders view the mired JPSU Train in the distance, knowing their
injured troops are aboard it, Im certain theyre wondering: What the hells
going on out there; how the blazes did they get there and what on earth are
they saying!?
24. Rather than working in-situ where the JPSU Train lies mired and
accepting, integrating or expanding on the obscure characteristics of the
JPSU/IPSC in its self-made wilderness, A Thoughtful Second Look applies
known and battle-tested Royal Canadian Electrical and Mechanical Engineering
(RCEME) doctrine to the task: Recovery and Repair.
25. The following COAs recommend Extricating the JPSU/DCSM Train from
where its mired, putting it back on the Doctrinal Rails, Recovering it to the
station, Repairing the Train, Modify it using Lessons Learned, Provisioning it
and then turn it over to CAF Leadership fueled-up, serviced, ready and raring to
go as JPSU Train Mk2. This time however, it will be run as a train should be run,
with proper engineers, conductors, rules, communications, and passengers,
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fully serviced, in fine-tune and back on the doctrinal rails with the rest of the
Canadian Armed Forces.
Key Commentary/Recommendations.
26. Rather than go through a complex situation and lengthy document at the
start, the Key Commentary and Recommendations in broad-strokes are as
follows:
JPSU Construct
27. Strategic Level.
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Strategic Level Command. It has been noted in Gen Andersons Report: At

present, DCSM (a Directorate at the Strategic Level) acts as the HQ for the JPSU
and the IPSCs. Indeed, DCSM and CO JPSU are the same person. This violates
a fundamental tenet of military command doctrine that states that line and
staff functions must be clearly delineated.
Commentary: This is a serious breach of doctrine that was allowed to flourish
unabated for many years. This provided a lengthy period for the JPSU to mature
and set-in in the exact wrong direction, an influence that should be taken into
account when reviewing the situation.
Recommendation: Separate DCSM from JPSU at the Strategic Level and attend
to the anomalies of the JPSU that may have taken place over time.
Strategic Level Structure. The JPSU currently uses a unit structure
normally found within the confines of a Base or Garrison. This structure is
seldom, if ever, used for Strategic Level C2.
Commentary: A Unit is an unsuitable structure to the tasks associated with
the JPSU, more so if a Director, who is simultaneously the Commanding Officer,
spends too much time in the trenches as a Commanding Officer evaluating the
Directors work.
Recommendation: Change to Formation Structure and include members
from Services and Service Partners (VAC, Health Services, Legion) on the
Strategic staff.
28. Operational Level.
Operational Level Command. Like at the Strategic Level, the JPSU
structure at the Operational Level is inadequate. The present structure is based
on a Company Headquarters light with an Officer Commanding.
Commentary: By 2012 some Regional Headquarters were supervising over
500 people (in some cases dispersed over multi-Provinces) with a staff that
usually consisted of a Command Team (Major (OC) and MWO (Sgt-Maj)), an
Adjutant (Captain), a Clerk (WO) and a Staff Car (Hyundai). It remains arguably
one of the most under-staffed, under-ranked, under-empowered, under-funded
and over-stretched command elements in CAF history.
Recommendation: Change to Regional Company structure to a Regional
Unit Structure and include a Senior Services Manager (and staff) for Regional
services coordination and a Service Partner (VAC/Health) for similar Regional coord.
29. Tactical Level.
Tactical Level Command. Like the Strategic and Operational Levels, the
JPSU structure at the Tactical Level is inadequate. The present structure is
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based on a Platoon light but without a higher level of leadership. The IPSC
Services component is also light and has no leadership component. The Platoon
Commander and Services Manager are two separate entities without a position
to unite them or provide a conduit to their Regional Headquarters.
Commentary: There are no formal command relationships between the
Support Platoon, the Services Section, and the IPSC Service Partners. In some
instances, this has led to friction, in other locations, a smooth and effective
modus vivendi has been established and in all instances effectiveness is a
direct correlation of interpersonal relationships - this is no way to run a chip
stand much less a military unit.
Recommendation: The IPSC (a term that will be amended) must be changed
to a Company structure with an Officer Commanding, a Headquarters staff and
adequate Services staff (led by a Services Manager(s)) and a Platoon(s) (led by
Platoon Commander(s)). The IPSC must be staffed appropriately to ensure
services and leadership are made available to the recently released, serving
soldiers, sailors, airwomen and airmen, military families and veterans in their
AOR.
Summary: Construct.
30. With the above recommendations, the JPSU becomes a recognizable and
proven construct from top-to-bottom with a solid chain-of-command in-place.
Terminology.
31. The DCSM/JPSU/IPSC employs some of the most confusing and nonconforming terminology in the CAF. In doing so, it adds to stigma, skepticism,
and general misunderstanding of the Mission of the JPSU. That said, the term
JPSU has been used for eight-years, is recognizable and should remain inplace.
Strategic Level.
Joint Personnel Unit (Formation)
Operational Level.
Joint Personnel Support Unit (JPSU)
Tactical Level.
JPSU Detachment (Det): Location
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Vital Ground. The below is the recommended Construct/Terminology at the

Vital Ground:
JPSU Det: (Enter Location Here):
- Headquarters:
o OC
o 2 I.C./Adj
o CSM
o WO/Ops/A-Clerk
o MWO/Clerk
o Sgt/Runner/Driver/A-Clerk
- Platoon(s):
o Pl Comd
o Pl 2I.C
o Pl WO/Clerk/Driver
o Sections:
Section Commander
Section 2I.C/Clerk/Runner/Driver
- Services Section:
o Services Manager
o Services Co-Manager
o Services Clerk/Driver
o Services Staff
- Service Partners:
o VAC
o OSISS
o HSvcs
o Etc.
Summary: Terminology:
With the adoption of preceding Construct and Terminology recommendations
the JPSU now has an instantly identifiable, approved, and workable structure
and language.
Staffing.
32. Throughout Gen Andersons report the woes of Reg Force staffing are noted
and a host of recommendations re: specialized training, selection, enticements,
incentives, minimum posting-time (2-3 years) and RegF augmentation
recommendations (such as a client tax) are tabled.
33. Originally there was no such issue they are issues that were made by a
change in staffing policy from a stable PRes staff to RegF and the poor
management of the JPSU.
34. In 2009, the JPSU had a select and stable staff of highly-motivated, hightrained, highly-experienced PRes staff in place and functioning effectively. Most
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staff applied for JPSU positions from the RegF and were required to component
transfer to be able to fill a JPSU position there was no option of filling a JPSU
position as a RegF in 2009 it was a sound and logical practice.
35. The use of select PRes (incl. RegF willing to transfer) staff allows the CAF to
carefully screen applicants and choose those who best suit the JPSU Mission.
The former logic for a successful RegF candidate having to component-transfer
to PRes was rock-solid. It was done to avoid the issues that now plague the
JPSU and resolve the host of challenges bought on by employing RegF staff.
36. While Gen. Andersons report provides recommendations to ensure select
RegF staff are chosen, what is missing is that the JPSU will have to go through
the recruiting / interview / selection / posting / training processes incessantly. A
newly posted-in RegF member will take time to get their bearings, then they will
have to receive specialized training. While they are receiving this training, their
positions will be vacant. When they are finally comfortable in their position and
properly trained, they will be posted-out and the process begins again. This will
stress the entire JPSU structure from top-to-bottom, staff and supported
personnel.
37. The preceding challenges do not apply to the PRes model once you have
PRes on staff, they become a stable force that can lead, learn, train and, most
importantly, get to know and support their injured/ill charges throughout their
convalescence and transition. This continuous interaction is an enormous
benefit to the injured or ill member going through what can be a traumatic
period, and something only time, stability, and leadership can provide.
38. One of the points brought forward by Gen. Anderson in using RegF staff was
that the civilian staff has now become the more stable workforce in the IPSC
and should be the de facto lead of the IPSC. I disagree. If that logic was applied
strategically, every unit in the CAF would be managed by civilian staff. The
JPSU must be supported by a stable military staffing structure.
39. While the JPSU is not a typical unit, it is a CAF Unit, and as Gen. Anderson
rightly points out, the largest unit in the CAF. To have a unit of close to 2000
CAF soldiers, sailors, airwomen and airmen overseen by a series of civilian
Service Managers is, to me, not a great idea.
Summary: Staffing.
40. The recommended use of Regular Force (RegF) personnel brings with it
tremendous disadvantages over the use of Primary Reservists (PRes) for the
specialized role of the JPSU. Almost all the commentary Gen. Anderson raised in
his report can be mitigated by the employment of suitable PRes personnel.
With a reversion to a select, experienced, trained and stable PRes military
component, the majority of the issues raised by using RegF are immediately
resolved.
Summary of Key Recommendations.
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41. The preceding are broad-stroke big-picture recommendations intended to

extricate the JPSU Train from where its mired back onto the doctrinal rails and
then recover it back to the station for repair, servicing and modification.
42. The JPSU has a very important mandate and, if properly managed, allows
for a host of positive impacts right across the military/veteran/military family
spectrum. But it hasnt been properly managed and the DCSM/JPSU/IPSC at the
time of this writing is in need of recovery and repair, not a field-expedient and
makeshift repair-in-place.
Recommendation/Commentary Addendum.
43. Here begins the paragraph-by-paragraph commentary on the Report of the
CDS Directed Review of Care for the Ill, Injured and Transitioning:
BACKGROUND
1. The care of our soldiers is both a command and a moral imperative. To that end, over the last
ten years, (1) the Canadian Armed Forces (CAF) ability and capacity to care for our ill and injured
has grown by leaps and bounds, and in a highly organic manner in response to a significant increase
in the number of ill and injured in the CAF. (2) The Joint Personnel Support Unit or JPSU structure
and its hardworking staff that has developed and evolved over time has worked tirelessly to care for
our ill and injured, and provided a very broad spectrum of services. (3) As part of our ever-present
drive to improve both our efficiency and effectiveness, it was evident that it was time for a broad
review of the program, its mandate, organizational structures and relationships, and delivery
mechanisms.
Para 1. Commentary: (1) The DCSM/JPSU failed to keep pace with support
challenges as they were anticipated and/or as they developed in real-time.
Therefore the proper ability and capacity to care for our ill and injured faltered,
staggered and lurched rather than leaped. The expected increase in the
number of supported personnel, the realization of those expectations, and the
requests for proportionate increases in staff are well documented. However the
DCSM/JPSU HHQ refuted the advice of its mid-level leadership and restricted any
attempt of improvements to staffing, training and policy. (2) The resulting
extraordinary efforts of the Regional staff are without question, but they are
also without cause. The Regional staff were left to their own professional, moral
and ethical standards to succeed where their strategic leadership failed them.
This was not so much a case of planned or natural evolution but of constant
reaction, damage control and concession. (3) Not to mention a host of ongoing
investigations and media reports on the JPSU.
2. Two weeks after assuming command, the Chief of Defence Staff (CDS) directed an immediate
and focused review of the Joint Personnel Support Unit (JPSU) construct to determine whether or
not changes need to be made to the system in order to better care for our ill, injured, and
transitioning. He tasked Brigadier-General David J Anderson, currently the CDS Liaison Officer to
the Chairman of the Joint Chiefs of Staff in the Pentagon to conduct this review on his behalf, over
a two to three week period, with a mandate to deliver a verbal brief to the Armed Forces Council
Executive, as well as a written report.
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Para 2. Commentary: My concern, from an independent perspective of Gen

