COMMITTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES Final Report of the Committee OFFICE OF THE SECRETARY OF DEFENSE OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON CQv'MITTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARi.ED FORCES 5 July 1949 TO: The Secretary of Defense SUBJECT: Final Report, Committee on Medical and Hospital Services of the Armed Forces REFERENCES; (a) Secretary of Defense Memorandum dated 1 January 194-6 to Dr. Paul R. Hawley, Chairman (b) The Committee’s report on the subject of ’’The Plan for a Joint Armed Forces Medical Supply System” dated 2 April 194-8, with supplements thereto dated 26 April *1948 and 9 December 1948* (c) The Committee’s report on the subject of "Standard- ization of Medical Nomenclature within the Armed Forces,” dated 28 April 1948. (d) The Committee’s report on the subject of "Plan for Uniformity of Medical Department Budgets,” dated 4 May 1948. (e) The Committee’s report on the subject of "Hospital- ization and Medical Service in the Panama Canal Zone Area,” dated IB May 1948. (f) The Committee’s report on the subject of "Armed Forces Hospital Facilities at Guam, M. I.” dated 15 June 1948. (g) The Committee’s report on the subject of "Medical Care for Dependents of the Armed Forces," dated 29 June 1948# (h) The. Committee’s report on the subject of "Standard- ization of Preventive Medicine Practices and Procedures within the Armed Forces," dated 13 July 1948. (i) The Committee’s report on the subject of "Medical Research of the Armed Forces," dated 28 July 1948. (j) The Committee’s report on the subject of "Medical Professional Services in the Armed Forces," dated 28 July 1948. (k) The Committee's reoort on the subject of "Medical Intelligence of the Armed Forces," dated 3 September 194-8. (Ij The Committee's report on the subject of "Physical and Mental Requirements for Entrance into and Disability Separation from the Armed Forces," dated 3 September 194-8* (m) The Committee's report on the subject of "Report of Subcommittee on Graphic Representation of the Principal Medical Facilities of the Armed Forces," dated 3 September 19A8* (n) The Committee's report on the subject of "Train- ing and Education Programs of the Medical Depart- ments of the Aimed Forces," dated 4- October 194-8* (o) The Committee's report on the subject of "The Army Medical Library," dated A October 194-8* (?) The Committee's report on the subject of "The Army Institute of Pathology," dated 4 October 1948. (q) The Committee's report on the subject of "Aviation Medicine in the Armed Forces," dated A October 19A8* (r) The Committee's report on the subject of "Coordina- tion of Design of Hospitals and other Medical Facil- ities of the Armed Forces," dated 3 November 19A8* (s) The Committee's report on the subject of "Standard- ization of Medical Forms, Recording and Reporting Procedures within the Aimed x‘orces," dated 10 November 19A8* (t) The Committee's report on the subject of "Programs for Hospitalization in the Aimed Forces and for Improvement in the Utilization of Existing Hospital Facilities," dated 7 January 19A9* (u) The Committee's report on the subject of "Improve- ment and Standardization of Cost Accounting Systems and Appropriation Accounting of the Medical and Hospital Services of the Armed Forces," dated 1A April 19A9* (v) The Committee's report on the subject of "Organi- sation, Management and Administration of the Medical and Hospital Services of the Armed Forces," dated 3 May 19A9* 2 (w) The Committee’s report on the subject of "Medical Department Personnel," dated 20 May 1949. (x) Memorandum of 20 June 1949 from the Secretary of Defense to the Secretaries of the Amy, Navy and Air Force; Chairman, Munitions Board, Chairman, Research and Development Board; Joint Chiefs of Staff; Chairman, Committee on Medical and Hospital Services of the Aimed Forces; Directors of Offices; Office of the Secretary of Defense, subject; Ad Hoc Committee on Medical and Hospital Services of the Armed Forces. (y) Memorandum of 22 June 1949 from the Executive Secretary, Office of the Secretary of Defense to the Secretaries of the Amy, Navy and Air Force; Chaiman, Munitions Board; Chairman, Research and Development Board; Joint Chiefs of Staff; Chaiman, Committee on Medical and Hospital Services of the Amed Forces and Directors of Offices, Office of the Secretary of Defense, subject: Subcommittees of the Ad Hoc Committee on Medical and Hospital Services of the Armed Forces. ENCLOSURES: (1) Copy of reference (a). (2) Committee and Subcommittee Organization* (3) Syllabus of Conclusions and Recommendations, with Tabs A to V inclusive# (4) Summary of Current status of and action taken on the several reports submitted by the Committee. 1# In a memorandum dated 20 November 1947 from Mr. Ohly, Special Assistant to the Secretary of Defense, the Secretaries of the Amy, Navy, and Air Force were advised of the nature of matters requiring their consideration -with respect to "Medical problems of the three Services," which had been made an item of the agenda for the next meeting of the Committee of the Four Secretaries. At that meeting held on 25 November 1947, the agreement was reached that a committee should be established consisting of the Surgeon General of the Army, the Surgeon General of the Navy, the Air Surgeon, and a civilian 3 chairman to be appointed by the Secretary of Defense, to study all questions of common interest to the three medical Services with a view to obtaining maximum efficiency and economy in the immediate future through optimum utilization of hospital facilities, coordina- tion of construction plans, coordination of medical training programs, establishment of maximum central services, etc* It was further agreed that the terns of reference for this Committee were to be issued by the Secretary of Defense* Pursuant to this decision, the Secretary of Defense appointed as chaiiman. Dr* Paul R. Hawley, Major General, U. S. Amy, Retired, -who more recently had served as Chief Medical Director of the Veterans Administration* This medical committee was designated as the "Committee on Medical and Hospital Services of the Armed Forces", and its terns of reference were issued by Secretary Forrestal in a memorandum addressed to Dr* Hawley, under date of 1 January 194-8• Dr. Hawley continued as chairman of the Committee until 2? January 1949, when he tendered his resignation* Upon his acceptance on 11 February 1949 of Dr* Hawley’s resignation, the Secretaiy of Defense simultaneously designated The Surgeon General of the Amy as the Acting Chairman of the Committee* 2* In accordance with the provisions of Reference (a), the Committee during the past eighteen months has diligently concerned itself with its assigned general task of conducting a "thorough, ob- jective, and impartial study of the medical services of the Armed Forces with a view to obtaining at the earliest possible date the maximum degree of coordination, efficiency and economy in the opera- -A- tion of these Services•** In effecting its study, the Committee has also given attention to the specific matters outlined in reference (a) which the Secretary of Defense considered should be undertaken by the Committee, and has endeavored to effect unification by orderly evolu- tion rather than by revolutionary change, conscious of an obligation that military medical preparedness be ever maintained® Its aim has been that of molding the three Services into a highly coordinated team designed to provide the highest possible level of medical service with the utmost economy in funds, facilities and personnel® In its work, the Committee has steadfastly and with faithfulness to legal precept been guided by the declaration of policy outlined in Public Law 253, 80th Congress, commonly cited as the MNational Security Act of 1947®lf In this law, the Congress declared its intent to for the estab- lishment of integrated policies and procedures for the departments, agencies, and functions of the government relating to the National Securityj to provide three military departments for the operation and administration of the Amy, the Navy (including naval aviation and the United States Marine Corps) and the Air Force, with their assigned combat and service components\ to provide for their authoritative coordination and unified direction under civilian control but not to merge them 3 to provide for the effective strategic direction of the aimed forces and for their operation under unified control and for their integration into an efficient team of land, naval, and air forces®M 3® In conducting such an extensive analysis of so complicated a problem, the Committee, in accordance with the provisions of par- - 5 ~ agraph 4 of reference (a), has sought and obtained the assistance and counsel of more than a hundred officers and civilians thoroughly qualified by long experience in the particular medical military problems and fields included in this study. It appointed some twenty- two (22) subcommittees, as depicted in the diagram attached hereto as Enclosure 1; each subcommittee was composed of an equal number of representatives from each of the medical services of the three Departments. Numerous task forces, also established on a tri-partite team basis, were appointed to assist the subcommittees in the various aspects of the problems under study by them. Much information and many data have been obtained by personal interviews of and corres- pondence with hundreds of officers who held key positions in head- quarters and medical organizations during World War XI, both in the Zone of the Interior and in the various Theate is of Operations. The individuals who composed the above-mentioned subcommittees and task forces have tackled the complicated questions and problems under study with unprejudiced and open minds and have been guided in their work by what was considered to be the best interests of the National Military Establishment and of the military defense of our Nation* 4* In the early months of its work the Committee was faced with the problem as it related to a shrinking military structure, with ex- pected continuing attrition. Suddenly the prospective-picture was reversed, and the Committee had then to view its problems in the light of a re-expanding military organization which was deemed necessary in the interest of national security. While the studies made, conclusions - 6 - reached, and recommendations submitted have extended over a longer period of time than would have been necessary had the many individ- uals involved been permitted to work on a full-time basis or had circumstances and events permitted an uninterrupted work schedule, it is considered that the time involved in the development of such conclusions and recommendations and in gaining a fuller understanding of the three medical services, as well as in the formation of inter- service friendships, have resulted in a firm and lasting foundation for a sound unification structure. 5* The Committee as a group, with the exception of Dr. Hawley, visited approximately one hundred fifty (150) medical installations of the three Aimed Forces within the continental United States, in the Panama and Caribbean Areas, in Hawaii, Guam, Japan, the Aleutian Islands and Alaska to obtain on-site information relative to unifica- tion possibilities. The medical activities so observed have included most of the principal medical installations of the Aimed Forces - General Hospitals, U. S. Naval Hospitals, Medical Supply Depots, Medical Research Facilities, Dental Clinics, special schools for in- struction and training of medical department personnel, and some of the larger Station Hospitals; a large number of the many smaller Station Hospitals, dispensaries and clinics were also visited. In addition, one member of the Committee spent six weeks in Europe study- ing the medical activities in that Theatre, and another member covered Southwestern Europe, the Middle East, and the Mediterranean areas during a different period. 6. As a result of the combined efforts of the Committee, its 7 several subcommittees and their task groups, a series of twenty- two (22) studies and reports, aggregating more' than six thousand (6,000) pages of material most pertinent to the subjects reported upon, has been prepared and submitted by the Committee to the Secretary of defense. Taken collectively, these several reports on the various subjects, listed above as references (b) and (w) in- clusive, together with this final report, constitute the Coramittee’s report to the Secretary of Defense on the assignments set forth in reference (a)* It is the opinion of the Committee that no useful purpose would be served by including in this final report a repetition of the lengthy discussions, data, information, and presentations and analyses of facts contained in the voluminous material already submitted and bearing on the many individual facets of the Committee’s comprehensive assignment* The essential features of these elements of the assigned problems have been covered in references (b) to (w) inclusive* 8* The Committee, however, wishes to reaffirm the views and concepts which have been set forth earlier by it in the above mentioned series of reports with respect to the medical and hospital services of the Armed Forces* Extracts of the principal conclusions and recom- mendations which have previously been made in this regard by the Committee in connection with each of the subjects studied and reported upon are submitted herewith in syllabus form as Enclosure 3 (Tabs A to V)* Many of the recommendations made by this Committee have been 8 approved in toto or in part; others are still in the process of consideration by appropriate authorities, departments, divisions and agencies of the National Military Establishment. A brief summary of the current status, as of 22 June 1949, of the reports which have been submitted by the Committee on the twenty-two separate subjects, and a resume of action which has been taken to date in regard thereto, is attached as Enclosure 4* Implementation of approved recommendations is proceeding. 