Andersons Report, is that there are recommendations that may not take the
unusual disposition of the JPSU into the equation. Moreover, the time
constraints imposed upon the report and action plan (Phases) stemming from it
are quite short. As there are several ongoing investigations into the JPSU that
have been active for years now, I think it prudent to pause a moment to allow
them to be tabled and review and consolidate their findings before moving
forward. In doing so, efforts of the CAF Ombudsmans Investigation, the Chief
of Review Services Investigation, the CDSs Investigation conducted by Gen.
Anderson (and perhaps this document) can be reviewed together and a more
informed COA made.
3. In concert with Chief of Military Personnel (CMP), a Terms of Reference (TOR) for the review was
developed (attached at Annex A). A Review Team was established, including BGen Anderson, the CMP
Command Chief CWO, CWO Thibault, and the Associate Director of Canadian Forces Morale and Welfare
Service (CFMWS), Mr Mike Ward. The Review Team was tasked with making observations and
recommendations in the following areas:
a.
b.
c.
d.
The mandate, functions, structure and manning of the JPSU, the Regional HQs, and the Integrated
Personnel Support Centres (IPSCs);
The relationships between the ill and injured member and both their former chain of command and
the JPSU / IPSC;
The relationship with supported and supporting chains of command; and
Integration with partners (VAC, Royal Canadian Legion, CF Health Services, etc)
to ensure comprehensive, focussed and consistent support.
Para 3. Acknowledged (Ack).

4. (1) There have been a number of reviews and surveys of the JPSU over the last few years,
including a DGMPRA Client Satisfaction Survey (attached as Annex B) and an Ombudsman Review
(attached as Annex C). To leverage this work and to avoid plowing the same furrows, the Review Team
developed an approach that was more intuitive than analytical, and less formal than previous iterations,
with an overarching intent of (2) discovering ground truth rather than seeking to assign blame or
responsibility.
Para 4. Commentary: (1) This statement has quite a different flavour than
para 1 and comes across as more accurate. (2) It is hoped that if during the
search for the ground-truth a circumstance should reveal itself to which the
assignment of blame or responsibility is warranted, that it will be acted upon.
With the truth comes the responsibility to act, and if that truth reveals a
miscarriage (in policy, leadership, action) then it must be addressed or
the results can be catastrophic, something the CAF has been through before (ref
A, B.).
METHODOLOGY
Para 5. (Note. Para 5 is missing on this particular document)
6. The Review Team was tasked with conducting a holistic review of the function of providing
support to our ill and injured. It was further directed in the TOR to approach the review from the
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perspective of both the soldier and their originating chain of command, as well as from that of the
JPSU / IPSC structure and function. In essence this allowed the team to view the problem through
the lens of the client, the customer, and the service provider.
Para 6. Commentary: From Para 1 to Para 5 the report has changed its tone
from time for a review to include terms such as assignment of blame,
problem and responsibility. If there is a predetermined problem with the
JPSU that impacts or influences this Report, it would be helpful to know where
this information originated and have it placed plainly in the text rather than
beginning with a glowing statement of the CAFs capacity increasing by leaps
and bounds.
7. In order to ensure that the review incorporated both geographical and cultural factors, Regular
Force and Reserve perspectives, as well as Service-specific and functional factors (field force versus
training establishments), the Review Team visited IPSCs and JPSU Regional HQs in Esquimalt, Edmonton,
Winnipeg, Toronto,(1) Petawawa, Trenton, Kingston, Valcartier, St Jean and Ottawa.
Para 7. Commentary: (1) Four of the ten visited sites are from my former
Region (Eastern Ontario Region) which gives this document added weight. It
would have been worthwhile to have visited the most remote militia unit
available to ascertain if knowledge of the JPSU had reached them. Regardless,
the fact that with eight-years of effort, knowledge of the JPSU had not
effectively reached even the main Bases is telling. Furthermore, the
responsibilities in JPSU Eastern Ontario Region included 33 Brigade Group and
the Canadian Rangers, something that was not mentioned in Gen Andersons
Report.
8. At each location, the review Team met with IPSC staff, representatives of the CFHS as well as
partner organisations, and (1) soldiers (clients) either posted to, served by, or having been processed
through the IPSC, in both individual interviews and collective town hall sessions. Additionally, a
number of soldiers - serving and retired - individually came forward to offer their views on the system. The
Review Team also consulted with representatives of the chain of command, as well as (2) Director
Casualty Support Management (DCSM) personnel, representatives of the Surgeon General, and finally
with the Commanding Officer of the JPSU.
Para 8. Commentary: (1) In this para begins the DCSM/JPSU terminology with
the definition of client finally revealing itself (a soldier). A grand component of
the issues plaguing the JPSU is unnecessary civilianized terminology. (2) Another
issue comes to the surface in para 8 in that the separate interviews noted with
the JPSU CO and DCSM are actually interviews with the same person (the DCSM
and CO JPSU are one-and-the-same). This underscores the confusion
surrounding the JPSU/DCSM/IPSC structure/CoC/Communications. (Note. I hope
that they also met with Regional HQ staff and military families and their
omission in para 8 is an oversight).
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9. Given the varied background of those interviewed, the Review Team was able to garner input from a
wide range of perspectives. Moreover, the internal structure of the Review Team allowed concurrent
analysis at the strategic, operational and tactical levels. BGen Anderson viewed the issues through a
strategic lens, focused on those elements of (1) the problem that can be addressed by the CDS and other
departments. (2) CWO Thibault focused on those issues that could be solved within the CMP structure
and authorities, and Mr Ward was hence able to focus on those things that were within the purview of
CFMWS and DCSM / JPSU. Although this report necessarily focuses on strategic level
recommendations, elements of the operational and tactical will also be reported on, especially where quick
and ready solutions are at hand.
Para 9. Commentary: (1) If there were known problems and issues

associated with the JPSU prior to the Report being conducted, it would have
been helpful to have them listed as additional rationale for the report. (2) Many
of the issues of the JPSU evolved directly under CMP structure and
authorities. As CMP is the largest structure in the CAF, Commanded by the
seconded-highest rank in the CAF, its about as much structure and authority as
one can get short of the CDS. The DCSM/JPSU level is only one-level down from
the CMP and therefore are under direct and intimate purview of CMP.
A NATURAL INFLECTION POINT

10. As the Review Team conducted background research prior to embarking on its fact-finding trip, and
in the early days of that trip,(1) it became apparent that the review was well timed, as the system had
reached (2) a natural inflection point in its growth, as follows:
a.
The structure had gone through eight years of organic and reactive
growth to its system, processes, structure and mandate;
b.
Originally established to deal with the influx of visibly injured

casualties from Afghanistan which represented approximately 90% of
the client base, there has been a transition to where 90% of the clients
have non-visible injuries;
c.
Although there are still casualties from Afghanistan presenting

themselves (due to the latency of many non-visible injuries), there has
been a dramatic reduction on the numbers of injuries related to that
operation;
d.
This reduction in operational casualties has led to an increasing focus

on Occupational Stress Injuries, vice Operational Stress Injuries;
and
e.
With new command teams in both CMP and CDS, it was evidently
time to conduct a thorough review of the system in place for caring
for our ill, injured, and transitioning members.
Para 10. Commentary: (1) This Review happened amid a storm of controversy
and attention focused on the JPSU and after years of controversy. (2) The
system had reached a crisis point, not an inflection point, and had to be acted
upon. This review, much like the JPSU, is reactive and I recommend a tactical
15/38

pause to await the results from other on-going investigations prior to

implementing those in this report.
10 a. Organic and reactive growth is more a description of an
untended garden than a military unit. The structure had gone
through eight-years of non-conforming doctrine allowing reactivity
to become a policy rather than an attribute, and processes,
structure and mandate to become an organizational crapshoot.
10 b. From its inception it was stated that the JPSU was intended
to replace an inefficient system (the SPHL) which CAF Commanders
had lost confidence in. At start-up Afghan related injuries in
Eastern Ontario Region was less than 10% with the vast majority
from other Missions. Visible injuries are many times connected to
mental injuries, at times more so depending on the severity/nature
of the injury;
10 c. As with the SPHL before it, there are now injured members
being held back from the JPSU by their unit commanders. The JPSU
should not be based on CAF Operations, it should be a foundational
unit prepared to deal with ill, injured, veterans, and their families
regardless of deployments, in times of peace, UN Missions, aid to
civil power or war;
10 d. An OSI vice an OSI yikes! Two identical abbreviations is
not good; and
10 e. There was another CMP driven review in 2014 (CRS) and still
another mentioned at ref.E.
DEVELOPMENT
11. The JPSU structure was established (originally as a project) in 2008 to (1) care for the influx of ill
and injured from operations in Afghanistan that was overwhelming the Rear Parties of parent units on
operations. As other partners and services have brought support programs on line, the mandate has
evolved to become a (2) one-stop shop for both care and transition indeed DCSM recently assumed
responsibility for all transitions out of the military, injured or otherwise. There has been an explosion of
benefits available to ill and injured, particularly over last 2-3 years, which (3) has increased the
complexity of providing support to ill and injured. (4) Finally, the client base has expanded
dramatically, with a 34% increase of personnel posted to the JPSU since 2011. As such, care of our ill
and injured has become a statistically significant problem: with 1400 clients and 300 staff the JPSU is
the largest unit in the CAF. (5) In most units, it is common to observe that 90% of the administrative
demands are generated by 10% of the unit and the most complex of those 10% are the personnel who
are generally posted to the IPSCs, which presents a unique and daunting leadership and administrative
challenge to the staff of the IPSCs.
DEVELOPMENT
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(1)
The first posted-in members of the JPSU were from the former (failed)
support system the Service Personnel Holding List (SPHL). Upon transferring
these injured members to the JPSU, the JPSU became fully tasked almost
instantly. Transfers from rear-parties came later.
(2)
The "One-stop-shop" moniker was brought in by the civilian-esq

relationship with DCSM/JPSU HHQ/IPSC/Services and is among a host of other
confusing and stigmatizing IPSC terminology. There is no "shopping" - the term
itself is demeaning and distracts from the Mission of the JPSU it is
consolidated support for an injured member, veteran and military families.
(3)
Given the staff-to-injured ratios used by the JPSU, if every posted-in

member was 100% fit, it would still be impossible to lead/manage them. The
increase of posted-in members was well forecasted, and recommendations were
made to increase staff as early as 2009; but all recommendations were
ignored/refused.
(4)
Yes, a 34% increase since 2011, but the staff had not increased since
2009 and I expect there was a few hundred-percent increase since that time. In
2014, the DCSM/CO reported to Parliament and issued a glowing report of the
JPSU (ref E), which is at odds with the problem statement.
(5)
This term and ratio, word-for-word, was used by the Regional HQ in

the past to justify more staff and was refused by the JPSU HHQ/DCSM. It remains
a relevant point and Im buoyed at Gen. Andersons acknowledgment this ratio.
This being the case, it begs the question (again) why the JPSU was disallowed
staff increases when using the same logic. I trust then that this equation will be
used (and staff increased) more so given the JPSU mandate to support recently
released service-members, veterans and military families as well.
JPSU
12. Mission. The JPSU mandate is to respond to requests for support and report to the chain of
command on issues of concern raised by ill and injured CF personnel. Its mission is to:
Through an integrated and individual-centric service delivery model, ensure the coordination and
facilitation of standardized, high quality, consistent personal and administrative support during all
phases of recovery, rehabilitation, and reintegration on return to service or transition following
release, for all injured and ill Canadian Forces members and former members, their families and the
families of the deceased
Para 12. Commentary: That is arguably one of the most expansive Mission
Statements ever produced in the history of the Canadian Armed Forces (see
spreadsheet for an edited version).
13. Organizational Structure. The JPSU is the largest unit in the CAF, with over 1700 personnel on
strength. Headquartered in Ottawa, it has 8 Regional HQs, to which are assigned a total of 24 IPSCs and
8 IPSC Satellite Centres, as follows:
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a.
Pacific Region (Chilliwack, Comox, Esquimalt, Vancouver)
b.
Alberta and Northern Canada Region (Calgary, Cold Lake, Edmonton, Wainwright, Yellowknife)
c.
Prairie Region (Moose Jaw, Shilo, Winnipeg)
d.
Eastern Ontario Region (Kingston, North Bay, Ottawa, Petawawa, Trenton)
e.
Southern Ontario Region (Borden, London, Meaford, Toronto)
f.
Quebec Region (Bagotville, St. Jean, Valcartier)
g.
New Brunswick and Prince Edward Island Region (Charlottetown, Gagetown, Moncton)
h.
Nova Scotia and Newfoundland and Labrador Region (Gander, Greenwood, Halifax, St. John's,
Sydney
Para 13. Commentary: The JPSU is:

-
the largest unit in the CAF;
covering the largest area in the CAF;
with the most injured members in the CAF;
with among the most complex missions in the CAF;
with the most restrictions to carry out their mission in the CAF;
with the greatest staff-to-supported ratio in the CAF; and
whose support also extends to the recently released, walk-ins, veterans

and military families and in doing so is probably supporting closer to
10,000 people.
JPSU HQ / DCSM
14. (1) The JPSU HQ is responsible to CO JPSU for the efficient delivery of programs and services to
the ill and injured. (2) It is co-located with the Directorate of Casualty Support Management (DCSM)
which provides policy oversight and manages programs for the ill and injured, and transition services for
all Canadian Armed Forces (CAF) members. (3) DCSM has technical / professional authority over all
Service Sections in the IPSCs, whereas JPSU Regional HQs are direct reports to CO JPSU.

(1) Not quite the JPSU HQ is in Ottawa and is led by the JPSU CO who is also the
DCSM.
(2) Yes, its co-located, its also the same person in the same building, on the same
floor, in same office, with the same telephone, the same computer and the
same coffee cup (the JPSU CO is the DCSM and vice versa).
18/38

(3) IPSC Services Sections should be part of the Regional IPSC construct under
control of the Regional HQ. The Services direct oversight, communications and
control by the Strategic Level (DCSM) made it difficult for the RHQ to manage its
own IPSCs. (DCSM/JPSU are one and the same).
15. The CO JPSU and Director DCSM are dual-hatted a single individual holds both line and staff
positions, and is responsible for both policy development and advice, and program delivery. As DCSM, the
individual is the point man for families of the fallen, all MINQUIRIES, the hot issue of day, and testimony to
Standing Committees. As CO JPSU, the same individual is the Commanding Officer of the largest unit in
the CAF, with over 1700 subordinates, of which approximately 1400 are clients.
Para 15. Commentary: This is a potential conflict-of-interest, for example, if a

person has issue with the JPSU CO and submits a redress, the DCSM (the same
person) could be the review authority.
JPSU REGIONAL HQ
16. There are 8 regional HQs, each of which has IPSCs and IPSC Satellite Centers under command. The
JPSU Regional elements, (1) commanded by an Officer Commanding, provide regional oversight and
guidance to the (2) IPSCs within their Area of Responsibility (AOR). (3) The Regional Officers
Commanding (OCs) report to DCSM; nevertheless, they are responsive to the local Base Commanders
and Unit Commanding Officers and are tasked to ensure that they are conversant with the priorities of
local chains of commands.

(1) The Regional Officer Commanding (OC) has little/no Commanding Officer
authority and limited oversight of IPSC Services who are largely
controlled by JPSU HHQ/DCSM.
(2) Less the component of the IPSCs (Services) that receives guidance
directly from the Strategic Level (DCSM) who is also the JPSU CO.
(3) This is at odds with the statement in para 14 (3), but remains accurate as
the DCSM and JPSU CO are the same person.
IPSC
17. There are 24 IPSCs across the country, and an additional 8 Satellite Centers. The IPSC is essentially
responsible for the (1) tactical delivery of support to the ill, injured and transitioning. Although they have
common structures across the country, they vary greatly in their cultures, outlook, infrastructure, manning
levels, and arguably effectiveness. (2) An IPSC has three main components, who work together but
without a formal command structure: a Services Section, a Support Platoon, and partner organizations,
as follows:
a
The Services Section is the actual deliverer of services, and has a direct technical / professional
link to DCSM. The positions are predominantly civilian personnel, the vast majority of whom
have prior military service. The Section is responsible for:
(1) Return to Work coordination
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(2) Casualty Tracking

(3) Outreach and advocacy
(4) Information, support, and advocacy services for casualty administration, benefits, and
programs.
(5) Administrative support to families of those CAF members who die while in service, including
the disengagement of the Designated Assistant
(6)
The Support Platoon. This platoon is responsible for command, control, and tracking of
personnel posted to IPSC, and they become the consistent POC for soldiers posted to JPS in essence, their
chain of command. All of the staff are military personnel. In the original manning model, these were almost
all Pres personnel. Between now and 2017 that will change as the vast majority of the positions will become
(3) Regular Force; and
(7)
IPSC Service Partners. Service partners work within the rubric of the IPSC to deliver onestop services for IPSC clients, be they posted in or walk-ins. They include:
(1)
(2)
(3)
(4)
(5)
(6)
Veterans Affairs Canada

Director Military Family Services - Family Liaison Officer
SISIP Vocational Rehabilitation
Personnel Support Programs including OSSIS
CAF Health Services, especially Nurse case managers
Base and Wing partners (Personnel Selection Officers, Chaplains, etc.))
Para 17. Commentary: The most significant piece of this paragraph is

missing there is nobody in-charge of an IPSC.
(1) Tactical delivery is a term that gets lost in the flood of unusual terminology
employed by the DCSM/JPSU/IPSC but it is accurate.
(2) The IPSC has a number of separate components led by no single position or
person; more of a cooperative / communal / collaborative-relationship /
meet you at the watercooler kind of a thing.
(3) The use of select Reservists provided a professional, mature, capable and
stable cadre that the former system (the SPHL) lacked. This JPSU staffing
model was in place and functioning well in 2009 that a lesser system
comparable to the failed SPHL model is scheduled eight-years later is
baffling.
THE POSTING PROCESS
18. Prior to outlining the findings of the Review team, it is essential to outline the process by which a
soldier is posted to the JPSU.
20/38
a.
(1) The process for posting a soldier to the JPSU is initiated by the parent unit CO. Once a
soldier is posted to an IPSC from his or her parent unit, a line serial is freed up in that unit to
allow the posting in of another soldier.
b.
The posting recommendation is reviewed and commented on by an MO, the OC of the JPSU
Regional HQ, and Director Military Careers (D Mil C). The final authority for the posting rests
with D Mil C and more specifically, with the Career manager (CM) of the losing trade /
branch, and not the CM for the Ill and Injured (who only assumes responsibility for th file once
the member is posted to the JPSU). Although an Administrative Review (AR) is conducted for

each case (in itself an onerous and time-consuming administrative process), the CM lacks the
medical and command perspective of the individual and the specific circumstances that the
BSurg and CO have. In essence, they would be over-turning not just a command decision, but
also a medical recommendation.
c.
The member is permitted to request a posting to the JPSU through his chain of command, but the
request is not binding. An MO can make a recommendation for the CO to consider a posting to
the JPSU, but it is also not binding.
d.
A soldier can be posted to a JPSU on a first Temporary Category (TCAT), or subsequent TCATs.
It has increasingly become the norm for Unit COs to postpone the JPSU posting process until the
Base Surgeon (BSurg) makes a recommendation for a PCAT, or even until a PCAT is directed.
e.
Once posted to the JPSU, the soldier now becomes a (2) client, and is under command of CO
JPSU. Although there are informal structures in place in some locations to maintain contact
between the parent unit and the JPSU / IPSC, in most cases the client loses contact with his
parent unit.
f.
Many of the members posted to the JPSU do so from an IR posting. As IR moves are treated as
normal cost moves, and CMs are faced with severe restrictions on the number of cost moves
allocated to manage their healthy branch or trade population, they are loathe to use a cost move
to reunite a member posted to the JPSU with their families. (3) In as many as 50 cases, we have
essentially stranded members to conduct their transition and healing apart from their family
and support network.
Para 18. Commentary: (1) Unless its been amended recently, the process
for posting a member to the JPSU is initiated by the Chief of Defence Staff (CDS)
through Canadian Armed Forces General Order, (CANFORGEN) 114/11. 114/11
directs Commanding Officers who have injured members requiring a
convalescence of six-months or more that they shall post them to the JPSU.
(2) They are not clients, but injured/ill soldiers, sailors, airwomen and airmen.
This term is an intrusion to the military model and shows the influence of the
JPSU / Services / DCSM / IPSC terminology. (3) Thats 50 families that suffered
needlessly as poor policy prevented getting these people back home. Its also
illogical to have an injured person on Imposed Restriction (IR) yet unable to fill
the position required of IR. This underscores the requirement of a Not
Withstanding authority for JPSU Regional Commanders to sort out this type of
situation in good time.
STRESSES
19. The existing JPSU system is under some severe stresses, as follows:
21/38
a.
The client base has increased over the last two years by 34%, but staffing and other resources
have either remained static or actually been reduced.
b.
The transition from predominantly visible to non-visible injuries demands different services, and
poses unique administrative and disciplinary challenges.