9# The concerted thought which members of the Committee have devoted to this broad subject in searching for workable solutions to the problems with which it has been confronted during the many months, has brought into clearer focus certain underlying and governing principles upon which, in the opinion of the Committee, the medical services of the Aimed Forces must be based if they are to properly perform the functions which they must serve. For example, the members of the Committee have become even more keenly aware of the close relationship which must exist between the Medical Departments and the respective Aimed Forces which they serve and support* The Committee is likewise convinced that certain medical functions of over-all general nature can be accomplished to the best advantage of all concerned by tri-service participation in joint performance of these functions* This is true in such matters as, for examples certain aspects of medical supply; some portions of hospitalization; the publication of medical bulletins and other professional literature; the operation of 9 a number of central medical services and facilities serving all three Services, such as the Armed Forces Institute of Pathology, the Armed Forces Medical Library, and a variety of schools, medical training facilities and medical coordinating bodies at the head- quarters of the National Defense Establishment in the several medical fields as recommended by the Committee in references (b) to (w) in- clusive* Fundamentally the individual medical services of the three Armed Forces must be permanently identified with and be integral parts of the three Departments of the Military Establishment which they primarily serve, with which they are operationally associated, and with which they intimately function in performing their missions* However, in the- interest of achieving all feasible economy and efficiency in their operations they must also work as a coordinated and integrated team in the performance of those functions which, like those indicated above, can be performed jointly to best serve the National Military Establishment as a whole* 10* It is the unanimous opinion of the Committee that as a result of its work a great deal of progress has been made toward effecting more uniformity and greater standardization of policies, methods and procedures and toward unification of the medical services of the Armed Forces; further, that added evidence of this will become increasingly apparent after a reasonable period of time has been allowed for observing the full fruition of approved undertakings toward this end* 11* As indicated in the various reports already submitted to 10 the Secretary of Defense, there is need for a continuation of the work along the lines pursued by this Coiranittee in the several medical fields of the Armed Forces. The Committee considers that in the absence of a complete merger of the three military departments as a whole into a single Aimed Force, studies of the medical military problems and the development of plans for their solution and the coordination of the medical services of the three Armed Forces will best be accomplished by a coordinating agency functioning at the level of the Office of the Secretary of Defense; further that this agency should contain military medical members chosen in equal numbers from the three medical services. Implementation of the approved re- commendations of such a continuing medical coordinating agency would be accomplished through the existing administrative and operational mechanisms of the three Departments and the established Agencies of the National Military Establishment. Furthermore, it is the opinion of the Committee that such a course of action constitutes a progressive and orderly method of transition toward a more complete unification of the Armed Forces’ medical services, and the Committee strongly urges that such an evolutionary method of development be followed* 12. The Committee is most appreciative of the encouragement, support and assistance -which it has received in the course of its work from the Secretary of Defense, his Special Assistants, and the various offices of the National Military Establishment* It is likewise deeply grateful for the valuable help -which has been rendered to the Committee by the scores of personnel of the three Services who participated as 11 teams on tri-partite subcommittees and task groups in conducting studies of the several subjects to which the Committee has devoted special attention* Without the full cooperation, diligence, and time-consuming effort of these many individuals, already burdened with a heavy volume of other work, the Committee's reports on its assign- ment would of necessity have been much less complete in content and coverage. 13* The Committee considers that, with the submission of this report, it has complied with the requirements of its terras of reference by having studied and recommended with respect to the matters to which its attention was directed by the Secretary of Defense. 14* In accordance with provisions outlined in references (x) and (y), this Committee will be dissolved upon assumption of office by the Director of Medical Services on or about 6 July 1949. RAYMOND W. BLISS, Major General, MG, U. S. Army, The-Surgep i General. CLBTQRD A. SWANSON, Rear Admiral (MC), U. S. Navy, The Surgeon General MALCOLM C. GROW, Major General, MC, USA, (AF) The Air Surgeon* YJ. T. BOONE, Rear Admiral (MC), U. S* Navy Executive Secretary 12 THE SECRETARY OF DEFENSE WASHINGTON 1 January 194-8 MEMORANDUM FOR DR. PAUL R. HAVifLE Y: Subject: Committee on Medical and Hospital Services of the Aimed Forces. 1. There are set forth in the succeeding paragraphs a list of some of the problems which I desire to have considered by the Committee on Medical and Hospital Services of the Armed Forces, of which you are the chairman and of which the Surgeon Generals of the Amy and Navy, and the Air Surgeon are the other members. In general, what I wish is a thorough, objective and impartial study of the medical services of the Armed Forces with a view to obtaining, at the earliest possible date, the maximum degree of coordination, efficiency and economy in the operation of these services* Your terms of reference embody any and every question whose solution may tend to further this broad objective* 2. Specifically, I would like your committee to give attention to the problems hereinafter set forth* This list is not meant to be exclusive or in any way to limit the avenues of your inquiry in furtherance of the above-mentioned general objective* On the contrary, it is in- tended to be illustrative and suggestive of the kind of problems which I feel must be tackled* a. Improvement in the utilization of the existing hospital facilities of the several medical services* This will include consideration of the number of hospital beds required in each geographical area to meet the collective needs of the three services, a study of which hospitals are so located as to make it feasible for them to serve more than one of the Departments, and a determination as to which hospitals, if any, should be closed, placed in standby status or disposed of as surplus. It will also require an examination and re-evaluation of the standards for hospitaliza- tion and an inquiry into the possibility of using other facilities, in lieu of regular hospitals, for minor con- valescence, periodic medical examinations, etc. The problem of utilization of hospital facilities should also be considered in relation to the availability of qualified medical personnel, both general and specialized, and consideration should be given to the question of whether certain types of medical services required by the Armed Forces, generally, or in specific areas, could be performed more efficiently and economically by utilizing civilian hospital facilities that may be available* b. Coordination of the current plans of the medical services of the Armed Forces for the construction of any new hospital facilities in the future, having in mind the type of considerations listed in a above, and also the possibility of developing joint criteria for the design of hospitals• c. Methods for improving the organization, management and administration of the several medical departments in the operation of both their hospital and medical programs, including the possibilities of consolidation or coordination of certain activities and functions thereof, and the reduction of the combined overheads of the medical services of the Armed Forces. d. Coordination or consolidation of the medical research programs of the medical services of the Armed Forces and the maximum joint use of research facilities. This should include consideration of the questions of whether there should be a completely joint research program or whether, irrespective of the wisdom of establishing a single Armed Forces medical and hospital service, a common research program should be undertaken by one service on behalf of all services. e. Coordination or consolidation of medical training programs of the medical services of the Armed Forces. This should include an inquiry into the possibilities of joint utilization of service schools, the coordination of post graduate training, the provision by one service for all services of general training or training in specialized fields, joint preparation of medical bulletins and specialized courses, common library facilities, etc. f. Allocation to one service of the responsibility for providing all hospitalization and medical care for all services in certain fields of medicine, as for example, in the fields of tropical medicine, neuropsychiatry, radiological injuries, prosthetics, and serious disorders of the ear and eye. g. Development, to the highest practicable degree, of common standards, practices and procedures among the medical serviced of the Armed Forces* with respect to (1) the physical and mental requirements for entrance into the services and for disability discharges; (2) preventive medicine; and (3) the organization, administration and operation of hospitals. h. Improvement and standardization of (1) medical records and nomenclature; (2) cost accounting systems; (3) fonns; (4) specifications for supplies and equipment; and (5) regulations. - 2 - i* Integration, coordination and consolidation of various operations in the supply systems of the medical services as for example, in procurement, storage and distribution* Maximum utilization of qualified medical personnel of the Armed Forces* Consideration should be given to the joint use of highly specialized personnel, to the possibility of interchange of medical personnel among the medical services depending upon requirements and facilities for such personnel, to the relief of qualified doctors from administra- tive responsibilities and to providing them with greater opportunity for exclusive attention to the practice of their profession, etc* k. Establishment of uniform changes and policies for the hospitalization and medical treatment of dependents of enlisted and commissioned personnel. 1* Development of common programs for the use of civilian consultants, and the joint use thereof by the medical services of the Armed Forces, m. Establishment of maximum central services of all types which might operate for the benefit of the whole of the medical services of the Armed Forces* n. The development of an organization or mechanism for the continuing examination of the type of problems hereinbefore mentioned* 3* In connection with such problems, I want the Committee not only to consider possible substantive solutions but also to examine the question of what further steps, if any, should be taken by me in the direction of making such solutions effective or in securing further consideration of these problems by a civilian commission reporting to me or to the President, or by seme other type of group* As to certain issues, for example, you may wish to gather all the relevant facts, clearly define the issues, state the alternatives, advise as to your own conclusions and then recommend that the matter be thoroughly examined by some group having no connection with the services. 4* In conducting this study, the Committee is authorized to consult with such persons in the Armed Forces as it may wish, and to call as witnesses such individuals or organizations from outside the regular military establishment as the Committee desires* The Committee is further authorized to call upon the Departments of - 3 - the Army, Navy and Air Force, and upon the Munitions Board, the Research and Development Board, and the Joint Chiefs of Staff, for such information and assistance as it may require, and to arrange for the appointment of such subcommittees, composed of representatives of one or more of such departments and agencies, as it may feel are necessary to carry out its work* My own office will cooperate in every way in providing accounting, management engineering and administrative assistance and services which the Committee may require, and will lend all possible aid in securing, or providing from its own staff, personnel necessary for any staff of the Committee* 5* You may find that certain of the problems which you feel are within your terms of reference are ones that have been, or are now being, considered by other agencies of the National Military Establishment, as for example by the Munitions Board in the field of assigning procurement responsibility or the Research and Development Board in the area of medical research* In such cases you should consult with, and coordinate your activities rdth, such agencies in order to avoid unnecessary duplication of effort* 6* I should like your report at the earliest practicable date but I do not want haste to detract from the submission of a thorough, comprehensive study. If, and when, you feel that a particular problem urgently requires action and that you have worked out an appropriate solution, you are authorized to submit a special interim report embodying your recommendations with respect thereto* Similarly from time to time, I may submit to your Committee special problems with respect to which I wish your advice* 7* Needless to say, I feel that there are few problems facing the National Military Establishment which have the importance and urgency of the matters your Committee is being asked to study* There is a real opportunity here for constructive accomplishment, and I am confident that such constructive accomplishment will be the outcome of your work• /s/ James Forrestal - 4 - 49 11911 THE ARMY INSTITUTE OF PATHOLOGY GRAPHIC REPRESENTATION OF EXISTING MEDICAL FACILITIES MILITARY MEDICAL RESOURCES COST ACCOUNTING AND FISCAL CLASSIFICATION AND DIAGNOSTIC NOMENCLATURE THE ARMY MEDICAL LIBRARY DESIGN OF HOSPITALS DENTAL MATTERS AVIATION MEDICINE COMMITTEE ON MEDICAL AND HOSPITAL SERVICES ARMED FORCES PERSONNEL BUDGETS MEMBERS ARMY COLONEL, MC. USA NAVY CAPTAIN. MC.USN AIR FORCE COLONEL. MC.USA(AF) EXECUTIVE COMMITTEE MEMBERS ARMY THE SURGEON GENERAL NAVY THE SURGEON GENERAL AIR FORCE THE AIR SURGEON EXECUTIVE SECRETARY THE COMMITTEE CHAIRMAN MEDICAL SERVICES FOR DEPENDENTS PROGRAMS FOR HOSPITALIZATION PHYSICAL AND MENTAL STANDARDS CLASSIFIED MATTERS TRAINING AND EDUCATION PREVENTIVE MEDICINE PROFESSIONAL SERVICES MEDICAL RESEARCH MEDICAL INTELLIGENCE MEDICAL FORMS. RECORDS AND REPORTS MEDICAL SUPPLY EXTRACTS FROM REPORTS INCLUDING ABSTRACTS OF THE PRINCIPAL RECOMMENDATIONS WHICH HAVE BEEN SUBMITTED TO THE SECRETARY OF DEFENSE THE COMMITTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES NOTE: For evaluation of the forwarding letters and summaries of recommendations contained in this compendium, reference should be made to the basic material con- tained in the more comprehensive reports on the respective subjects as submitted to the Secretary of Defense by the Committee. INDEX CF SUBJECTS ON WHICH THE COMMITTEE TEAS SUBMITTED REPORTS AND REGOiiMENDATIOi IS TO THE SECRETARY OF DEFENSE DATE SUBMITTED TO SECRETARY OF DEFENSE HUB. TITLE CF SUBJECT A Joint Amed Forces Medical Supply System B Standardization of Medical Nomenclature within the Armed Forces 0 Uniformity of Medical Department Budgets D Hospitalization and Medical Service in the Panama Canal Zone Area S Amed Forces Hospital Facilities at Guam, M. I. T ~~ Inter-Service Reciprocity in Medical Care of Dependents of Military Personnel 0 Standardization of Preventive Medicine Practices and Procedures within the Armed Forces H Medical Research of the Armed Forces 1 Medical Professional Services of the Amed Forces J Medical Intelligence of the Amed Forces 8 April 194-8 28 April 1948 4 May 1948 18 May 1948 15 June 1948 29 June 1948 23 July 1948 29 July 1948 29 July 1948 3 Sept. 1948 TAB NO. TITLE OF SUBJECT DATE SUBMITTED TO SECRETARY OF DEFENSE K Physical and Mental Requirements for Entrance into and Disability Separation from the Aimed Forces L Graphic Representation of the Principal Medical Facilities of the Aimed Forces M Training and Education Programs of the Medical Departments of the Aimed Forces N The Army Medical Library 0 The Amy Institute of Pathology P Aviation Medicine in the Armed Forces Q Coordination of Design of Hospitals and other Medical Facilities of the Aimed Forces R Standardization of Medical Forms, Recording and Reporting Procedures within the Aimed Forces S Programs for Hospitalization in the Aimed Forces and for Improvement in the Utilization of Existing Hospital Facilities T Improvement and Standardization of Cost Accounting Systems and Appropriation Accounting of the Medical and Hospital Services of the Armed Forces U Organization, Management and Administration of the Medical and Hospital Services of the Armed Forces V Medical Department Personnel 3 Sept. 1948 3 Sept. 1948 4 Oct. 1948 4 Oct. 1948 4 Oct. 1948 4 Oct. 1948 3 Nov. 1948 10 Nov. 1948 7 Jan. 1949 14 Apr. 1949 3 May 1949 20 May 1949 3 JOINT ARMED FORCES MEDICAL SUPPLY SYSTEM Recommendations of the Committee in regard to JOINT AHMED FORCES MEDICAL SUPPLY SYSTEM a. That an "Armed Forces Medical Materiel Board," he established under the Joint control of the Secretaries of the Army, Navy and Air Force. The “Board” shall be composed of three members, one each from the Army, Navy and Air Force, designated respectively by The Surgeon General of the Army, the Surgeon General of the Navy, and the Air Surgeon. The “Board" shall perform its functions under rules and regulations ap- proved by the Secretary of Defense. b. That there be created, within the “Boards an "Armed Forces Medical Materiel Agency" to function as an operating agency under the supervision of the "Board", The "Agency" will consist of a commanding officer and a staff composed of military personnel detailed from the three Armed Forces and of civilian personnel. c. That there be created an "Armed Forces Medical Materiel Com- mittee" under the Joint supervision of the Surgeon General, Army, the Surgeon General, Navy, and the Air Surgeon, Air Force, comoosed.of representatives from the three medical services and from the "Agency". d. That, contingent upon and concurrent with approval and imple- mentation of the foregoing, the Secretary of the Army and the Secretary of the Navy Jointly: (i) Deactivate the Army-Navy Medical Procurement Agency and the Army-Navy Medical Procurement Office, and transfer their functions to the ’’Board” effective upon activation of the ’’Board”. (il) Transfer to the Armed Forces Medical Stores Fund the sums of $2,000,000 and $1,000,000 from the appropriations •’Medical and Hospital Department, Army” and “Bureau of Medicine and Surgery, Navy,” respectively. (iii) Transfer to an Armed Forces Medical Stores Account those depot medical stocks required by the"Board, (It) Transfer "management" and "technical" control of the follow- ing depots to the "Board, " "Command" control will remalq with the department. (1) Havy !a) Havy Medical Supply Depot, Brooklyn b) Havy Medical Supply Depot, Oakland (2) Any (a) St. Louis Medical Depot (b) Louisville Medical Depot (c) San Francisco Medical Depot (▼) Transfer "technical" control only of the medical sections of the following depots to the "Board"| (1) Havy (a) Havy Supply Depot, Spokane (b) Havy Siqaply Depot, Clearfield (o) Havy Sxpply Depot, Mechanicsburg (2) Any (a) San Antonio General Distribution Depot (b) Columbus General Distribution Depot (c) Schenectady General Distribution Depot (d) Richmond General Depot e. That contingent upon and concurrent with approval and implementa- tion of the foregoing, the Secretary of the Army establish the present Medical Section of the Atlanta General Distribution Depot as the "Atlanta Medical Depot" to serve the medical supply requirements of the Armed Forces in that area. If this be deemed impractical, transfer the technical control only of the Medical Section, Atlanta General Distribution Depot to the "Board." f. That action taken to implement this plan be such that the joint medical supply organisation can commence operations on the first day of a new "fiscal year." OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON COMMITTEE ON MEDICAL AMD HOSPITAL SERVICES OF THE ARMED FORCES 9 December 1948 MEMORANDUM FQRs The Secretary of Defense Subject* The "Plan for a Joint Armed Forces Medical Supply System" as recommended by the Committee on Medical and Hospital Services of the Armed Forces Reference! (a) Memorandum for Secretary of Defense from Joint Chiefs of Staff under date of 11 August 19A8, on same subject Enclosure! (1) Copy of reference (a) 1* A copy of the comments submitted to you under date of 11 August 1946 by the Joint Chiefs of Staff on subject "Plan" has been transmitted to the Committee by your office for informatioa and requesting further discussion on the points raised therein. *»hile the following discussion, elaborating upon aspects of the "Plan for a Joint Armed Forces Medical Supply System" as recommended by the Committee on 2 April 1946, is primarily related to the memorandum of the Joint Chiefs of Staff (reference (a)), parts of it are also relevant to similar points which have been raised by other agencies and departments of the National Military Establishment. 2. The comments of the Joint Chiefs of Staff are essentially a statement of well recognized general principles which should be reflected in any supply plan. The recommended plan for a "Joint Aimed Forces Medical Supply System" is predicated upon and preserves these fundamental principles. 3. The "Plan" and the comments thereon by the Joint Chiefs of Staff are discussed herein in their relation to the three phases of logisticsi* requirements (totermination, procurement, and distribution. The problem is further analyzed on the basis of exploring functions involved in these three phases by first determining which functions must be separately per- formed, and those which may be performed jointly or by one service for the others. ** *u*ther analysis and comparison, it is sought to determine whether the functions in the latter category would be better performed separately, Jointly, or by one Service for the other two Services* Having arrived at a set of conclusions as above by considering functions per se those conclusions are re-examined in the light of extrinsic influences * brought to bear by necessities and preferences of mutually conflicting nature which are peculiar to the individual services* 4* The Determination of Requirements* (a) General* The statement of requirements is inseparable from the strategic plans, is directly related to operational responsibilities, And is an iiqoortant element of command# The analysis and solution of the technical duplications of these requirements is a proper responsibility of the respective technical service or bureau, and is the basis upon 'which procurement and distribution are sequentially worked out. (b) Relation to the Proposed Joint Medical Supply Plan. The above principles of "direct influence by the military commander on the kind, quality, and quantity of medical support," and the obligation of the technical service or bureau to provide material are fully respected in the Plan* Specifically, each medical service receives from its military command authority a statement of broad requirements for particular military plans and situations* Each medical service then translates this broad state- ment of requirements of its respective Service into qualitative and quantita- tive technical materiel estimates in consonance with the terms of the strategic and logistic olans* The toetermination of these "Planned" requirements is the direct responsibility of the respective Services* "Planned" requirements comprise Special Service Programs and Projects (including both overseas and fleet maintenance), fie serve, and. Mobilization requirements* This leaves only continental maintenance requirements as the responsibility of the joint agency; their determination will be based upon directives and information received from appropriate sources in the three Services as to current and projected personnel strengths and distribution, relevant Service plans and policies, and environmental or technical considerations affecting medical materiel, and will take into consideration issue and stock status data sub- mitted directly to it regularly by the principal .continental medical suoply depots. The joint agency is obliged to accept each Services* statement of "Planned" requirements and the directives referred to immediately above, as ‘given; and, is without authority to alter them without the concurrence of that Service* In essence, the separate Services control all the factors of requirements except the mechanical calculation of those for continental maintenance, the calculation and evaluation of regional and over-all issue rates, and the consolidation of quantities of both categories of requirements fox* purposes of procurement from industry* When all categories of require- ments are consolidated by the joint agency and the totals derived appear beyond the capacity of supply (industry) as determined by the industrial surveys conducted by the joint agency, appropriate elements of the Services will be advised immediately* Apportionment of available supply will be determined by inter-departanental agreement and not by the joint agency (when differences are insoluble on the department level recourse will be made to the Munitions Board as prescribed by the joint letter of the Secretaries of the Army, Navy, and Air Forces, Subject: Procurement Coordination in Periods of abort Supply, dated 12 December, 1947). This consolidation is better and more economically performed by a joint office, and no substantive conflicts of interest are apparent* 5* Procurement* The term "Procurement" as used above and in the proposed Plan for a Joint Armed Forces Medical Supply System refers to the acquisi- tion of the required material (medical supplies and equipment) from the national sources of supply (industry)* (at) General. Procurement is determined quantitatively by requirements, with the conditioning factor that where requirements exceed the possibilities of procurement (the capacity of industry), requirements must be reduced (or allocations must be made, which in effect amounts to the same thing), or, as an alternative, reserves bought or on hand must be committed ahead of schedule* Qualitatively, procurement depends upon cataloging and specifications before the fact, and upon inspection there- after* Placing an order for material, of course, requires a written con- tract* Liquidation of this obligation requires available funds* In summary, "Procurement" Involves all the above elements* (b) Relation to the Joint *edlcal Supply Plan. (1) Quantitative* The only interest to a oarticular Service in this connection would arise from inability to acquire sufficient medical material to meet its requirements* As stated previously, no substantive disadvamage exists in such a Joint procurement operation even during periods of short supply since the Joint agency has no authority to alter the separate Services' requirement projections, or to apportion the available potential supply without the concurrence of all interested parties. In single-Service (cross) procurement operations, the client Services are less well informed of developing materiel situations and are therefore in a disadvantageous position. (2) Capacity of Suppliers. The determination of industrial capacity is purely factual* Equitable allocation of plant capacity is of vital concern to each service. Allocations, are, however, determined by the Munitions Board and any conflicts are resolved on that level* However, and this is considered most important, in a Joint operation each service retains control of its allocated industrial plant capacity though, for economy, it effects the administration thereof in a unitary manner* This would not be true of a single-Service operation where the controlling Service controls all the plant capacity* (3) Qualitative* Catalogs identify material* Specifications define the material and performance characteristics expected in and from the item; they also denote the labeling and packaging required* Inspection guarantees compliance with specifications by the contractor* Each Service must make use of these instrumentalities in conducting procurement* Identical catalogs, specifications and inspection afford significant advantages in the utilization of industrial capacity and for logistic cross-supoly at all levels, and are productive of appreciable ecqnomies. Achievement of these objectives is constantly urged by higher authority* The Joint operation furnishes the ideal environment for most satisfactory acconrolishnent of these desirable ends. • (A) Contracts* All Federal agencies are obliged to conform to definite laws and procurement regulati ns in purchasing* There is no inter- Service conflict in this matter; nor does any individual Service have any special interest in this feature other than validity of the contract* There- fore, the economy realized by a Joint agency preparing contracts (subject to technical control) does not in any way conflict substantively with the interest of the individual Departments* (5) Money* Action to obtain funds for its needs must, of course, be originated by each Department* Wien the Departments have obtained these funds, there can be no conflict involved in a joint agency receiving alloca- tions of funds from the separate Services and expending said funds for materials for use by the individual Services, provided such expenditures are proportionate to the money received from the individual Services* 6* Distribution* (a) Generl* Distribution starts with receipt from the supplier (industry) and ends with the receipt by the ultimate consumer* There aret (1) phases of this which must be completely under the control of the separate Services, (2) phases -which can be performed jointly or by one Service for the others without substantive disadvantage to any Service and, (3) phases which of necessity will be under the control of extrinsic agencies not directly related to any Service, such as intra-continental rail and truck transportation* In summary, distribution'comprehends the initial destination of shipments from industrial producers and vendors olantsj the receipt, storage, and disposition of material; and, transportation* (b) Relation to the Joint Medical Supply Plan* (1) Initial Destination of Material* Transfer of material from the contractors plant to the initial destination (in certain instances from contractor direct to continental consumer or to dockside for overseas) is effected in accordance with the geographical distribution of personnel, facili- ties, and materiel ihich are projected in the logistic plans of the separate Services* "Planned11 separate service materiel moves to points designated by the respective Service* Continental maintenance joint materiel moves initially to principal continental depots and their controlled satellite storehouses or stores sections under agency directives tailored to meet individual Service requirements (corollary to par* 4(b))* Hence, there arises no conflict of interest in acconplishlng this terminal phase of the procurement cycle through the medium of the joint agency* (2) Receipt and Storage* Each of these functions has two elements* The first element is the operation of the continental depots and their con- trolled satellite storehouses or stores sections* The second element is the operation of overseas and floating medical supply installations* The control of the first element by the joint agency (under the terms of the Plan) im- poses no substantive disadvantages on any Service, but does afford signifi- cant economies, efficiencies, flexibility and celerity of cross-supply over that obtainable by separate operations* As a corollary to paragraph 4(b), the control of the second element of these functions wrould fall within the province of the Service or Services having jurisdiction afloat or in the area. The Plan interposes no obstacle to this concept, and the lines of demarkation of the respective supply responsibility are clearly defined# 4 (3) disposition of Material* disposition involves several factors, e.g*, ownership, accounting, transfer from the custody of the warehouses to consignee, and reimbursement* As a coroll*iy of par 4(b), all categories of ••Planned" materiel are carried in separate accounts, and the title resides with the separate Service even though it is in physical and accounting custody of the Joint agency ; and, this materiel can only*be disposed of as directed by the owning Service and may not be diverted to the use of another Service without the consent of the owning Service* When "Planned11 materials cease to be required by the owning Service because of changes in its projected needs or strategical plans, that Service may relinquish its equity to another Service having need for the material, or to the Joint agency for inclusion in the Joint Medical Stores Account (subject to reimbursement in either instance); thus economy and flexibility in the utilization of national resources is effected* All "continental maintenance" medical material, however, is the property of the Joint agency (through the proposed Joint Medical Stores Fund and Account), and withdrawals by activities of the separate Services must be paid for by each Service* The Joint agency will account monthly to each Service for separate Service- owned materiel and will bill it for the *ledical Stores Fund and Account material issued* Joint Agency physical custody and property accountability passes to the separate Service via the common carrier or the overseas freight terminal when the material shipment and the bill of lading are delivered to and accepted by the carrier or terminal, since each shipment will move on separate Service bills of lading* The evidence of this transfer of custody and property accountability is the signature affixed on the invoices by the designated respective Service representative at the shipping depot* There appears to be no intei>-Service conflict or infringement of special interest#; and, the division of Joint and separate Service custody and accountability is well defined* A cardinal virtue of Joint over single Service operations lies in this separate Service—ownership and the consequent disposition - control of materiel vital to its logistics, and in the ability of each Service to protect its interests in the Joint agency operation through board (AFMMB) action* (4) Transportation* The common carrier rail, truck, commercial bottom, or parcel post is outside the Jurisdiction of the services (it is assumed that the QDT and VBA or analogues will be activated in case of National emergency)* Therefore, the only Service interest in connection with this ex- trinsic control by agencies which transport materiel would arise from the inability of the extrinsic agent to move goods according to plan* Hence, there arises no intei*-Service conflict, as all shipments Trill move on separate Service bills of lading (except parcel post)* 7* The divisions of responsibility and authority outlined in theplan (and discussed above) carefully define and fully protect separate Service interests* Those functions identified as suitable for unitary administration are equally well defined, and do not invade the necessary prerogatives of the separate Services* The successful performance of the functions indicated as suitable for unitary administration can unquestionably be accomnlished by separate, or Joint, or single (cross) Service action* However, unitary administration of those functions which are appropriate for and amenable to unitary administration will produce definite efficiencies and economies as compared with separate- Service performance. Single-Service (cross-Service) and joint procedures both possess similarities as to advantages of economy and efficiency, but single-Servioe operation has the disadvantage (not present in a joint ac- tivity where all are equals) of poor control as regards responsiveness tq the logistic necessities of the client Services’ military command and technical authority. Client liaison adequate to provide true responsiveness to the needs of all three Services (if liaison can functionally neutralize single-Service oomnand authority - which is considered rather doubtful) would require more total personnel for a single-Service (cross-Service) op- eration than for a joint operation. 