c.
Over the last three years there has been a large increase in the types and complexity of benefits
offered from a wide range of partners. This has made it very difficult for clients to navigate
through the various programs and incentives, and that is often exacerbated by the effects of some
mental health injuries on the ability to concentrate and process new information.
d.
The case management approach to care and the transition planning model both require inputs
from a number of sources, including Nurse Case managers, IPSC Services, the Support Platoon,
VAC, Family Liaison Officer, etc. Despite a formal process that allows clients to indicate their
willingness for full disclosure of their medical details to all parties, there exists strong
institutional resistance from the Health Services to do so, which hampers effective holistic case
management.
e.
Given that the benefits available to a member who releases under a 3b Medical release are
substantially higher than under a normal end of service release, we should anticipate an increase
in 3b release, and hence an increase in the number of clients handled by the IPSCs and their
partners.
f.
Although the JPSU construct originally envisioned a significant percentage of soldiers who
would heal and return to full duty (RTD), this is no longer the case. Given that most clients are
now posted to the JPSU only upon a recommendation of Permanent Category (PCAT), the vast
majority of IPSC clients are now transitioning out of the military vice returning to duty.
g.
It is accepted that there is some abuse of the IPSC system by some soldiers. This is very hard to
quantify, and anecdotal observations from both staff and other clients range from 5-50%. The
truth is probably somewhere in the 5-15% range.
h.
The above two items contribute to an erosion of the credibility of the IPSCs and the JPSU
structure writ large in the eyes of both the chain of command (the customer) and the members
themselves (the clients).
i.
All of these factors create significant stresses on the staff of the IPSCs, and this is manifesting
itself with a substantial amount of turnover, some cases of burn-out, and a surprising number of
staff who transition to becoming clients of the IPSCs. In essence, the staff are the ones that bear
the burdens of the stresses on the system.
Para 19. Commentary: In 2009 almost everything in para 19 was brought

forward as points of immediate and/or future concern. The number of persons
who Return-To-Duty (RTD) may be lower than expected because the JPSU is
overly stressed and cant support them properly. The erosion in credibility is
justified, the JPSU HHQ put the unit on a triage, reactive and compromising
footing almost immediately. This frayed and ripped the JPSU support fabric
allowing injured and ill to fall into the abyss and with them some JPSU staff. For
some, the depth of that abyss may have been measured with feelings of
abandonment, pointless medical releases, isolation, fractured families,
permanent injuries, grief, anger, pain, loneliness, depression desperation and
suicide.
FINDINGS
20. The Review Team made a significant number of findings on a wide array of issues and topics. This
report will group the findings thematically, and include recommendations as findings are disclosed. A
summary of recommendations will then be provided, with specific OPIs identified.
Para 20. Commentary: Ack.

22/38

COMMAND PHILOSOPHY
21. Although there is a chapter in the CDS Guidance to Commanding Officers on the JPSU system, there
is no clear statement of CDS intent that articulates the priority that CDS will place on the care of the ill,
injured and transitioning. As a result, there are no exemptions from existing policies and procedures, as it
is not clear that this is a command imperative.
Recommendations
Issue a CDS CANFORGEN that articulates the priority that the CDS will place on the ill and injured
Issue CDS direction that directs a review of internal policies to ensure that the ill, injured and transitioning
are accorded the benefit of the doubt: in essence, a statement that says that a tie goes to the runner.
Para 21. Commentary: The benefit of the doubt statement is a promising

one and should be elaborated upon, so too who would be the determining
authority for this call. In the past it was suggested that a Not Withstanding
authority be given to JPSU OCs (hopefully now to be COs). This authority would
allow them to make decisions on the ground, in real-time when poor policy got
in the way of ethics, ethos, compassion and common sense. The other
suggestion to review all future policy for contents that might not suit injured/ill
personnel is far too time consuming.
CHAIN OF COMMAND
22. (1) The parent unit or chain of command (C of C) is the initiating point of the JPSU process, and in
essence they represent the JPSUs customers. The Review Team made the following findings:
23/38
a.
(2) The C of C is relatively unsighted to the great work that is being done by the IPSCs, and
predominantly views an IPSC as the place where a soldier goes to release, vice a unit that
provides the optimal conditions for a soldier to heal and RTD.
b.
(2) The C of C lacks trust in the IPSCs to provide suitable supervision, leadership, and care for
their ill and injured.
c.
(3)The C of C has often used the IPSC as a dumping ground for their more problematic
soldiers
d.
(2) The C of C frequently resists posting their ill and injured to the JPSU in the usually mistaken
believe that they can look after their troops better. Often as not, postings only happen once a
soldier is on PCAT, at which point the most likely result is release of the member.
e.
(2) The C of C has expressed frustration at their lack of access to their soldiers once posted to
the JPSU. Conversely, many of the clients in the IPSCs expressed disappointment that their
unit did not maintain contact with them, leaving them to feel abandoned by the C of C.
f.
(3) Some soldiers have indicated that they see the IPSC as a safe haven and they mean
from the C of C. A unit is not always the best place to recover from an injury especially a nonvisible injury. The command climate can be as supportive as possible, but all it takes is one illplaced and insensitive comment by a co-worker or lower level supervisor to stigmatize the
soldier and their injury.

g.
(3) There are equally soldiers who consider the IPSC to be a dumping ground, and they resist
the self-perceived stigma attached to the unit, and believe that a posting to the JPSU inevitably
means that they will be released. All have expressed concern over the loss of environmental
allowances (and especially Land Duty Allowance) upon posting to the JPSU.
h.
(2) A number of soldiers predominantly with non-visible injuries - stated that if they had just
been allowed to go the IPSC after their first TCAT, they would probably be ready to RTD, and
that they just need a break from the unit and to take a knee for 4-6 months. By the time they
actually got posted to the JPSU, they had lost faith in the C of C, and had no intention of
attempting to RTD.
i.
(2) The C of C mistrust of the IPSC and the perception that it is where a soldier goes to release
essentially stigmatizes the IPSC as well as a soldier that is posted there and by extension, their
injury, especially if it is non-visible.
Para 22. Commentary: (1) Technically, the CDS through CANFORGEN 114/11
is the initiating point of the JPSU posting process. (2) The perception by CAF
Commanders are well-founded and accurate. (3) If these statements are
accurate, there is a huge problem in the senior leadership of the CAF.
Recommendations
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Develop a communications plan that better informs the chain of command of the purpose of the
JPSU, emphasizing the task to maximize the number of soldiers that RTD, and focus on
destigmatizing the process
Encourage the C of C to consider early posting to the JPSU as early as a first TCAT in order to
allow soldiers to heal
Reconsider the policy on Environmental Allowance and specifically LDA. Soldiers who continue to
serve in an LDA designated units receive LDA, even if they are unable to deploy to the field, whereas
those who are posted to the JPSU lose that allowance. This is a disincentive to early posting to allow
for healing.
Allow the JPSU posting process to be initiated not just be the CO, but also by the BSurg or the
member themselves. Once the process is initiated, all levels of it must be completed, irrespective of
the Unit CO recommendation. This will favour the idea of an IPSC as a place to heal, and empower
both the soldiers and the Medical Officers.
No longer permit D Mil C and the losing Branch / Corps CM to have the decision-making authority
for posting to a JPSU. At the very least, any review should be conducted by the CM for the Ill and
Injured due to their familiarity with the particular needs of those members, and ideally either the
recommendation of the CO / BSurg is accepted without interference, or a separate review body
incorporating CMP, the losing Service, and CFHS could be established.
Direct a one-time program, using year-end money, to relocate all of the stranded JPSU members
currently on IR but posted to an IPSC apart from their families.
Establish a separate pool of cost moves specifically to facilitate to transition or healing of members
posted to the JPSU.
Formalize links between the parent unit and the IPSC to foster an ongoing sense of ownership from
the C of C, and belonging from the members. Options include Liaison Officers in the IPSC or JPSU
Regional HQ, or amending the JPSU command and control structure to more formally incorporate
the C of C.

Para 22. Commentary Chain of Command: None of the recommendations

can be successful unless the DCSM/JPSU/IPSC has the ability to succeed in its
Mission and staffed, trained and led properly. (See spreadsheet).
COMMAND AND CONTROL STRUCTURE
22. As with any military undertaking, it is imperative that the Command and Control (C2) structure be
firmly established, and designed to optimize both effectiveness and efficiency. Any changes to the existing
C2 structure should also be designed to shape cultures, and to assist in destigmatizing the JPSU and its
processes. This report will review the C2 structure from the perspective of DCSM / JPSU, CO JPSU, the
JPSU Regional HQ, IPSCs themselves, and finally the C of C.
Para 22. Commentary: These are recommendations which have been

communicated to the JPSU HHQ/DCSM years ago.
23. DCSM / JPSU. The current structure appoints one individual as both primary staff officer and the
line commander, who is responsible for both policy development and advice, and for program delivery. (1)
This violates a fundamental tenet of military command doctrine that states that line and staff functions
must be clearly delineated. Furthermore, a distinct and unambiguous chain of command that coherently
integrates strategic, operational, and tactical headquarters, and elements, needs to be in place 1. As
DCSM, the requirement to focus on national and political imperatives, the personal handling of high
priority / sensitive cases, and being the primary Point of Contact (POC) for families of the fallen
necessarily detracts from oversight and supervision of the day to day running of the largest unit in the
CAF. This manifests itself in a number of ways, including the fact that although there are a number of
great policy and process initiatives underway, such as the Injured Soldiers Network, many of them are
either less than fully effective, or incompletely fielded.
Para 23. Commentary: (1) This observation is a critical component of the

difficulties facing the JPSU both internally and by non-acceptance externally. It
is not only that the DCSM and JPSU CO are the same person but DCSM2
concurrently filled Regional OC positions; DCSM Ops, concurrently filled JPSU
Ops positions and so on. Ironically the mid-level leadership applied great
pressure to correct the CoC issues over the course of years, but were met with
greater pressure from HHQ/DCSM to keep it as-is.
24.CO JPSU. The JPSU is the largest and most geographically dispersed unit in the CAF. Exercise of
administrative, financial and disciplinary authorities over such a unit from a central location in Ottawa is
extraordinarily time-consuming, and adds time to the processing of even the most routine administration,
such as leave accumulation, approving routine travel, Terms of Service, etc. (1) This detracts from
important activities such as outreach to the C of C and command presence or battlefield circulation in the
JPSU Regional HQs and the IPSCs themselves.
Para 24. Commentary: (1) It actually detracts from the task of putting on
brunch it is a ridiculously overstretched task for a unit including for a single
person double-hatted as a Director and CO.
25/38

25. JPSU Regional HQs. A detailed literature review and individual interviews with JPSU Regional staff
suggest that there is no clearly defined and widely accepted understanding of the function of the JPSU
Regional HQs, which leads to the following issues:
a.
Tasked in the original Master Implementation Plan with provid(ing) regional oversight and
guidance to the IPSCs within their Area of Responsibility the Regional HQ do not actually seem to
have any explicit authorities, and have little if any authority to reassign resources such as funding or
staffing from one IPSC to another. This leads them to be not much more than a (1) mailbox in many
instances. Moreover, they have little if any control over either Services Sections or IPSC Service
Partners, so they essentially supervise the Support Platoons and their clients in the various assigned
IPSCs.
b.
Although also tasked in the MIP with being responsive to the local Base Commanders and Unit
Commanding Officers, the tyranny of distance and the span of control given the number of
customer units makes this a very difficult mandate to achieve, unless it is focused at the Wing / Base /
Formation level, freeing up IPSCs to establish and maintain local relationships.
c.
The Regional HQs do not appear to have established and maintained contacts with the regional
counterparts representing the IPSC Service Partners at the local level. This includes VAC, OSSIS,
and outreach to regional business organisations to generate Return to Work (RTW) opportunities.
Para 25. Commentary: (1) RHQs have become a mailbox because the
JPSU/DCSM/DCSM Ops /JPSU Ops routinely bypass the RHQs to go directly to the
Tactical (IPSC) Level and vice-versa. This effectively keeps the RHQ (Operational
Level) out-of-the-loop. To add to this, the DCSM/JPSU CO employs a policy where
any posted-in member of the JPSU can contact the Strategic Level directly
without having to go through their Section Commander, much less their RHQ.
By 2012 some RHQs were tasked with over 500 people (in some cases
dispersed over multi-Provincial areas) and usually consisted of a Command
Team (Major (OC) and MWO (Sgt-Maj)), an Adjutant (Captain), a Clerk (WO) and
a Staff Car. It remains arguably one of the most under-staffed, under-ranked,
under-empowered, under-funded and bypassed elements employed in CAF
history.
26. IPSCs. (A) On the whole, the IPSC structure is appropriate, and effective if appropriately staffed
and resourced. Indeed, as the tactical face of the organization and the ultimate deliverer of effects, they
are essentially the Vital Ground of the entire enterprise. The following observations were made:
a.
(1) There are no formal command relationships between the Support Platoon, the Services Section,
and the IPSC Service Partners. (2) In some instances, this has led to friction, in other locations, a
smooth and effective modus vivendi has been established and in all instances effectiveness is a
direct correlation of interpersonal relationships.
b.
The Services Section is predominantly manned by civilian employees, although the vast majorities are
retired military members. (3) Given the nature of their employment conditions, they provide and
become the continuity within the IPSC. It is also the Services Section that coordinates the delivery of
the vast majority of effects, and (4) they have a direct technical / professional reporting relationship
with DCSM which they leverage to great advantage.
c.
The Support Platoon is the military element of the IPSC. All (5) clients in an IPSC are under the
command of the Support Platoon Commander, who is the (6) de facto leader of the IPSC. Many of
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the Support Platoons across the country have more clients than they can reasonably be expected to
manage, with (7) client bases running from 50-160 members, often with only one supervisor due to
staffing shortfalls (which will be discussed later in the report). (8) This leader to led ratio must be
reduced to increase effectiveness of control.
d.
Although every client in an IPSC has individual and often quite disparate circumstances, they
basically fall into (9) two categories: those that want to return to duty, and those that want to get out
of the military. Each of those categories have very differing needs, but at present they are not
divided that way, mostly due to a lack of Support Platoon staff.
Para 26. Commentary: (A) The above paragraph is in conflict with the rest of
this document (and in some cases with itself). It begins stating the structure is
appropriate, and effective and then details why it isnt either of those.
(1) The IPSC is a JPSU HHQ/DCSM model forced upon Regional Headquarters
(RHQ), primarily to control the civilian (Services) staff in the IPSCs. While
the IPSC is a sub-unit of the RHQ, internally it is controlled by nobody,
and externally not even by its own RHQ. Instead the IPSC Services and
Military staff were encouraged to get along by the Strategic Level (JPSU
HHQ/DCSM) and the RHQ staff were tasked essentially as bystanders and
conflict resolution staff at the Operational Level.
(2) It states that in all instances effectiveness is a direct correlation of
interpersonal relationships. It is for this reason that somebody is
normally in charge of a group of people this provides a person to build
cohesiveness, ensure the unit Mission is maintained and to solve interunit disagreements. Mission effectiveness shouldnt be based on the luckof-the-draw of having good inter-personal relationships it should be
based on sound leadership and teamwork. Even at the first leadership
level (Master Corporal - MCpl) there is someone in charge that people
can turn to, be it the MCpl or a Sergeant. The IPSC has nothing like that,
and it is an extremely large sub-unit. The IPSC model is a remarkable
non-structure unique in the CAF (or anywhere for that matter). There was
also a trend for the civilian staff to disassociate themselves from the JPSU
itself - at times stating that IPSC Services was a separate entity even
from the co-located Support Platoon. Services often stated the Support
Platoon was the JPSU component of the IPSC which to Services was just
another unit grouped in among the other supported units.
(3) Granted this is true, the Services now have continuity, however the same
held true for the military staff until the JPSU HHQ/DCSM changed the
staffing philosophy from select Reservists to a standard Reg Force Posting
cycle, disrupting the unit right across the board.
(4) In many ways the civilian staff's "direct technical / professional reporting
relationship with DCSM which they leverage to great advantage" wasn't
so much leveraged, but nurtured from the top down while the military
component scrambled to keep up with unknown (to them) developments.
Add to the mix that there was no single person that spoke for the IPSC,
well then it was a very confusing situation for everybody.
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(5) The civilianization of military culture (e.g a soldier being labeled a

client upon posting to the JPSU), mismanagement (160 person
platoons) and structure (Whos in charge here? Um nobody!) is
another reason unit commanders are wary of the unit.
(6) The Platoon Commander is the de facto leader because permission
could not be received to make the Platoon Commanders the actual IPSC
leaders from DCSM/JPSU HHQ.
(7) Client Base is a civilianized term for Platoon Strength that will also draw
skepticism from line-commanders as their troops are one minute a
Soldier and the next a client. A Platoon is normally 30 people, at the
JPSU its been allowed to swell to 200 (with less staff than a regular
Platoon).
(8) The leader-to-led ratio maxed-out in 2009. Great effort was expended by
mid-level leadership (Regional HQs) to convince JPSU HHQ/DCSM to
increase staff commensurate to posted-in increases, but this was refused
resulting in the current obscene ratio.
(9) Disagree. The two categories are: those who meet Universality of Service
(and can return to duty) and those that cant meet Universality of Service
(and are prevented from returning to duty). If someone wants to get out
of the CAF, they dont have to get posted to the JPSU a voluntary
release is a memorandum away.
27. Chain of Command. It is evident that the current (1) C2 structure divorces the C of C from the
soldiers that they send to the JPSU, which frustrates both the unit and the soldiers themselves. It is also
clear that the C of C holds a negative view of the JPSU structure, based primarily on their lack of
understanding of the function and purpose of the JPSU, which is hampering the ability of the JPSU to
fulfill all of its functions, and especially enabling injured soldiers to RTD. The current structure allows the
C of C to post problem soldiers to the JPSU without penalty. (2) All of these factors serve to reinforce the
stigma attached to the IPSCs, soldiers who are posted there, and by extension their injuries, especially in
the case of mental health injuries. These factors are also a direct result of the current C2 structure, which
completely separates the C of C (the customer) from its former soldiers (the clients)

(1) The current JPSU C2 structure divorces its own CoC from itself. The RHQ
(Operational Level) is divorced from Services at the Tactical Level (IPSC). At the
Tactical Level (IPSC), the IPSC Services component is divorced from the IPSC
Support Platoon. The only thing in the JPSU that isnt divorced is the one thing
that should be divorced: JPSU HHQ/CO and DCSM. As the JPSU is divorced from
itself internally, everything goes sideways from there and this is seen by
external CoC at the supported Base. All of the issues in this paragraph are
directly connected to the poor management and structure of the JPSU. If the
JPSU had been staffed, structured and led like a regular CAF Unit, these
problems wouldnt exist today.
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(2) When its the truth it isnt a stigma, its an unpleasant reality. By going the route
they did, JPSU HHQ/DCSM created a system even worse than the one it replaced
(the SPHL). The JPSU turned from a great beginning into something
questionable through mismanagement. Being posted to a unit that was in
permanent crisis that called you a client instead of who you were a soldier
does not instill confidence.
Recommendations
Separate the line position of CO JPSU and the staff position of DCSM to avoid the disadvantages of
dual-hatting the same individual.
Devolve the vast majority of administrative, financial and disciplinary authorities from CO JPSU to
the Regional OCs in order to reduce CO JPSU workload and increase responsiveness to the Regional
HQs and IPSCs.
Develop a robust and commonly understood TOR for the Regional HQs
Direct Regional HQs to focus outreach at the Wing / Base / Formation level, to include presence at
command councils and O Groups
Direct Regional HQs to establish regional partnerships with IPSC Service Partners as well as
business organisations.
Consider reviewing the internal command structure within an IPSC, such that the Services Manager
becomes the de facto leader vice the Support Platoon Commander.
Retain the technical / professional links between IPSC Services Sections and DCSM, irrespective of
any other C2 changes
Consider organizing the IPSC with two streams clients who want to stay in, and those who want to
get out.
Direct a wholesale review of the C2 structure in order to involve the C of C in the ongoing care of the
ill and injured, with a specific goal of destigmatizing the IPSCs and increasing the likelihood of
soldiers returning to duty.
Convene a CMP-led SOPG with input from the Services, CFHS, and JPSU / IPSC staff to consider
the following potential Courses of Action:
o
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Enhanced Status Quo. Establish JPSU as a formation (separate from DCSM), and appoint
JPSU Regional OCs as COs. Direct formal relationships between CO Regional JPSUs and
regional service formations (Divisions, Fleets, etc)
This option is the least disruptive, but is also less likely to induce cultural change
and foster C of C involvement
Chain of Command Centric. Disband JPSU HQ. Place JPSU Regional HQs under
command of the existing CAF Regional Command Structure (JTFP, JTFW, JFACC, JTFC,
FOIE, JTFA).
This option places the onus for care of the ill and injured squarely upon the C of C
and will permit local reallocation of resources to best suit the regional needs for
their respective JPSU. It maintains the IPSCs within the sphere of Regional JPSUs.
It is the most disruptive option.
Hybrid. Maintain JPSU HQ (separate from DCSM) and allocate JPSU Regional HQs
OPCOM or OPCON to Regional Service Formations (ie JPSU Prairie to 1 CAD, JPSU
Alberta to 3 Div) and IPSCs OPCON or TACON to formations and bases (ie Edmonton to 3
CDSG, Kingston to CFB Kingston).
This option induces C of C involvement at the regional and tactical level (IPSCs),
while maintaining national command of JPSUs.