8. The joint mechanism is superior to single-Service (cross-Service) opera- tions in the feature of positive and immediate responsiveness to separate Service necessities and command. This jse ns itive ne s s is generated by the relation of the proposed Armed Forces edical materiel Board to the Aimed Forces Medical Procurement Agency; it Is the analogue of the relation of the present Army-Navy Medical Procurement Agency and its executive office the Armv-Wo-- -““edical Procurement Office which has operated effectively and Harmoniously (without recourse to higher authority) for three years. The board is composed of three members, each of whom has equal authority in the board as the representative of his Service,, and in that capacity is completely responsive to his Services' necessities and to its military command. The board is an immediate, informed to its composition), and authoritative (as regards direction of the agency) common point of reference for the resolu ■ tion of difficulties. Its peculiar virtue lies in the prevention of incongruities, and in the prompt reconciliation of Service viewpoints at the operational level. In the event that differences are insoluble on its level, it is the medium for early and simultaneous projection to higher authority in the respective Services of identical reports detailing the premises in- volved. Three years experience with the joint Array-Navy Medical Procurement Agency and Office operation in procurement and other closely related medical materiel fields indicates that the Board direction and supervision of the Agency as recommended in the Plan will prevent, rather than seek remedies for, incompatabilities on the" operational level; and that the mechanism does in practice provide effective command direction in the operation of a Joint Medical Supply Agency. 9# In single-Service operations, the client Services are dependent upon the controlling Services' administration; and, as effective as liaison may be, it is a poor substitute for what was surrendered by the client Services. This will be most noticeable in areas and periods of materiel scarcity. Under single-Service operations there will inevitably ensue a deterioration in the effectiveness of client parti- cipation in technical determinations with respect to materiel, and if such deterioration were unimpeded, the present almost absolute identity of standard medical materiel and its specifications will become only relative; the con- sequence of this would be the impairment of theoptimal utilization of Industrial capacity and resources (by numerical increase in specifications). Attainment and retention of maximal identity of materiel used by all Services is of great logistic importance; it is the result of continuing conscientious effort to justifiably restrain the normal centrifugal tendencies of profes- sional personnel and techniques in the several Services to impose minor or 6 major variations of materiel according to personal preferences* 10* In summary the advantages of a Joint supply operation ares (a) Equal authority in the administration and conduct of the operation* (b) Complete coordination of suoply activities, as no one Service can pursue courses disruptive of the common good* (c) Each Service contributes its best logistic personnel, as there is professional opportunity regardless of Service* The elimination of needless duplication of personnel (for liaison), and of major supply facilities. (e) Clerical and paperwork procedures are simplified and made more uniform* (f) Each Service retains closer professional and technical relations with industry and its research and development activities* (g) It is more economical* 11* The disadvantages of single-Service vcross) operations aret (a) Client Services have no effective voice in the adm nistration and conduct of the operation, and thus have no adequate means of forestalling non- performance or of effecting prompt corrective action in case of unsatisfactory oe rfo nuance • (b) Affords only minimal impetus to coordination of materiel identity, specifications, inspection, requirements and distribution* (c) Client Services will lose logistic "know-how* and able personnel of the client Services will be reluctant to enter and engage in this imoortant field whenever there is no future in thit field within their own Service* (d) Larger number of personnel required, due to need for client Services to maintain liaison in the central operations and also in the many distribution depots* (e) Clerical and paper procedures are definitely more complicated* (f) Diminished opportunity of the client-Service for professional and technical contact with industry* (g) It is less economical* 12* The Plan for a Joint Aimed Forces Medical Supply System as recommended by the Com’ ittee applies the most advantageous method of an integrated and co- ordinated system of medical supply for the Aimed Forces* The Plan preserves and safeguards the fundamental principles of command and supply, and insures continued recognition of the essential MyWeWtltadi#ach of the three Departr- ments in respect to medical materiel and its suoply# The Plan clearly delineates where common (joint) requirements procurement, and distribution ceases; and where individual separate - Service functions and responsibilities in medical supply begin# The implementation of the Plan would not complicate or hamper the flow of medical materiel into the operational logistic pipelines of tao individual Departments or Services# Effectuation of the Plan would not only be productive of economies and increased efficiency in peace time, fcut would be of even greater value under the emergency conditions which might prevail during the next war# Through the flexibility provided for in the Plan the uniterrupted supply of medical material to all' tne Aimed Forces in the event of war is more surely protected# Mobilization or war time conditions would require only an increase in the rate and quantity of initial procurement (purchase) and an expansion of the size and/or number of the principal con- tinental reservoirs (principal medical supply depots) to feed logistic pipe- lines of the three Services# 13# The relative smallness of the number of medical items of supply and equip- ment, of their total dollar value, or their tonnage, is no measure of the im- portance or essentiality of medical materiel in comparison with other types of material# The professional nature of the material, the fact that specifications for this material has been standardized, that for a period of three years medical supply and equipment has been successfully and satisfactorily procured from industry by a Joint Agency or Office for all three Services on single con- tracts, that a joint medical supply catalog has been developed and is now in daily use throughout the three Services, characterize the field of medical material as one in which further extension of the current oractice of joint performance of certain functions is now practicable to the degree orooosed in the Plan# The prooosed joint Armed Forces Medical Supply System, can, if later found to be in conflict with any overOall system of Armed Forces Supply which may subsequently be developed and adopted after completion of thelong and ex- tended studies which will obviously be necessary before resolution of such a comprehensive problem, be readily adjusted in consonance with any over-all supply system for the Armed Forces which may ultimately be evolved# 14* The Committee again recommends ap royal of the proposed Plan for its early implementation* PAUL R. HAWLEY, M. D. Chairman, Committee on Medical and Hospital Services of the Armed Forces RAYMOND it. BLISS Major General, MC, USA The Surgeon General CLIFFORD A# SWANSON Rear Admiral (L'C), USN Surgeon General J* T. BOONE Rear Admiral (MC), USN Executive Secretary MALCCOI C. GROW Major General, MC, USA The Air Surgeon THI JOIST CHIEFS OF STAFF Washington 26, D, C# U August 1948 MEMORANDUM FOB THE SSCBZTABT OF DBOTSI SUBJICTs Plan for a Joint Araed Tore** Medical Supply Syetaa fieferanca is Bada to your ■saw rendu®, dated 10 April 1948, requesting comments on a plan for nodical supply of tha Armed Forces submitted by the Committee on Medical Hospital Services of the Armed Forces to tha Secretary of Defense, The Joint Chiefs of Staff have considered the proposed "plan" and submit the following comments. Comments sure not Bade upon every detail of the propoeed "plan" or its organizational features. Bather, the oonclusions reached reflect general principles that the Joint Chiefs of Staff consider must be observed in the impleswntation of this, or any supply plan. The primary concern of the Joint Chiefs of Staff is to provide in any supply system for maximal military effectiveness in times of emergency. This postulates that any proposed organisa- tion for medical supply be one that can nost effectively perform its mission under conditions of the next war. Any plan that is adopted should insure flexibility to the extent that any military commander will have direot influence upon the kind, quality and quantity of medical support deemed necessary to fulfill his mission. It is the responsibility of tha various departments to institute studies concerning details of implementation of any common medical supply system which may be adopted. Any plan that la laplanantad nuat preacrlhe where conaon distribution ceases and indlrldnal aarrloa distribution 'begins. Initially, the common distribution system should include only principal continental distribution agencies such as outlined in the “plan". The establishment of subsidiary depots (distribution points) required to meet indiridual service medical supply re- quirements is a matter for individual service determination. The establishment of such additional facilities should be coordinated to the maximum extent among the three military departments. Hie inclusion of additional subsidiary depots or distribution points in the supply system is a matter for approval of the three military departments. Implementation of any plan which may be adopted should make provision to safeguard the fundamental principles of command and supply as pointed out in preceding paragraphs. The Committee on Medical and Hospital Services of the Armed forces has not made a comparative examination of a system in which a single Service acts as procurement agent for Medical supplies for the three Services, or a system of eross-Serviee procurement. It is recommended that the relative efficiency, economy and flexibility of these systems be compared with that proposed in the "plan” before aay consolidation of Medical supply systems is approved. for the Joint Chiefs of Staff! /•/ William D. Leahy WILLIAM D. LZAHI, Heat Admiral, U, 8, sary, Chief of Staff to the Contender in Chief of the Armed force a. - 2 - COMMITTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES 26 April 19U8 MEMORANDUM TO LT. GEN. LB ROY LUTES, MUNITIONS BOARD Chairman, Facilities and Services Conmittee Reference* Special Meeting 23 April 19U8, Conmittee on Facilities and Services Forwarded herewith is a supplement to a Report of the Sub- comnittee on Medical Supply of the Committee on Medical and Hos- pital Services of the Armed Forces dealing with certain questions raised at the meeting of your Committee on 23 April, 19U8, End* J. T. BOONE Rear Admiral (MC), U. S. Navy Executive Secretary SUBCOMMITTEE CN MEDICAL SUPPLY FOR THE ARMED FORCES 26 April 1?U8 SUBJECT: Supplement to Report of Subcommittee on Medical Supply for the Armed Forces* dated 22 March 1?U8 TO: Rear Admiral J. T* Boone, MC, USN, Executive Secretary of the Committee on Medical and Hospital Services of the Armed Forces, Room 3D685, The Pentagon 1* At a meeting on 23 April 19U8 of the Committee on Facilities and Services of the Munitions Board**, the report of the Subcommittee on Medical Supply for the Armed Forces, dated 22 March 19ii8, Was dis- cussed and certain criticisms made. The principal criticisms levelled at the report and the "plan1* which it jr esented wera; a* That the desirability of the plan was not clearly established* b* That the relationships between the Armed Forces Medical Materiel Board and other agencies of the National Military Establishment were not clearly stated* c* That implementation of the plan should be deferred pending standardization of supply procedures and forms of the three departments* d« That the advantage of the proposed joint supply system over single service "cross supply** was not established. e. That the plan removes the Surgeons General of the Ajjny and Navy and the Air Surgeon from the control of the Logistics Chiefs of the three departments. 2, That the desirability of the plan was not clearly established* Secretary Forrestal*s letter of 1 January 19118 to Dr* Paul Hawley stated, "Specifically I would like to have your committee give attention to the problems hereinafter set forth ********* i - Integration, coordination and consolidation of the various operations in the supply systems' of the medical services, as for example, in procurement, storage and distribution"• The subcommittee interpreted the above statement to mean that the Secretary of Defense considered integration, coordination and consolidation of the various operations in the supply systems of the medical services to be desirable if a workable plan could be developed# Consequently* it felt that the desirability of integration* coordination and consolidation need not be further elaborated# 3. That the relationships between the Armed Forces Medical Materiel Board and other agencies of tne National Military Establishment were not clearly stated. The Subcommittee's report did not spell out these relation- al lps in detail because it was felt that they would be self-evident. The Armed Forces Medical Materiel Board would be an expansion of the existing Amy—Navy Medical Procurement Agency, and would have the same relationships as does that agency. The proposed board is merely a servant of the Surgeons General of the Amy and Navy and the Air Surgeon. In effect it is a joint agency to which would be delegated certain authorities and responsibilities in the field of supply and procurement now resting in each of the above. It is the concept of the subcommittee that the board will have no authorities or powers which the Surgeons General do not now possess by virtue of law, regulation or custom. The board would be responsible to the Research and Development Board and the Munitions Board through technical service or bureau and general staff or CNO-OUSN channels oh matters under their cognizance. On all matters the board would likewise be responsible to the Secretaries of the three departments through technical service or bureau and general staff or CNO-OUSN channels as at present. Forces Medical Materiel The plan provided that "decisions of the board will have the concurrence of each member. In the event of lack of unanimity* the issue will be referred to the Surgeon General, U# S# Amy, the Chief* Bureau of Medicine and Surgery* U. S. Navy, and the Air Surgeon, U# S# Air Force, for decision". The sub- committee did not mean to inply that the latter three had final decision, but rather that in case of disagreement at that level* the matter would be referred to the three proper general staff agencies, then if necessary to the Under or Assistant Secretaries, then if necessary to the Secretaries, with th.e Secretary of Defense as a court of last resort. The subcommittee desires to emphasize that in its 28 months of operation, the Arny-Navy Medical Procurement Agency has never had a disagreement at its level necessitating appeal to the Surgeons General for decision# I*. That implementation of the plan should be deferred pending standardi- sation of the supply procedures and forms of the three departments. While the standardization of certain procedures and Borins is desirable, complete standardi- zation will require many years.' Furthermore, implementation of the proposed plan requires the standardization of a far forms only, the principal ones being the requisition and the depot shipping document. It is to be borne in mind that the proposed plan does not carry below the depot level. 5, That the advantage of the proposed Joint supply gystem over single service "cross supply*1 was not established,, Because of close association with 2 the operation of the joint Army-Navy Medical Procurement Agency during the last two years, the members of the subcommittee are "sold11 on joint activity in the field of medical supply# It is the opinion of the subcommittee that joint operation should be used in only a few fields, but in those instances where it can be used, it is superior to single service cross operation# For joint operation to be successful, the folloiring criteria must be met; a* The participating units must have the same or very nearly the same missions* b* The participating units should be on the same organizational level in their respective departments# c# In the case of procurement or supply operations there must be a high degree of standardization of items between the participating units# The advantages of joint operation ares a* Each participating unit has an equal voice in the affairs of the agency. b. There is complete coordination and it is impossible for any one of the participating units to pursue a single, uncoordinated line of action. c. The best brains of all participating units are brought to bear on common problems# d# Needless duplication or triplication is eliminated# e* It is economical* The disadvantages of single service cross operation are: a. The participating units are not equals in this operational relationship. One unit is rendering a service to another unit# Throughout business life this relationship is agent to principal, a relationship which is understandably abhorrent to corresponding units of the Armed Forces# 3 b. There is no Impetus to coordination. The unit receiving and paying for -the supplies or service can demand what it wants regardless of supplies or services routinely being furnished by the servicing unit. Any of the participating units can go its c*m way. c. Because of the above, duplication and triplication are not eliminated. d. The unit receiving the supplies or service has no adequate means of getting corrective action in case of unsatisfactory performance by the servicing unit. 6. That the plan removes the Surgeons General of the Arcy and Navy and the Air Surgeon from the control of the Logistics chiefs of the throe Deparinienta,1 This unfortunate impression was created by the subcommittee *s report, however, paragraph 3 above clarifies this matter. At the danger of belaboring the point, it is desired to point out that the plan does not envisage a change in the functional or organizational status of the Surgeons General of the Arny or Navy dr the Air Surgeon. The plan provides that the three Departmental Secretaries create the joint board under the control of the Surgeons General of the Army and Navy and the Air Surgeon, such board to exercise certain supply functions near exercised by them. The subcommittee suggests that this objection to the plan could be overcome by the inclusion of a clarifying statement in implementing legislation op directive, such as: "Nothing in this shall be construed to change the relationships of the Surgeons General of the Arny or Navy or the Air Surgeon to the Secretary of Defense, their respective Departmental Secretaries, Under Secretaries, Assistant Secretaries, or General Staff Agencies or to the Munitions Board or the Research and Development Board"* As evidence of action previously taken by the Surgeon General, u* 6* Army, and the Chief, Bureau of Medicine and Surgery, U-. S* Navy, in line* with this philosophy, attention is invited to the three letters outlined below: a* Chief, Bureau of Medicine and Surgery letter to OUSN (Office General Council) BuMed-U2l-PRC:Ia LB-2/JJ Serial: 18728, dated 13 October 191i7, in which the Chief of Bureau of Medicine and Surgery requested that paragrqp hs 121.U and 121*5 of a draft of Navy Procurement Regulations be modified to delete the designation of the ANMPA and the Director, ANMPA as an office and official respectively on the Bureau and Chief of Bureau level with respect to procurement* b. Chief, Bureau of Medicine and Surgery Letter to OUSN (Chief, Material Division) Buile d-h2l-PRC LB/JJ Serial 20207 of 29 March 19U8, in which the Chief, Bureau of Medicine and Surgery requested that identical action proposed by the Monitions Board in a draft of proposed Armed Services Procurement Regulations, Section I, Part 2, paragraphs !• 201*3 and 1.201*1*, be amended to delete the authorities proposed to be conferred on the Agency and the Conmanding Officer, Amy-Navy Medical Procurement Office* c. Surgeon General, U. S. Amy, letter to Director of Logistics, GSUSA, dated 26 March subject "Armed Services Procurement Regulations", in which an identical request to (b) above was forwarded* L. G. JORDAN Captain, IC, USN Chairman S. B. HAYS Colonel, MC, USA Member JOHN LUFT Major, MSC, USA Member 5 OFFICE CM OF defense WASHINGTON C OMIT TEE ON MEDICAL AND HOSPITAL SERVICES OP THE ARMED FORCES 2 April 1948 Tot The Secretary of Defense Subjects Flan for a Joint Aimed Forces Medical Supply System References (a) Memorandum from Secretary Forrestal to Doctor Paul IU Hawley, dated 1 January 1948, subject, “Committee on Ifedical and Hospital Services of the Aimed Forces•“ Enclosures (A) Report of a proposed plan for a Joint Aimed Forces Medical Supply Operation, dated 22 March 1948* 1# In the memorandum terms of reference given by you to this Committee under date of 1 January 1948 (reference (a)), you asked that among other matters, the Committee give attention to the problem oft •Integration, coordination and consolidation of various operations in the supply systems of the medical services, as for example, in procure- ment, storage and distribution#" 2# In accordance with paragraph 4of reference (a), a Subcommittee on Medical Supply was appointed by the Conan it tee to study, analyze, report and recommend to it in respect to this specific problem# The Subcommittee on Medical Supply has submitted its report to the Committee as a proposed “Plan," which is trans- mitted herewith as Enclosure (A)# 3# The Committee has given careful and thoughtful consideration to this “Plan," and oleheartedly supports and concurs with the concept contained therein# 4* The Committee is aware that the plan advances a concept which varies in some respects from previous customs and procedures# While the concept may represent a pioneering undertaking, the Committee feels that such an approach is necessary if maximum coordination, efficiency and economy of operation of the medical supply systems are to be achieved# 5* In essence, the "Plan" calls for the reservation of necessary authorities to the Surgeons General and The Air Surgeon, and for the delegation of other authorities to a Joint Armed Services Medical Materiel Board# Under the "Plan," the "Board" will delegate operational authorities to a subordinate Armed Ser- vices Medical Materiel Agency tut will retain cognizance of policy determinations and evaluation of "AGENCY" performance# 6* In effect, the recommended "Plan” involves extension of the currently functioning joint irmy-Navy Medical Procurement Agency to permit unified joint operation of a single medical supply system be- yond the limited functions now performed by the existing mechanism* The joint operation will include the performance of requirements de- termination, material control, accounting, and fiscal functions inci- dent to supply control, development, cataloging, preparation of speci- fications, procurement, inspection, storage, distribution, maintenance, and disposition of supplies and equipment peculiar to the Medical De- partments of the Army, Navy, and Air Force, in the manner and to the degree set forth in the "Plan," enclosure (A)* 7* The establishment of this joint organisation will produce appre- ciable savings of money, personnel, and facilities, and will provide an effective mechanism which can efficiently discharge the medical supply responsibilities of the Army, Navy, and Air Force* In the event of war the proposed organization can bo successfully and economically expanded without functional, organizational, or procedural changes* 8# Legislation will be required to establish a revolving fund to be known as the Aimed Forces Medical Stores Fund, for the procurement of medical supplies and equipment, and to permit the advancement of money by the Army and Navy from appropriations available for the purchase of medical stores subject to reimbursement® No "new* money appropriation will be required from the Congress to establish the revolving fund* Public Law 413, 80th Congress, does not provide the necessary sanctions* 9* In regard to Section 11, paragraph A, subparagraph 1 (3), on page 18 the Committee concurs in the recommendation made therein by the subcommittee relative to the fiscal point covered thereby* 10, In regard to Tab I, paragraph 14, pages 2 and 3, the Committee haB concluded and agreed that the Naval Medical Supply Depot, Brooklyn, and its Edgewater Annex, should be continued in operation and that the Binghamton Medical Depot should not be reactivated. 11* In event of approval of the * Plan," the dates of activation must of necessity be at the start of a fiscal year unless funds other than those obtainable through reimbursable advances of money envisioned in the "Plan" can be provided, in which instance the date of activation would be optional* Further, considerable detailed work will be required to firm and complete the definitive procedural and operational details* 12* Your committee unanimously recommends approval of this "Plan* 2 13• This special interim report, covering the matter of "medical supply systems," constitutes the first increment of the Committee's report to you on its overall assignment* PAUL R» HAWLEY, M. D# Chairman, Committee on Medical and Hospital Services of the Armed Forces RAYMOND W. BLISS Major General, MC, USA. The Surgeon General CLIFFORD A. StIANSON Hear Admiral (MG), U* So Navy Surgeon General MALCOIi! C. GROW Major General, MG, USA The Air Surgeon Jo To BOONS Rear Admiral (MG), U# S# Navy Executive Secretary STANDARDIZATION OF MEDICAL NOMENCLATURE WITHIN THE ARMED FORCES Heoommendations of the Committea in regard to STANDARDIZATION 0? MEDICAL NOMENCLATURE WITHIN THE ASKED JORGES A, That the Armed Torees undertake to produce morbidity and mortality statistics that are comparable not only in basic diagnostic classification and nomenclature, but also in such auxiliary terms by which diagnoses are qualified, as are common to all services. B. That the Armed forces adopt a uniform classification and nomenclature of diseases, injuries and conditions. C. That the elMsification follow the lines of the 1948 revision of the International Classification of Diseases, Injuries, and Causes of Death. D. That the Standard Nomenclature of the American Medical Associa- tion be used as a general guide to terminology. B. That the uniform service classification and nomenclature of diseases, injuries and conditions be published as an abridged list in format appropriate for Inclusion in the manuals of each service. T. That work and study be continued on details of processing the additional qualifying data associated with diagnoses, as well as with respect to the terminology and abbreviations authorized for reporting such data, in order that early agreement be reached in these natters to the extent necessary to assure comparability of statistics* OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON COMMITTEE ON MEDICAL AND HOSPITAL SERVICES CF THE amp FOBCE9 28 April 1948 Tot The Secretary of Defense Subjects Standardisation of Medical nomenclature within the Amed Forces References (a) ifenorandun from Secretary Forrestal to Doctor Paul R. Hawley, dated 1 January 1948, subject, "Committee on Medical and Hospital Services of the Armed Forces." Enclosures (A) Report of Subcommittee on Classification and Diagnostic Nomenclature of Diseases, Injuries, etc* - (Exhibits with- drawn). 1. In the memorandum terns of reference given by you to this Committee under date of 1 January 1948 /reference (aVyou asked that among other matters, the Committee give attention to the problem of s "Inprovament and standardisation of medical records and nomenclature." 2. In accordance with paragraph 2h of reference (a) a Subcommittee on Classification and Diagnostic nomenclature of Diseases and Injuries was appointed to assist the Committee in a thorough studfy- of the subject and in formulating pertinent recommendations with respect to this specific problem. 3* For several decades international studies have been in progress relative to standardization of medical nomenclature. Within the United States, various medical professional organizations and government depart- ments including the State Department, the United States Public Health Service and tlie Armed Forces have conducted similar studies designed to off net an over-all standardization of nomenclature coordinated with inter- national standards. 4. Up to this time any attempt to coordinate nomenclature standards within the Amed Forces has been purely voluntary and without authority tive direction. By implementing the recommendations contained within this report the following desirable objectives can be accomplished* au Standardisation of all nodical and clinical terminology within the Azsaad Forces. b. Standardisation of statistical analytical data within the Aimed Forces resulting in more accurate observation of health trends, non-effective rates and the nature and morbid affects of battle casualties and special hasards* This will materially enhance the value of medical statistics in logistic planning In the future. o« Standardisation and simplification of the maintenance of accurate clinical records, eliminating potential confusion in cross hospitalisation of military personnel* d. Simplification of mutual understanding of terms in any nixed departmental assignment of medical personnel. • • Standardisation of clinical tema coranon to military and civilian medicine. 