Recommendations, Commentary: The current JPSU model cannot be built

upon - it is a battered structure that must be rebuilt. The JPSU must be led,
organized as a military unit and not civilianized to the point you need a
flowchart, an interpreter and a glossary of terms to figure out what they are
doing and saying. However, salvage of the JPSU it is not that difficult it just
has to extricated, recovered and repaired. Implementing Formation structure,
select PRes stability, flexible policy and on-the-ground decision-making
authority will put it back on track.
Proposed Recommendations as follow:
Take a Tactical Pause.

Use the Formation Model for the JPSU > Joint Personnel Support
Formation (JPSU-F).
Get a General Officer and staff to command the JPSU-F from Ottawa,
review the shortfalls of the JPSU and sort it out with senior members of
the Service Partners.
Regional Headquarters to become Regional Units (JPSU Eastern Ontario
Region) with a Commanding Officer (LCol) with appropriate authority and
staff.
Regional JPSU HQs to include a Senior Services Manager and Service
Partner Rep.
IPSCs to be renamed JPSU Detachments (Det) followed by the place its
located at.
JPSU Dets to be modeled on a Company structure with a Major as
Officer Commanding.
Technical / Professional links between Det Services Sections and DCSM to
be coordinated by JPSU Senior Services Manager under control of
Regional Commanding Officers.
Staff made up primarily of a select group of Primary Reservists for
stability, maintenance of corporate/personnel knowledge, economy of
effort and economy of funds.
28. As has been previously stated, it quickly became evident to the Review Team that the IPSCs are the
Vital Ground of the entire enterprise, and the IPSCs and their staff are providing an essential and
necessary service with compassion and dedication. It became equally clear that the IPSCs are doing so
within a restrictive policy environment, and, most critically, while dramatically under-staffed. The
following observations were made:
a.
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Under-staffing is chronic at the IPSCs (with 35 of 150 Pres positions currently unfilled), and this is
causing significant attrition and burn-out, particularly in the Support Platoons. Either the demand
needs to be reduced / attenuated, or staffing must be increased. Given that it has been established
that we can expect an increase in the number of members served by / posted to the JPSU, it is unlikely
that demand will be reduced. On one large Base with a military population of 8,000, there is a single
staff member in the IPSC Support Platoon who has 160 personnel under command, without any other
subordinate staff on yet another large base, with assistance from the customer units, a ratio of 1:45
has been maintained, significantly reducing the burn-out / turnover rate.

b.
Selection and screening processes are in place at the national level, but they are not always followed.
With the evolution of military staffing from 100% Reservists to predominantly Reg F by 2017,
selection will be of paramount importance. It is also imperative that quality personnel are posting in,
with no perception of a lessening of career potential.
c.
While the transition to (1) Reg F personnel will assist with continuity and reduce staffing swirl, there
remains a requirement for some Pres staff, to reflect the service conditions and experiences of the
clients. This is especially the place in IPSCs such as Toronto.
d.
Many of the clients stated that constant changes in military staffing made it very difficult to navigate
through the return to work (RTW) or RTD process. Continuity of staffing is key. This fact was
highlighted by the significantly higher RTW rate in Valcartier, which has the most stable staffing
levels of all IPSCs visited.
e.
All of the Services Section positions are manned by civilian personnel. A substantial percentage of
those positions are currently unfilled, and the filling of these positions has not been prioritized.
Given the leanness of the Services structure, this means that in many cases there simply isnt anyone
to provide services to the clients, or there are inordinately long delays in acquiring assistance.
f.
Although a formal training plan has been established as recommended in the 2013 Ombudsman
Report, the staff has indicated that it is inadequate. A number of courses have been developed,
including Orientation, Support Platoon Staff, Designated Assistant, and Unit RTW coordinator.
While helping improve staff capability, a thorough evaluation is required to ensure content is meeting
the need.
g.
With the exception of Valcartier, none of the IPSCs have trained professional transition experts who
are skilled / experienced at assisting members in preparing for transition to a civilian career. It is
counter-intuitive to expect a former military member who is working as a DND civilian at an IPSC to
be able to offer much advice on the skills required to succeed in the civilian workplace. The
Valcartier model of employing professional transition counselors is improving the transition process,
and is clearly worth CAF-wide emulation
Para 28. Commentary: (1) How can employing a RegF model (which must be
continually rotated) add continuity over a PRes model which does not? There is
a PRes Platoon Commander at one IPSC who has been in-place since 2009 that
would have been (at a minimum) three-rotation cycles of a RegF person. The
JPSUs original staffing model using highly-experienced, vetted Reservists (many
with substantial Regular Force experience) was a system that suited the Mission
of the JPSU perfectly. The proposed system (reversion to Regular Force) is a
huge step-backward and complicates staffing the JPSU dramatically. To properly
staff the JPSU using the proposed (Reg F) system, the search for suitable
candidates will be endless rather than limited (for a non-rotating PRes staff).
When a Regular Force member is rotated-out, all the training they received that
is unique only to JPSU Ops is rotated-out with them. This makes the JPSU-based
Training as endless as the search for suitable candidates. The entire JPSU has
been allowed to deteriorate and its staff and posted-in personnel have paid
dearly because of the shift to a RegF staffing model.
A component of the transition of any soldier to civilian life should be a detraining module where a soon-to-be civilian can be given their civilian
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indoctrination. This is the logical opposite of basic training when a civilian is

indoctrinated into the military.
Recommendations
(1) Establish a benchmark for Support platoon Staff to clients of no greater than 1:30. This will
mean establishing and manning section Commander positions in the Support Platoons
(2) Establish a customer tax. Parent formations / Bases should be tasked with providing
reinforcements to the IPSCs it is after all their people that are being cared for.
(3) Reinforce and strengthen the screening and selection process, to include interviews with JPSU
Regional OCs, much akin to posting to CFLRS.
(4) Incentivize the posting of high quality staff through the application of bonus merit points on
promotion board SCITs, as is currently the case with Recruiting positions
(5) Establish an asymmetric staffing model that ensures that there is PRes staff representation in
locations with significant numbers of Pres clients.
(6) Direct that Posting to the JPSU will be for a minimum of 2 years, and preferably 3 years. Local
reinforcements through a customer tax must be for a minimum of a year.
(7) Direct ADM HR (Civ) to establish a priority hire process for civilian vacancies in the JPSU.
(8) Conduct a bottom-up review of the training program with significant input from the current IPSC
staff to better meet their training needs.
(9) Hire or out-source the career transition function to ensure an effective level of support for
transitioning members.
Para 28 Recommendations, Commentary:
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Take a Tactical Pause.

See Recommendations for para 27, 28.
(1) The staffing of the Platoon should mirror the standard construct and
fall under a military Company structure keeping in mind the 90/10
complexity percentage.
(2) A Customer Tax. They are not their people, they are our people
and a customer tax is not only a bizarre concept, but again civilianizes
a military unit (the JPSU) with yet another strange (and unattractive) term
tax. Assisting with Operational Effectiveness of the line-units is (was?)
a component of the JPSU Mission, taking fit soldiers away from their lines
is counterintuitive. The JPSU is bound by bad policy that prevents them
from exploiting a huge talent pool of releasing personnel in their own unit
lines.
(3) It would be more correctly stated to reintroduce the screening and
selection process that was cancelled, and those select personnel replaced
with non-select personnel. Reintroduce the select Reserve staffing model
it makes perfect sense from every angle.
(4) Using Reservists will also untangle what is starting to look to be an
extremely complicated task of employing a rotating staff of select Reg
Force personnel.
(5) As per (3), and this statement glosses over the fact the PRes the JPSU
once employed as staff had component transferred from the RegF with
years of RegF experience, but no pressure of an upcoming posting. As an

example, I point to CDS email 7.2, where the Sergeants Major (a highly
experienced PRes annuitant) contract expired weeks before his
replacement (RegF) was scheduled to arrive. This meant his replacement
(from a hard-Navy trade posted-to an Army Base) had no handover (less
the one the (now civilian veteran Sgt-Maj) did on his own accord). This
put the entire Regions staff and posted-in members at risk.
(6) Once again, there was a perfectly suitable system in-place that has
some annuitants still in-place today in the JPSU for eight-years. Why
anyone would want to replace this system by a far less suitable, highly
complex, unstable, administratively burdensome, expensive and
ultimately unworkable system (which in many ways resembles the SPHL),
is a mystery.
(7) Concur and make these permanent positions.
(8) Somewhat concur but normally training requirements originate at
the top to suit the needs of the staff this is done by a Needs
Assessment and is fairly straight-forward.
(9) Somewhat Concur, if SA isnt lost on the transitioning member.
CLIENT MANAGEMENT
29. There are a number of directives from JPSU HQ that govern the management of clients within the
IPSCs, but the Review Team found that these directives are being unevenly applied, and in some cases, not
at all. (1) Moreover, the transition to a predominantly non-visibly injured client base has created new
dynamics not originally envisioned when the JPSU was established. The following observations were
made:
a.
The triage system is not synchronized. The IPSC uses a system of colour coding (red, yellow, green)
that is designed to reflect both the medical and administrative complexities of the case, whereas the
Nurse Case Managers and CFHS uses a binary complex vs non-complex convention based solely on
the medical situation. The two systems have no point of common reference, and there is no
established mechanism for synchronizing the two systems.
b.
Self-starters thrive in the IPSC environment. They make either getting better or preparing for
transition their job, and apply themselves assiduously to the process. Most clients however struggle
with lack of direction and are unable or ill-equipped to chart a clear path to success. There are no
mechanisms that allow the success stories to share their knowledge or to encourage others
indeed there is very little interaction between the clients at all, even though they are all members of
the same unit.
c.
(2) There are two types of soldiers that are in the IPSC: those that want to stay in the military, and
those that want to get out. Each of these groups has differing needs and motivation. At present, due
mostly to under-staffing, they are not grouped in that manner, which means that staff must master two
different sets of processes and policies.
d.
The staff at the IPSC has encountered difficulties in the maintenance of discipline. Many of the
clients have Medical Employment Limitations that restrict the wearing of uniforms or appearance at
a military facility, which is not necessarily conducive to the maintenance or normal discipline.
The nature of their injuries or circumstances often precludes the application of normal minor
punishments. This leaves the staff with little if any recourse to maintain discipline without
exacerbating the clients medical progress.
33/38