5* Implementation of tie recommendations contained herein requires no legislative or executive proceduresj It can bo accomplished by an Admin- istrative Order from the Secretary of Defense j the recommendations ore non-controvorsial in nature and will result in no encroachment on the prerogatives of ary authority within the Armed Forces or other government agency| and tlie program proposed herein is in accord with approved medical procedures within the United States. 6. Should this report be approved, any Implementing instrument should make provision that the program he effective on the first day of a calendar year in order to avoid confusion in compiling annual medical statistics. It should make authoritative provision for continuing interdepartmental study and coordination to insure the permanence and the currency of medical nomenclature common to the Armed Forces. 7. After careful study, the Committee unanimously supports and concurs with the report of the Subcommittee and iterates the following recommendations t A* That the Armed Forces undertake to produce morbidity and mortality statistics that are comparable not only in basic classification and nomenclature, but also in such auxiliary terms by which diagnoses are qualified, as aro common to all services. 2 B* That the Aimed Forces adopt a uniform classification and nomenclature of diseases. Injuries and conditions* C. That the classification follow the lines of the 194# revision of th» International Classification of Diseases, Injuries, and Causes of Death* D* That the Standard Nomenclature of the American nodical Association be used as a general guide to terminology* S« That the uniform service classification and nomenclature of diseases, injuries and conditions be published as an abridged list in format appropriate for inclusion in the manuals of each service* F* That work and study be continued on details of processing the additional qualifying data asoociatod with diagnoses, as well aa with respect to the terminology and abbrevia- tions authorised for reporting such data, in order that early agreement be reached in those matters to the extent necessary to assure comparability of statistics* 8* This special interim report, covering tho matter of "Standardisation of ilodlcal Nomenclature within the Armed Forces," constitutes the second increment of tho Committee *8 report to you on Its overall assignment* PAUL R* HAWI£T, M. D. Chairman, Committee on Medical and Hospital Services of the Armed Forces RAYMOND W. BLISS Major General, MC, USA The Sure©on General CLIFFORD A* SWANSON Roar Adairal (MC), U* S* Navy Surgeon General J. T. Boom Hear Admiral (MC), U* S. Navy Executive Secretary MALCCOI C* GROW Major General, MC, USA The Air Surgeon 3 UNIFORMITY OF MEDICAL DEPARTMENT BUDGETS Recommendations of the Committee in regard to UNII’OHMITY 0? MEDICAL DEPARTMENT BUDGETS 1* Rgcommandations The recommendations of this subcommittee are: (1) That each Medical Department budget be revised to contain as close to 100$, as may be practicable, of the full and complete operating expenses of Medical Department activities with the exception of military pay and routine military travel, and that each Medical Department be charged with the responsibility of carrying out these newly budgeted functions. (2) That necessary changes be made in the appropriatlon&l language for each of these budgets. (3) That such funds as are appropriated for the construction of Medical Department facilities in the Army be definitely earmarked and restricted to the cost of actual construction without being subject- ed to reductions to pay a portion of the operating costs of the Corps of Engineers, (4) That an essentially uniform type of budget be submitted by each service, to afford ready comparison and evaluation of the total cost and the unit costs of each program involved. COMMITTEE ON MEDICAL AND HOSPITAL SERVICES 0? THE AHMED FORCES 4 May 1948 To: The Secretary of Defense SubJj Plan for Uniformity of Medical Department Budgets H«fi (m) Memorandum from Secretary Porrestal to Dr. Paul H, Hawley dated 1 January 1946, subject "Committee on Medical and Hospital Services of the Armed forces.* End: 1 (HW) Report of a proposed plan for uniformity of Medical Department budgets dated 16 April 1948. 1. In reference (a) you asked that, among other matters, the Committee give attention to the problem of: "Development to the highest practicable degree of conon standards, practices and procedures among the medical services of the Armed Forces." 2. In accordance with paragraph 4of reference (a), a Subcommittee on Medical Department Budgets for the Armed Forces was appointed by the Committee to study, analyte, report and recommend in respect to this specific problem. This Subcommittee has submitted Its report to the Comlttee as a proposed plan for uniformity of Medical Department budgets which is transmitted herewith as enclosure 1. 3. The Committee has given careful and thoughtful consideration to this "Plan” and whole-heartedly supports and agrees with the Ideas contained therein. 4. The Committee is aware that the "Plan.41 advances certain concepts which vary in some respecte from previous customs and procedures. While these concepts may represent a pioneering undertaking, particularly with ftespect to the Department of the Army, the Committee feels that such an approach is indicated if uniformity and adequate coverage of the Medical Department budgets are to be achieved together with uniformity of control of funds. 5. This "Plan” proposed a functional type of budget essentially along the same lines as was proposed by the Department of the Navy for fiscal year 1948 In an effort to simplify budgetary structure and control. 6. Considerable differences are apparent not only in budgetary coverage but in the control of funds and in the methods of budgetary presentation. Izoluding the pay of military personnel and the cost of their routine travel. the Army Medical Department budgets for approximately 56$ of the cost of operation of their Installations. However, of these funds, the Army Medical Department has direct control of approximately 60$ of the funds budgeted and, therefore, budgets for and controls approximately one-third of the funds re- quired to operate their installations and to discharge their responsibilities. On the converse side, the Havy Medical Department budgets for and fully con- trols approximately 80$ of the funds required for the operation of its installations, exclusive of military pay and routine travel. Such an arrange- ment does not lend itself to ready comparison by higher reviewing authorities. 7. Tab ▲, beginning on page 17 of enclosure 1, shows the differences in the control of appropriations by each Medical Department and in a tabulated list shows the source of each item of expenditure required. 6. Tabs C, D and 1, beginning on page 35 of the enclosure 1, list those items which are included in one budget and not in the other, as well as those items which are not included in either budget. 9. The advantages and disadvantages of standardisation in budgetary procedure in the Medical Departments are listed on pages 10 and 11 of enclosure 1. 10. The proposed "Plan" for similarity of budgetary control and ocjterage is contained in Tab X, beginning on page 27 of enclosure 1. This "Plan" provides that each of the three Medical Departments will budget for and control the funds for approximately 98$ of the cost involved in the discharge of their responsibilities, exclusive of military pay and routine military travel. Omitted from budgetary coverage because of impracticability, are the maintsaanee and utilities requirements for dispensaries. 11. If this "Plan" should be adopted, the necessary appropriations! language changes are contained in Tab 0, beginning on page 34 of enclosure 1. 12. Minor changes are proposed in the methods of budgetary presentation as noted on page 8 of enclosure 1, so that each department nay have set out clearly the complete cost of each activity Rnd so that any activity in one budget can be readily Identified and compared with a similar activity in the other budgets. 13. To implement this "Plan," no executive or legislative measures will be required with the exception of the appropriation language changes. 14. If this "Plan" should be approved, it is suggested that it be effected with the IT 1950 budget submission. 15. Tour Committee unanimously recommends approval of this "Plan.* 2 16. This special Interim report covering the matter of uniformity of Medical Department budgets constitutes the third Increment of the Committee's report to you on Its overall assignment. 17. A study of, and a proposed plan for improvement and standardisation of cost accounting systems and fiscal procedures for ths medical departments of the Armed forces will be submitted at a later date. That "Plan," when sub- mitted, will Include considerations and recommendations consistent with ths Implementation of this budget "Plan," PAUL R. HAVLET, M. D. Chairman, Committee on Medical and Hoepital Services of the Armed forces HAIMOND W. BLISS Major General, MC, USA The Surgeon General OLIffOED A. SWANSON Rear Admiral (KC), USN Surgeon General MALCOIA4 C. GROW Major General (MG), USA The Air Surgeon J. T. BOONE Hear Admiral (MC), U. S. Navy Executive Secretary Enel. 3 HOSPITALIZATION AND MEDICAL SERVICE IN THE PANAMA CANAL ZONE AREA Recommendations of the Committee in regard to HOSPITALIZATION AND MEDICAL SERVICE IN THE PANAMA CANAL ZONE AREA (a) Discontinue the designation of the hospital at Fort Gulick (located on the Atlantic Side of the Isthmus) as a Station Hospital, and reduce that medical activity to the status of a dispensary, with only physical maintenance of the unused hospital spaces. (b) That Margarita Hospital be closed as a hospital activity and, with the exception of those limited facilities which may be required in active operation for the continuation of an out-patient clinic at this location, tnat the Installation be preserved in a maintenance status. (c) That tne hospitalization of civilian employees of the Panama Canal and the Panama Railroad and their dependents on the Atlantic Side of the Isthmus, heretofore provided through the operation of two Canal hospitals, i,e., Colon and Margarita Hospitals, be provided by continued operation of only one of these two hospitals, viz,, the Colon Hospital, (d) Utilize the U, Naval Hospital, Coco Solo, C.Z,, as the principal hospital facility for all the Armed Forces located on the Atlantic Side of the Isthmus, (e) Utilize the Fort Clayton Hospital, under the designation of a "station hospital,*1 as the principal hospital facility for all the Armed Forces located on the Pacific Side of the Isthmus. (f) That Gorgas Hospital continue to be operated by the Panama Canal administration to hospitalize and provide out-patient clinic ser- vice on the Pacific Side of the Isthmus for the civilian employees of the Panama Canal and Panama Railroad and their dependents, and for such other miscellaneous personnel for whom medical treatment is authorized by law, regulation, or treaty; to provide such specialized clinical pathology and central laboratory facilities and services required in the medical care of civilian personnel of the Canal Zone as are not available in the smaller outlying Panama Canal medical activities; to provide hospitaliza- tion and specialized treatment facilities on a **general hospital*1 or ■medical center" level for selected cases from among the civilian person- nel patients of the Panama Canal Area as a whole; and to provide, from its available means, such specialized consultative, diagnostic and treatment services, or hospitalization as may be requested by the military services for selected patients at or from medical activities of the Armed Forces, (g) Insofar as personnel and accommodations are available, render out-patient and in-patient medical care to dependents of the Armed Forces personnel at all Armed Forces medical installations within the Panama Canal Zone and at rates established by the Departments of the Army and Wavy (Navy Department rates for dependent medical care are established by Executive Order 9Ull, dated December 23, 19h30 Corresponding Army Department rates are established by administrative measures. Studies are now being made by the Committee on Medical and Hospital Services of the Armed Forces with a view to recommending measures designed to bring about reciprocal rates for dependent medical care at Armed Forces medical installations•} (h) Render outpatient and in-patient medical care at Panama Canal medical installations to civilian employees of the Armed Forces and their1 dependents and to civilian employees of the Panama Canal and their de- pendents at such rates and in accordance with such regulations as have been or may be established by the Governor of the Panama Canal® (i) That no change be made in present arrangements relative to operational costs of Panama Canal Hospitals insofar as they pertain to the hospitalization of civilian employees of the Armed Forces and their dependents® (j) In order to afford the best possible professional medical care and service for the Panama Canal Areas as a whole with the total medical resources available in the area, and to effect coordination of area medical planning and effort with its resulting elimination of unnecessary dupli- cation and overlapping, the following plan is recommended for implementa- tion; (i) Establishment of a permanent Area Joint Medical Advisory Committee consisting of the Chief Health Officer of the Panama Canal and the senior medical officer on each of respective staffs of the Army, the Navy and the Air Force Commanders in that area. Such Committee would meet at regular stated intervals, as required, for the purpose of coordinating and supervising all medical activities within the area, such as hospitalization, preventive medicine, out-patient or dispensary service, professional service (Including the use of consultants), ,training of Medical Department personnel, medical supply, disaster planning, etc,, and submitting pertinent recommendations to the Commander-in-Chief for appropriate action. The senior medical officer on the Area Joint Medical Advisory Committee would be designated Chairman and would rep- resent that Committee as the Medical Director on the staff of Commander-in-Chief, Caribbean Command, 2 (ii) The institution of a plan, or program, designed to afford the best possible professional medical care and service for the Panama Canal Area as a whole by utilizing within the hospitals (civilian and military) throughout the area the total medical professional means available within the area, utilizing the consultative and professional assist- ance of all duty certified or accredited medical special- ists on duty anywhere within the Panama Canal Area re- gardless of branch of service or duty assignment. (iii) Make provision whereby all medical officers of the more junior grades in the Armed Forces who may be detailed to dispensary and other non-hospital duty in the Panama Canal area will be given opportunity for reasonable’ periods of temporary duty in professional service, in one of the hospitals, and whereby medical officers of the more junior grades in the Armed Forces who are regularly detailed for hospital assignment and not serv- ing in status of interne or resident training may be rotated with the aforementioned medical officers by temporary duty assignment to one of the non-hospital medical activities. 3 ARMED FORCES HOSPITAL FACILITIES AT GUAM, M. I. OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON CCWMITTffi ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES 15 June 19U8 Tos The Secretary of Defense Subjects Armed Forces Hospital Facilities at Guam, M. I. 1. The Committee on Medical and Hospital Services of the Armed Forces unanimously recommends that one military general hospital be operated on the Island of Guam to provide for the combined requirements for general hospital beds to meet the peacetime needs of the Army, Navy and Air Force in that locality. 2. The Committee recommends that this become effective as soon as one such hospital having the capacity to acdoomodate the current combined general hospital patient-load of the Army, Navy and Air Force at Guam can be con- structed or otherwise provided. 