Para 29. Commentary: There is a lot of reactionary activity by the frontline

(IPSC) staff trying to make it work and with that, certain important processes
of the JPSU get sidelined it is a triage upon itself. (1) This statement is
incorrect; the senior medical officer of the CAF stated in 2010 that the CAF
(JPSU) should prepare for a wave of OSI-related injuries from Afghanistan. It was
further stated there could be a four-to-five-year (+) latency period before OSI
related symptoms surfaced and to be prepared for casualties from other
Operations as well. An injury is an injury and it is stigmatizing to categorize
visible and non-visible injuries. (2) Injuries are Medical Employment Limitation
(MEL)-based and from there a suitable transition/RTW plan instituted. Moreover,
this statement negates the fact that many visibly injured personnel have
non-visible injuries.
a. Perhaps they arent synchronized because there are influences that
are different on the two systems.
b. Sometimes its difficult to be a self-starter when youre saddled
with serious injuries, PTSD, family stress and employment worries.
Then add to that series of woes that youve just been posted to a
unit for help but there isnt anyone around to help you. The lack of
direction having an impact on the posted-in members is directly
attributable to the lack of JPSU military staff. In some Regions,
members arent allowed to know who else is posted to the same
platoon. (Some Regional OCs believe this information is
confidential in that some posted-in members feel its a slight to be
identified with the JPSU).
c. (2) This is poorly stated; the two types are those that can meet
Universality of Service (and can remain in the CAF), and those who
do not (and must be released).
d.
The wearing of uniforms and location have nothing to do with the

maintenance of discipline they are prescriptions from medical
staff. There are many methods to maintain discipline beside
normal measures, but the JPSU is in disarray and the
maintenance of anything is difficult.
Recommendations
(1) Develop a national and synchronised triage system that reflects medical, administrative and
psycho-social aspects of each case.
(2) Establish a system of peer mentors that pairs the new arrivals with those already some way along
the process of healing, RTD or transition.
(3) Group clients according to their goals: to RTD or to transition. This will allow Section
Commanders to develop expertise in one of the two processes.
(4) Establish a series of best practices and techniques that enforces discipline without hampering
medical recovery.
Para 29. Recommendations, Commentary:
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(1) Somewhat concur, it must be kept in mind that factors complicating

oversight of an injured member (leadership) might not be the same
complexities as medical oversight (treatment).
(2) Somewhat concur. I suggest staffing the JPSU properly first, reinstituting
the Reservist employment model, and taking stock of the situation before
moving forward.
(3) At the JPSU transition is not normally goal-based, it is
medically/Universality of Service driven towards civilian or military
service.
(4) They are already in-place and fall under the
knowledgeable/compassionate leadership model used by competent
leaders.
MEDICAL
30. Although the JPSU is not part of the CFHS, much of its work deals with coordinating and supervising
medical care and treatment for its clients. On the whole, the IPSCs are effective at coordinating with the
CFHS, although there are local variances based on capacity and personalities. The Review Team made
the following observations:
a.
Nurse Case Managers are the Critical Vulnerability within the system. They coordinate the medical
care for their clients (of whom approximately 60-70% are also posted to the JPSU), and are the
primary interface with the IPSCs. There are only 66 Nurse case managers in the CAF, and although
the ideal Nurse to case ratio is 1:50, many are dealing with in excess of 100 cases. There are clear
signs of strain within the system due to overwork, and a lack of common understanding within the
CFHS and the chain of command of the vital role that Nurse Case managers play.
b.
There are regional and local stresses to the system. Petawawa lacks ready access to Mental Health
professionals, and Kingston is dramatically short of Case Managers.
c. The PCAT review process is currently overwhelmed, with a 10 month waiting period for a PCAT
recommendation from a BSurg to be reviewed by Director medical Policy (D Med Pol). The current
policy is for every recommendation to be reviewed, in order to maintain standard application across
all elements of the CAF. This is a 100% Quality Assurance process that maintains full control at the
expense of efficiency. At the request of the Review Team, D Med Pol reviewed their process, and
determined that currently only 5% of recommendations are being over-turned, and are now
considering some amendments to their approach.
d.
Once a PCAT is confirmed, and any representations by the member have been made, the policy states
that a medical release will occur in 6 months or less, granting the member the option of releasing
earlier. Many transition plans include education and courses, but clients are not entitled to sign up
for them until their release date is finalized and 6 months is frequently insufficient time to complete
necessary transition training, depending on the start date of classes etc.
Para 30. Commentary: Concur.

Recommendations
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Reinforce Nurse Case managers through increased staffing, using the target of 1:50 as the basis for hiring
and assignment. Conduct periodic gatherings of the Nurse Case Managers to focus on best practices and
to provide a platform for acknowledgement from the CofC
Fund contracted Mental Health professionals in Ottawa, and provide transport to and from Petawawa.
Prioritize the hiring of Nurse Case Managers in Kingston.
Establish a policy of representative sampling of PCATs to maintain standardization but decrease the
turnaround time, and devolve the authority for PCAT for the remainder of files to the B Surg.
Increase the time window for release once a release message is received from 0-6 months to 0-12 months,
and devolve the authority to elect the date to Individual Transition Plan Team, which includes the Nurse
Case Manager, Services Manager, Pl Comd, and the client.
Para 30. Recommendations, Commentary: Concur.

POLICIES AND PROCESSES
32. There are a number of policies and processes that should be adjusted to reflect the specific
circumstances of the ill, injured, and transitioning, but many of these are quite tactical in nature, and will
be reported by other means. These include processing of CD applications, handling of Depart with
Dignity paperwork, and other minor administrative matters. Of greater concern are the following:
a.
Many members have received release message with dates that fall just short of critical milestones of
service, such as 10, 20, 25 and 35 years of service. Some of these milestones have a financial impact
in terms of access to pension, but as importantly, these milestones have an emotional element as well.
Failing to recognize this does a disservice to those who have loyally served.
b.
Currently, allocation of cost moves to the JPSU for the ill, injured and transitioning is the
responsibility of the losing CM. This places the onus on a CM with little understanding of the
specific requirements of the JPSU client to weigh the value of that posting against the moves required
to manage the trade or branch.
Para 32. Commentary: Concur.

Recommendations
Establish a policy for determination of a release date that acknowledges the import of significant
milestones. A reasonable accommodation would be to favour the member within a 100 day window
of the strictly interpreted release date.
Establish a separate cost move funding envelope for the movement of JPSU personnel, under the
control of CM for Ill and Injured. Fund it generously, and favour the client in the considerations
the tie will go to the runner.
Para 32. Recommendations, Commentary: Concur.

SUPPORT
33. (A) Although on the whole support for the JPSU is adequate, there are number of areas that coud be
reinforced:
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a.
Infrastructure for the IPSCs vary greatly from location to location. The JPSU has a detailed
infrastructure plan on place, but it may be inadequate due to the VAC decision to increase its
footprint in most IPSCs.
b.
It was evident to the review team that off-site locations have many advantages. Many clients and
staff interviewed stated that on-Base IPSCs are intimidating to a large number of clients and
reporting-in can contribute heightened anxiety/stress. IPSCs that are located in off-Base
accommodation (such as Kingston) offer perception of a neutral/non-military environment that
enhances client support.
c.
Many clients lack DWAN access as they are either not required or not able to attend military
facilities.
d.
The current process for approval for reimbursement of costs for attending medical appointments is
cumbersome and uneven, and we are essentially asking the members to sort out their own
transportation.
e.
Maintaining contact with a large and disparate client base is problematic for the IPSC Support
Platoons and Services sections. Face to face meetings are critical, but often difficult to arrange.
Para 33. Commentary: (A) That is one incredibly conflicted statement given
the prior conclusions in this document and at odds with earlier statements in
this report.
2.
a. A closer look should be taken at IPSC Petawawa (with the absence
of Base elements in the building), the Eastern Ontario RHQ is a
suitable design (both BFA). VAC is a valuable component of an IPSC
but also one that can be expanded to locations off-base to better
serve veterans. IPSC-based VAC locations on CAF Bases are perfect
for serving or soon to be transitioning military members.
b. Off base should be the exception to the rule the IPSC in Kingston
was a desperate measure as there were no suitable Base buildings
available. The vast majority of persons using the JPSU do not have
limitations regarding going on Base, and on-Base locations allow
people not posted to the JPSU to conveniently use their services as
walk-ins. There is also the perception of the CoC that needs to be
taken into account and the stigmatizing effect of having a military
unit (JPSU) located in a mall.
c. Thats because it so alarmingly under-manned that it is difficult to
accomplish.
Recommendations
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(1) Off-Base IPSC accommodations should be leased to meet the needs of most IPSCs.
(2) Field a dial-in capability for IPSC clients.
(3) Allow the use of Skype for face to face interviews, and equip all IPSCs with the capability.
(5) Purchase a van for each IPSC and satellite staff for the specific purpose of transporting members
to medical appointments, and direct the supported chain of command to provide a dedicated driver.