3. In recognition of the necessity of providing for essential local medical services (other than hospitalization) at the several major posts, stations and activities of the Army, Navy and Air Force on Guam, the Committee re— conn ends that such be furnished by station dispensaries to be operated by each of the Forces as required to meet their local needs. U. The Committee is keenly aware of and acutely concerned about the deplorable state to which the physical condition of the temporary wartime hospital structures on Guam has deteriorated, and recommends that remedial action be expedited. /a/ Paul R. Hawley by J.T.B, PAUL R. HAWLEY, M. D. Chairman, Committee on Medical Hospital Services of the Armed Forces /a/ a. w. Bliss RAYMOND W. BLISS Major General, MC, USA The Surgeon General /a/ J. T. Boone J. T. BOONE Rear Admiral (MC), U. S* Navy- Executive Secretary /s/ C, A. Swanson CLIFFORD A. SWANSON Rear Admiral (MC), U. S. Navy Surgeon General /s/ M, C. Grow MALCOLM C. GROM Maj or General, MC, USA The Air Surgeon INTER-SERVICE RECIPROCITY IN MEDICAL CARE OF DEPENDENTS OF MILITARY PERSONNEL Recommendations of the Committee in regard to INTER-SERVICE RECIPROCITY IN MEDICAL CARE OF DEPENDENTS OF MILITARY PERSONNEL (a) That there be full reciprocity among the Armed forces in the matter of hospitalization and medical care of dependents of Service personnel, bach of the three Armed Forces should be authorized to render such medical attention, both in-patient and out-patient, to the dependents of personnel of the other two Services on a parity with that afforded de- pendents of personnel of the Service which furnishes the medical c are. (b) That uniform charges and policies be established with respect to hospitalization and medical treatment of dependents of military per- sonnel of all the Armed Forces, (c) That Committee is keenly aware of the increasing shortage of medical department personnel in all the Armed Forces, and of the further necessary restriction on the scope of medical care which can be afforded dependents imposed by the limited suitable facilities which are avail- able to provide in-patient and out-patient medical care for. dependents, Notvylthstanding these handicaps and difficulties, the Committee is of the firm opinion that the Armed Forces should continue to render medical care (both in-patient and out-patient) to dependents of military personnel of the thrbe services insofar as it may continue to be practicable within the limits of available medical personnel and facilities and so recommends. (d) That action be taken at the earliest possible date to ef- fectuate the policy of reciprocal care for service dependents under uniform rates. The Committee is of the opinion that this will be in the best interests of the Armed forces, aid will facilitate more satisfactory implementation of plans and programs for a greater degree of common utiliza- tion of medical facilities and services such as that recently approved for the Panama Canal areao COMMITTEE CM MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES 29 June 1948 Tot The Secretary of Defense Subject t Medical Care for Dependents of the Armed Forces Reference i (a) Memorandum from Office of the Secretary of Defense dated 24 June 1948, transmitting for comment the Secretary of the Navy's letter with enclosure of 21 June 1948, all on same subject# Enclosures (1) Copy of reference (a). !• At a meeting of the Committee held this date, referenced correspondence was made a matter of immediate attention# 2# The Committee has been cognizant of the fact that the initial letter forming the basis .for tlte referenced corresponds rce was originated by the Surgeon General of the Navy after consultation with the Surgeon General of the Army and the Air Surgeon* All were in common agreement that such action by the Surgeon General of the Navy would constitute the most reasonable and tangible approach to a resolution of the problems involved in providing reciprocal medical care for Service dependents under uniform rates of charge# 3« The Committee concurs with the proposals made by the Acting Secretary of the Navy in the referenced letter, and submits the following comments in connection therewith* (a) The Committee is in unanimous agreement with the objective of establishing uniform charges and policies with respect to hospital- ization and medical treatment of dependents of military personnel of all the Armed Forces# (b) The Commit tee also is in unanimous accord with the expressed desirability of full reciprocity among the Armed Forces in the matter of hospitalization and medical care of dependents of Service personnel# Each of the three Armed Forces should be authorized to render such medical attention, both in-patient and out-patient, to the dependents of personnel of the other two Services on a parity with that afforded dependents of personnel of the Service which furnishes the medical care. (c) The Committee is keenly aware of the increasing shortage of medical department personnel In all the Armed Forces, and of the further necessary restriction on the scope of medical care "which can be afforded dependents Imposed by the limited suitable facilities which are available to provide in-patient and out-patient medical care for dependents* Notwithstanding these handicaps and diffi- culties, the ronmittoe is of the firm opinion that the Armed Forces should continue to render medical care (both in-patient and out- patient) to dependents of military personnel of the three services in so far as it may continue to be practicable within the limits of available medical personnel and facilities* (d) The following is the consensus of the Committee in regard to charges which should be levied against personnel of the Armed Forces for medical attention rendered to their dependents* (i) A collection should be made from the person in the Armed Forces for whom in-patient medical care is furnished to his dependent, and that such charge should be on a per diem rate approximating the cost of the daily ration plus a small additional charge approxi- mating the average daily cost of medicines and dressing materials consumed in the care of such patients* The flat rate of sl*7s per day charged such patients by the Navy in accordance with Executive Order No* 9AH of December 23 1943# appears to serve satisfactorily for this purpose* (ii) It is considered appropriate that each of the three Services afford out-patient medical examinations and treatments to the legal dependents of personnel of the other two services on the same basis as that afforded dependents of personnel of the providing Service* 4* The Committee believes that action should be taken at the earliest possible date to effectuate the policy of reciprocal care for service de- pendents under uniform rates* The Committee is of the opinion that this will be in the best interests of the Armed Forces, and will facilitate more satisfactory implementation of plans and programs for a greater degree of coranon utilization of medical facilities and services such as that recently approved for the Panama Canal area* 5* This special interim report deals specifically with proposals discussed in the referenced correspondence relative to reciprocity in affording medical care for Service dependents and at uniform rates in the Military Establishment* The Committee intends to submit at a later date a summary report pursuant to paragraph 2k of its terns of reference dated 1 January 194S* Ihile that report will discuss the broad problem more fully, the recommendations of the Committee in regard to the specific matters raised 2 in this correspondence will be in line with the proposals contained in the referenced letter from the Acting Secretary of the Navy and the comments thereon hereinbefore made by the Committee* PAUL R. HAWLEY, M. D. Chairman, Committee on Medical and Hospital Services of the Ajnaed Forces RAYMOND W. BLISS Major General, M 3, USA The Surgeon General CLIFFORD A* SHANSOM Rear Ackniral (113), U* S« Navy Surgeon General MALCOLM C. GROW Major General, MC, USA The Air Stu'geon J. T. BOONE Roar Admiral (IC)# U# 8# Nary Executive Secretary 3 RESTRICTED OFFICE CF THE SECRETARY CF DEFENSE Washington 24 June 1948 MEMORANDUM FOR ADMIRAL BOCKE SUBJECTi Medical Care for Dependents of the Aimed Forces* 1* Attached hereto is a letter from the Acting Secretary of the Navy to the Secretary of Defense, dated 21 Jane 1948, with reference to the above subject, and reconnending the issuance by the Secretary of Defense of an attached order establishing a Military Establishment policy under which the several services would afford medical care for dependents on a reciprocal basis, and by iftiich rates charged for medical care of dependents and others would be made uniform throughout the Military Establishment 2© It is my understanding that the Committee on Medical and Hospital Services of the Armed Forces is considering the problem raised in the attached letter from the Acting Secretary of the Navy pursuant to paragraph 2k of the memorandum mhich establishes this Committee* 3© It will be appreciated if the Committee on Medical and Hospital Services would comment on the proposals of the Acting Secretary of the Navy© These comments may be made separately or as part of any report which you intend to suhnit covering this general subject* /s/ John H* Ohly JOHN H. OHLT Special Assistant to the Secretary THE SECRETARY OF THE NAVY WASHINGTON June 21, 1948 The Honorable The Secretary of Defense My dear Mr. Forrestal: The Navy Department considers it highly desirable that the several services reciprocate in the medical care of dependents of service personnel* Conferences and communications at various levels with officials of the Army and Air Force indicate that the other services share this view. The services are presently precluded from interchanging dependent care on a reciprocal basis by the restrictive nature of the Act of 10 May 1943 (57 Stat* 80), which specifies the conditions and subjects for medical care in Naval facilities, and an implemental Executive Order which prescribes the rates for such care (Executive Order 9411 of 23 December 1943)* Under the Act and order, hospitalization and medical treatment in Naval facilities for persons other than dependents of Navy and Marine Corps personnel are authorized only outside the continental limits of the United States and in Alaska* The rates for such oersons are ss*oo per day for hospitalization and $l.OO for each out-patient treatment* The rate for hospitalization of Navy and Marine Corps dependents is sl*7s per day* On the other hand, medical care of dependents and others in medical facilities of the Amy, and rates covering such care, are governed by departmental regulations* The present rate consists of a subsistence charge, which varies around to sl*ls per day, plus a daily drug charge of 50 cents, or a total daily charge of approximately sl*6o* Under the present set-up, the Navy cannot official extend any medical services to Army or Air Force dependents within the United States* Whenever such services are extended outside the United States, the depen- dents of the other services are required to pay ss*oo per day or &I*oo for each dispensary treatment as indicated above* The Army may extend medical attention to dependents of the other services, both within and outside the United States, and care is afforded at the rate charged its own dependents For instance, on the Pacific or "Army end” of the Panama Canal Zone, Navy dependents are hospitalized in Army facilities for approximately sl*6o per day# On the "Navy end" Army dependents are hospitalized for ss#oo per day # The Army and Navy are both willing, and the Amy is able, to cooperate in working out a program of uniform and reciprocal care for service dependents and others# It is believed* that such a program would result in more effective and economical use of medical facilities, and would tend to eliminate or reduce duplication and overlapping of such facilities within the Military Establishment# The hands of the Navy are tied, however, by the aforementioned statute and implemental order# The Judge Advocate General of the Navy has expressed the opinion, copy of which is enclosed for information, that the authority reposed in the Secretary of Defense by the National Security Act of 1947 (Pub- lic Law 253, 80th Congress) to promulgate programs and policies for the Military Establishment, and to do away with overlapping and dupli- cation in certain fields, including the field of health, amounts to a repeal or modification of existing laws which occasion overlapping and duplication# The Judge Advocate General also points out that the President has directed, pursuant to the authority vested in him by the National Security Act of 1947 (Executive Order 9877 of 26 July 1947), that, as a matter of general policy, each service "shall make use of the personnel, equipment and facilities of the other services in all cases where economy and effectiveness will thereby be increased#" With particular reference to the rate structure now prevailing for care of dependents and others in Naval facilities, the Judge Advocate General invites attention to the fact that the President, in transmitting the order prescribing the present rates (Executive Order 9411 of December 23, 1943), declared that such rates were to be considered aa temporary only, and were to be superseded upon the establishment of standard, uniform rate policies applicable throughout the service# In view of the considerations set forth in the above opinion, it is the view of the Navy Department that the Secretary of Defense may lawfully and properly promulgate for the Military Establishment a policy of reciprocal care for service dependents under unifoim rates, and authorize the respective departments to collaborate in the effectuation of such policy# It is accordingly requested that such policy and authority be announced in order that the Navy Department may proceed in working out with the other services the desired program of reciprocity# There is enclosed for your consideration a proposed communication to the various services embodying the above action. Sincerely yours, /a/ W JOHN KENNEY Acting Secretary of the Navy Enclosures 2 STANDARDIZATION OF PREVENTIVE MEDICINE PRACTICES AND PROCEDURES WITHIN THE ARMED FORCES Recommendations of the Committee in regard to STANDARDIZATION 07 PREVENTIVE MEDICINE PRACTICES AND PRDCTOJRBS WITHIN THE ARMED FORCES (a) That there he coordination, correlation and standardization of the Preventive Medicine Programs of the Army, Navy, and Air Force. (h) That there he established a Coordinating Committee on Preventive Medicine composed of the respective Chiefs of the Preventive Medicine Divi- sions of the Army, Navy, and Air Force. (c) That the Coordinating Committee on Preventive Medicine, recommended in (h) above, he responsible for the performance of its functions to the Surgeon General of the Army, the Surgeon General of the Navy, and the Air Surgeon, conjointly, or to some type of an over-all Medical Advisory and Coordinating Board, at the level of the Office of the Secretary of Defense, should such be recommended and/or established at a later date. (d) That the present Army Epidemiological Board be expanded to reflect the needs of the three forces in the fields of operational and research problems of preventive medicine. It would then be redesignated the Armed Forces Epidemiological Board and in its field would act as an advisor to the Surgeon General, U. S. Navy, the Surgeon General, U. S. Army, and the Air Surgeon, U, S, Air Force. OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON CCMOTTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES 13 July 1948 To; Secretary of Defense Subj; Standardization of Preventive Lledicine Practices and Procedures within the Armed Forces Refs (a) Memo from Secretary of Defense to Dr« Paul R* Hawley, dtd 1 Jan 194-85 Subj: Committee on Medical and Hospital Services of the Armed Forces End: 1* (HW) Report of the Subcommittee on Preventive Medicine 1* In the memorandum terms of reference given by you to this Committee under date of 1 January 1948, you asked that among other matters the Committee give attention to the problem of; "Development to the highest practicable degree, of common standards, practices and procedures among the medical services of the Armed Forces with respect to ... . Preventive Medicine." 