Para 33. Recommendation, Commentary:

(1) Disagree, suitable accommodation can be had on base and is convenient
to the vast majority of those interested in or requiring JPSU support.
Bases also have significant medical, I.T., lecture and physio (Base
Recreation) facilities to be exploited and keep the IPSC in the military fold
as a military unit.
(2) Disagree, a dial-in capability for soldiers should only be used as an
exception to the rule, but still viable depending on the circumstance
this is a leadership call at the IPSC level.
(3) Concur.
(4) Somewhat Concur. The mass majority of injured members can drive
themselves, many IPSCs already have a dedicated driver on staff, Base
Transport is another option, civilian transport (taxis) another suggest
you leave the line-units alone.
(5) This is a Corporals task not a Generals.
BRANDING, CULTURE, and STIGMA
34. (1) Stigma is a function of culture, which has been discussed at some length, and branding. It is
evident that the JPSU as a unit and a process has been stigmatized by the chain of command, and by the
very soldiers that they are meant to serve. The stigma can be attacked in a host of ways, all related to the
culture of the organization, but ultimately there may be a requirement to re-brand the process and the
structure in order to overcome the drag of pre-conceived notions and understanding of the unit and the
system. The Review Team observed the following:
a.
IPSC and JPSU are very precise doctrinal titles that serve strategic audiences and IPSC Service
Partners well, but does nothing to enhance brand identity of the IPSC with either soldiers or CofC.
b.
In many case, when soldiers or the C of C expressed concerns with the services provided at the
JPSU / IPSC, their issues were just as likely to be with VAC, CFHS, or SISIP. Although an integrated
services model is efficient, it leads to integrated blame.
Para 34. Commentary: (1) Stigma is not a function of culture, it is a result of

ignorance, and in the CAF, a loss of discipline. The JPSU is a unit in crisis and the
external (and internal) chains of command know it. This is not stigma, this is
fact and is a smart move by Commanders to avoid putting their injured
personnel at risk in a poorly managed unit, just as they did with the SPHL.
a.
IPSC and JPSU are both JPSU, they are just saddled with confusing
terminology that should be changed to reflect known
terminology/structure (JPSU and JPSU Detachment).
b. This is result of poor management of the JPSU/IPSC, the integrated

services model is divorced from the military component (Support Platoon)
within the IPSC there is no single point of control such as an OIC IPSC.
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Because of this, the IPSC is internally adrift so direction and advice comes
from all sides a confusing situation
Recommendations
Consider renaming the IPSCs in concert with any planned change to the C2 structure. The clients of the
IPSCs made a number of suggestions, such as Warrior Transition Center. Branding along the lines of
Fisher House may be appropriate: such as The Vimy Center.
Para 34. Recommendations, Commentary: Call it a JPSU Detachment: IPSC:

(insert Base/location name) and then call it a day. Right now the Petawawa IPSC
is JPSU, IPSC Petawawa, Black Bear Support Centre. If you wish to dedicate the
buildings after people (the norm) then do so on a respectful brass plaque at the
entrance of the building. Naming the building after its function is a longstanding and effective policy. E.g. 2 Service Battalion Headquarters cant be
misinterpreted, but call it Bluebell House, with RCEME House across the street
and Kangaroo House down the road, then things start to get muddled.
SUMMARY OF KEY RECOMMENDATIONS
35. The JPSU system is essential to discharging our obligations to our ill, injured, and transitioning. It
has served the institution and, more importantly, our soldiers well over the last eight years, often in spite of
structural, cultural, and policy barriers to success. This report has made a number of recommendations,
ranging from the strategic to the tactical. The key recommendations are as follows:
(1) Issue a CDS CANFORGEN that articulates the priority that the CDS will place on the ill and
injured.
(2) Issue CDS direction that directs a review of internal policies to ensure that the ill, injured and
transitioning are accorded the benefit of the doubt.
(3) Develop a communications plan that better informs the chain of command of the purpose of the
JPSU.
(4) Allow the JPSU posting process to be initiated not just be the CO, but also by the BSurg or the
member themselves.
(5) No longer permit D Mil C and the losing Branch / Corps CM to have the decision-making
authority for posting to a JPSU.
(6) Direct a one-time program, using end-year money, to relocate all of the stranded JPSU
members currently on IR but posted to an IPSC apart from their families.
(7) Separate the line position of CO JPSU and the staff position of DCSM. Devolve the vast majority
of administrative, financial and disciplinary authorities from CO JPSU to the Regional OCs.
(8) Direct a wholesale review of the C2 structure.
(9) Reinforce the IPSCs with increased staffing.
(10) Accelerate hiring of civilian staff to fill current shortfalls.
(11) Reinforce Nurse Case managers through increased staffing.
(12) Consider renaming the IPSCs in concert with any planned change to the C2 structure.
(13) Purchase a van for each IPSC and Satellite Center to provide transportation to medical
appointments.
Para 35. Key Recommendations, Commentary:

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(1) Concur Somewhat I think its time for a joint (CAF/Ministerial/VAC)

statement.
(2) Concur Somewhat thats a rather broad statement and requires more
detail.
(3) Concur.
(4) Concur.
(5) Concur.
(6) Disagree no injured member should be stranded from his home, friends
and family.
(7) Strongly concur and make OCs COs.
(8) Concur, less some of the recommendations in this document.
(9) Concur.
(10)
Concur with permanent positions.
(11)
Concur.
(12)
Change IPSC to JPSU Detachment (insert location here).
(13)
This recommendation serves to show the dire situation at the JPSU.
Getting a van is a task befitting the rank of Corporal. In the case of the
JPSU, it has been passed to the Commanding General of the Canadian
Armed Forces for action in a General Order.
WAY AHEAD
36. The following immediate way ahead is recommended:
Issue a CDS CANFORGEN that clearly states the importance of care for our ill, injured and
transitioning, and incorporates the following points:
o Direction that policy be interpreted in favour of the member.
o Direct CMP to issue a Master Implementation Plan that will act on the recommendations of
the report.
o Direct those policy and administrative changes that can be enacted without reference to
external agencies.
o As an indicator of immediate change and using end-year money, direct the purchase a van
for each IPSC location, and post the JPSU members currently stranded on IR.
Para 36. Commentary: This report contains more problematic

recommendations than helpful ones. I suggest holding off moving forward until
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a sober second review is conducted using the points Ive put forward and the
information from the yet-to-be released upcoming Ombudsmans Report.
CONCLUSION
36. (1) The JPSU and its personnel are to be congratulated for their extraordinary work in caring for
our most vulnerable. To their great credit, they have succeeded (2) despite structural, cultural and policy
impediments. Having said that, the care of our soldiers is both a command and a moral imperative, and
we can and must do better. This report highlights a number of changes that will allow us to do exactly
that.
Para 36 (Note. 36 is Repeated Typo). Commentary: (1) The JPSU staff

should be congratulated in their extraordinary work just as the survivors of the
Royal Newfoundland Regiment should have been congratulated on their heroic
efforts at Beaumont Hamel. Like the effort at Beaumont Hamel, the efforts of
the JPSU staff were the result of some incredibly poor leadership.
The common-denominator with the incidents in France, Dieppe, Somalia and
Rwanda is that when leadership fails, it is the rank-and-file and families which
pay for it. (2) The JPSU staff were put in an untenable situation and kept there
for nearly eight-years the impediments placed in the path of JPSU staff were of
the JPSU/DCSMs own making and could have easily been avoided.
The stresses this created were not limited to the staff, but also impacted the
JPSU posted-in ill and injured members, their families and veterans directly who,
as noted in General Andersons report, are our among most vulnerable people.
A unit that has been allowed to go in this ill-advised direction for as long as it
did may very well have caused professional trauma to its staff. For some JPSU
staff, I expect they are now indoctrinated to the JPSU culture, a culture they
may view as a CAF model. This perspective will not serve them well at other
traditional CAF units.
However, as serious as the situation facing the JPSU has become, more serious
concerns come to light in how such a situation could develop and maintained in
the first place. The JPSU itself was under direct control of one of the highest
echelons in the CAF (only two levels away from the CDS) and reported directly
(and inaccurately) to Parliament (ref. E). The JPSU was staffed with extremely
capable leadership at the Regional Level, the vast majority of whom used their
experience to advise JPSU/DSCM not to go in the direction it did. Of them, some
were fired, some didnt have their contracts renewed, some resigned, some
took ill and some carried on.
Document Summary.
44. The CAF has lost many valuable years during which it could have developed
a world-class military-based support structure for our most vulnerable: the Joint
Personnel Support Unit. It remains an outstanding concept that shouldnt be
compromised. The staff and persons intended to be supported by the JPSU
have suffered and waited long enough for that (proper) support to materialize.
With the particular interest of the current Chief of Defence Staff, I hope that
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their wait and trials are at an end and that they can soon receive support
services and military leadership from what the JPSU was always meant to be.
Barry Westholm
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An Independent Review:

Report on CDS Directed Review of Care

A Thoughtful Second Look

A Thoughtful Second Look:

A Thoughtful Second Look:

Date. 28 December, 2015

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MWO (retd) Barry Westholm, CD

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9. In doing so, MWO (retd) Westholm has remained an engaged, independent,

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Strategic Level Command. It has been noted in Gen Andersons Report: At

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Vital Ground. The below is the recommended Construct/Terminology at the

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41. The preceding are broad-stroke big-picture recommendations intended to

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Para 2. Commentary: My concern, from an independent perspective of Gen

Para 3. Acknowledged (Ack).

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Para 9. Commentary: (1) If there were known problems and issues

A NATURAL INFLECTION POINT

Originally established to deal with the influx of visibly injured

Although there are still casualties from Afghanistan presenting

This reduction in operational casualties has led to an increasing focus

A Thoughtful Second Look:

pause to await the results from other on-going investigations prior to

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The "One-stop-shop" moniker was brought in by the civilian-esq

Given the staff-to-injured ratios used by the JPSU, if every posted-in

This term and ratio, word-for-word, was used by the Regional HQ in

A Thoughtful Second Look:

Pacific Region (Chilliwack, Comox, Esquimalt, Vancouver)

Prairie Region (Moose Jaw, Shilo, Winnipeg)

Eastern Ontario Region (Kingston, North Bay, Ottawa, Petawawa, Trenton)

Southern Ontario Region (Borden, London, Meaford, Toronto)

Quebec Region (Bagotville, St. Jean, Valcartier)

Para 13. Commentary: The JPSU is:

the largest unit in the CAF;

covering the largest area in the CAF;

with the most injured members in the CAF;

with among the most complex missions in the CAF;

with the greatest staff-to-supported ratio in the CAF; and

whose support also extends to the recently released, walk-ins, veterans

Para 14. Commentary:

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Para 15. Commentary: This is a potential conflict-of-interest, for example, if a

Para 16. Commentary:

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(2) Casualty Tracking

Veterans Affairs Canada

Para 17. Commentary: The most significant piece of this paragraph is

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Para 19. Commentary: In 2009 almost everything in para 19 was brought

Para 20. Commentary: Ack.

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Para 21. Commentary: The benefit of the doubt statement is a promising