2. In accordance with paragraph 2g, of reference (a), a Subcommittee on Preventive Medicine was appointed to assist the Committee in a thorough study of the subject and to formulate pertinent recommendations with respect to this specific problem. 3* Up to the present time, coordination of preventive medicine practices and procedures within the Armed Forces has been purely voluntary and vdthout authoritative direction. However, cooperation and coordination has been very close, especially in matters of venereal disease control, insect and pest control, sanitation, immunization requirements and problems of quarantine. 4. A digest of the pertinent features of this study is contained in Enclosures B and C of the Subcommittee's report submitted herewith. By implementing the recommendations contained within this report, the following desirable objectives can be acccmDlished; (a) Complete coordination, correlation, and standardization of the preventive medicine programs of the Army, Navy and Air *orce. (b) Joint use of certain facilities. ■(c) Joint use of consultative groups. (d) Advancement in the practices and procedures of modem preventive medicine• (e) Improved health of the Armed Force. (f) Saving of personnel and funds. 5* Implementation of the recommendations contained in the report requires no legislative or executive procedures; with support of the three Departments it can be accomplished by administrative action of the Secretary of Defense. The broad general recommendations are considered to be non--controversial in nature and will result in no encroachment on the prerogatives of any authority with- in the Aimed Forces or other government agency; further, the program proposed in the report is in accord with the approved common public health and medical standards. 6* After careful study, the Committee unanimously supports and concurs with the report of the Subcommittee and recommends its approval. The Committee suggests and requests, however, that the recommendation contained in paragraph b.(2) on page of Enclosure (c) of the Subcommittee’s report not be made a matter for consideration at this time. The Committee will recommend at a later date with respect to the specific matter proposed in the above-mentioned portion of the Subcommittee’s report, when analysis of other studies not yet concluded has given more definite indication as to the necessity for, the specific nature and the several functions of some such permanent high-level coordinating and advisory medical board. 7« The following recommendations are submitted by the Committee as the basis upon which depends the effectuation of the proposals for developing, to the highest practicable degree, of common standards, practices and procedures among the medical services of the Armed Forces with respect to Preventive Medicine. Their early approval, as constituting the essential prerequisite to the above desired end, is unanimously recommended by the Committee: (a) That there be coordination, correlation and standardization of the Preventive Medicine Programs of the Amy, Navy, and Air Force. (b) That there be established a Coordinating Committee on Preventive Medicine composed of the respective Chiefs of the Preventive Medicine Divisions of the Army, Navy, and Air Force. (c) That the Coordinating Committee on Preventive Medicine, recommended in (b) above, be responsible for the performance of its functions to the Surgeon General of the Amy, the Surgeon General of the Navy, and the Air Surgeon, conjointly, or to some type of an overfall Medical Advisory and Coordinating Board, at the level of the Office of the Secretary of Defense, should such be recommended and/or established at a later date. (d) That the present Army Epidemiological Board be expanded to reflect the needs of the three forces in the fields of operational and research problems of preventive medicine* It would then be redesignated the Armed Forces Epidemiological Board and in its field would act as an advisor to the Surgeon General, U. 3, Navy, the Surgeon General, U. S. Army, and the Air Surgeon, U. S, Air Force. B* This report, covering the matter of ’’Standardization of Preventive Medicine Practices and Procedures within the Armed Forces,” constitutes an increment of the Committee’s report to you on its over-all assignment. PAUL R. HAWLEY, M. D. Chairman, Committee on Medical and Hospital Services of the Armed Forces RAYMOND W. BLISS Major General, MG, USA The Surgeon General CLIFFORD A. SViANSON Rear Admiral (MC), USN Surgeon General MALCOLM C. GROW Major General, MC, USA The Air Surgeon J. T. BOONE Rear Admiral (MC), USN Executive Secretary 3 MEDICAL RESEARCH OF THE ARMED FORCES Recommendations of the Ooimittee in regard to NIDI GAL BISXABCE 07 THE AHMED 70E0B (A) That the present Management-control of the separate medical research activities maintained by the three Services he not disturbed. (B) That the Chiefs of Medical Research Divisions of the three Departments mast at regular intervals* on call of the senior Chief, and not less frequently than once a month* tot (1) Discuss with one smother all new research project proposals received since the previous meeting, in order to (a) In the case of projects for accomplishment in service facilities* determine i. Which service facility is best equipped to undertake the project* and ii. What assistance or cooperation, either by personnel or research tools should be furnished by facilities of the other armed forces, but ill. The right of any of the three research chiefs to undertake a project independently shall not be designed by the above reviews. (to) In the oast of projects for accomplishment by contract in civilian institutions, declds which projects should be undertaken in Joint sponsorship and stqpport. (0) That where Joint s\qoport of research projects is agreed tq>on* the service which is primarily Interested* or which is the initial sponsor of a particular project, will cause the contract to be negotiated through its regularly designated channels* and will bill the contributing services for their agreed portion of the cost* on a Standard form 1080 to effect reimbursement. The contracting agency will then also act as the legal agent in this particular project, will keep records as to the obligation and expenditure of said project funds, and will be responsible for all reports. (D) That the Hesearch and Development Board of the National Military Establishment be asked to study contract methods and procedures in the Medical Services of the Armed Forces with a view toward promoting: (1) Uniformity, (2) Standardization of overhead charges, and (3) Extension of period of availability of appropriated funds. (X) That, giving practical consideration to the limitations imposed by command and administrative aspects and responsibilities, particularly in the fields of bacteriological and radiological varfare, all research in the fields of medicine or medical allied sciences should be conducted under the technical sxqpervision of the Surgeon General (or Air Surgeon) concerned. (7) That the novel, unique or unusual research facilities of one Service be utilized by all of the Services, when desirable, after appro- priate and mutually satisfactory arrangements are effected. (G) That greater consideration be given to the pooling of research resources into Jointly conducted projects where common and mutual concern exists and where the specialized nature of facilities or personnel suggest this action. (H) That medical material development be undertaken as a Jointly controlled, staffed, and financed activity, centered in an Armed Forces Engineering Development Laboratory. 2 r FICE OF THE SECRETARY OF DEF® WASHINGTON COMMITTEE OH MEDICAL AND HOSPITAL SERVICES 07 THE ARMED FORCES To; The Secretary of Defense Subjects Medical Research of the Armed Forces References (a) Memorandum from Secretary Forrestal to Dr, Paul Hawley, dated 1 January 1948, Subjects "Committee on Medical and Hospital Services of the Armed Forces," Enclosures (l) (HW) Report of Subcommittee on Medical Research of the Armed Forces, , 1, By the terms of reference given in Reference (a) you ask that among other things the Committee give attention to the problem ofs "Coordination or consolidation of the medical • research programs of the medical services of the Armed Forces and the maximum Joint use of research facilities. This should include coxw sideration of the questions of whether there should be a completely Joint research program or whether, irrespective of the wisdom of es- tablishing a single Armed Forces medical and hospital service, a common research program should be undertaken by one service on behalf of all Services," 2, In consonance with paragraph 4of Beference (a), the Committee appointed a Subcommittee on Medical Research of the Armed ?orces to ass& the Committee in conducting Its study of this subject. The report of that Subcommittee Is submitted herewith as Enclosure (l). 3, In its consideration of this subject the Committee has taken into account the functions, duties and responsibilities of the Research and Development Board as set forth in Sec, 214 of the Rational Security Act of 1947, Hote has also been taken by the Committee of the establishment by the Research And Development Board of a Committee on the Medical Sciences to assist the Board in the conduct of its functions in that field. Each of the three Depart- ments has two medical officers as representatives in the membership of that recently organized Committee, which is further composed of two civilian members and a civilian chairman. Die six medical officers on that Committee are individuals moat familiar with the medical research programs and activities of their respective Departments, and constitute a participating membership which is satisfactory to the Surgeons General and to the Air Surgeon, Die charter of that Committee, which was concurred In by the Surgeons General and the Air Surgeon, contains terms of reference which have an Important And direct bearing on the repeal—Metiene eC-.t&e ttee on Medical and Hospital Services of the Arm ad forces. The aforementioned char tar Includes the following obligations, quoted in part ohly (sea Annex C of Soclosure (l) for the full taxt)i "Section bi 'Analyse and evaluate , . , information in order tos *(l) Determine the major goals and problems in 'the field of medioal and allied sciences and direct appropriate and constant emphasis npon them i '(2) Assess the adequacy of plans *(3) Determine the presence of unjustifiable duplication ... *(4) Determine the presence of serious gaps which exist in the programs; 1 (6) Assess the adequacy of facilities, personnel and equipment , , , 1 (6) Appraise the degree of coordination . • "Section di •(1) Prepare not less frequently than once a year an integrated plan (2) Allocate and, when desirable, reallocate responsibility among the military departments fop research ... '(3) Specify meant whereby maxi gram advantage may be taken of critical resources and new advances, solution of problems may be speeded, undesirable duplication, waste or neglect may be avoided, end liaison, cooperation and direct dealing among agencies may be furthered; *(4) Present te the Board • • • recommendations for expenditures • • •1 R 4. It is thus seen that the National Military Establishment now has, within the organisational structure of the legally established Hesearch and Derelop- ment Board, the appropriate mechanism for effecting coordination, avoiding 2 undesirable duplications, and providing broad guidance in the field of Medical Research in the Anted forces. 5. Hie Committee on Medical and Hospital Services of the Armed forces is in accord with the report of its Subcommittee on Medical Research. The Committee believes that implementation of the recommendations contained therein vould not conflict with the functions of the Research end Development Board or with the terms of reference given by the Board to its Committee on the Medical Sciences, which review and make determinations on these matters at the level of the Office of the Secretary of Defense, On the contrary, the Committee believes that effectuation of these recommendations will further the commendable objectives of the Research and Development Board in the field of the Medical Sciences as outlined in paragraph 3 above, will service to com. plement the work of that Board, and will facilitate the origination, develops, ment and pursuit, within the level of the Departments, of appropriate and coordinated Medical Research projects and undertakings which will subsequently be subject to scrutiny and review by the Research and Development Board and its Committee on Medical Sciences. The aforementioned recommendations are} (a) That the present management-control of the separate medical research activities maintained by the three Services be not disturbed. (B) That the Chiefs of Medical Research Divisions of the three De- partments Met at regular intervals, on call of the senior Chief, and not less frequently than once a month, tot (l) Discuss with one another all new research project proposals received since the previous meeting, in order to (a) In the case of projects for accomplishment in service facilities, determine 1, Which service facility is best equipped to undertake the project, and ii. What assistance or cooperation, either by personnel or research tools should be furnished by facilities of the other armed forces, but 111, ®he right of any of the three research chiefs to undertake a project independently shall not toe designed toy the atoove reviews. (to) In the case of projects for accomplishment toy contract In civilian institutions, decide which projects should toe undertaken in Joint sponsor- ehip and support. 3 (0) That where Joint support of research projects is agreed upon, the service which is primarily interested, or which is the initial sponsor of a particular project, will cause the contract to he negotiated through its regularly designated channels, and will hill the contributing services for their agreed portion of the cost, on a Standard Torsi 1080 to effect re- imbursement, The contracting agency will then also act as the legal agent in this particular project, will keep records as to the obligation and ex- penditure of said project funds, and will he responsible for all reports. (D) That the ]tesearch and Development Board of the National Military Establishment he asked to study contract methods and procedures in the Medical Services of the Armed Torces with a view toward prosiotingi (l) Uniformity, (2) Standardization of overhead charges, and (3) Extension of period of availability of appropriated funds. (E) That, giving practical consideration to the limitations Imposed by command and administrative aspects and responsibilities, particularly in the fields of bacterlological and radiological warfare, all research in the fields of medicine or medical allied sciences should he conducted under the technical supervision of the Surgeon General (or Air Surgeon) concerned. (?) That the novel, unique or unusual research facilities of one Service be utilized by all of the Services, when desirable, after appropriate and mutually satisfactory arrangements are effected. (G) That greater consideration he given to the pooling of research resources into Jointly conducted projects where common and mutual concern exists and where the specialized nature of facilities or personnel suggest this action. (H) That medical material development he undertaken as a Jointly con- trolled staffed, and financed activity, centered in an Armed Torces Engineer- ing Development Laboratory (Annex D), 6 In connection with recommendation (H) above, attention is invited to the fact that as more fully discussed in Annex D of Eaclosure 1, its approval will result in reorganization and redesignation of the Engineering Develop- ment Division of the Army-Navy Medical Procurement Office (ANMPO), together with its Engineering laboratory and Shop which is located at Tort Totten, New York as the "Armed Forces Medical Materiel Eiglneering and Development laboratory." Further, that it will, through the medium of the Surgeons General and the Air Surgeon and a governing hoard having appropriate representa- tion from each of the three medical Services, place that reorganized and re- designated agency which has to do with development in the field of Medical Materiel more appropriately in closer contact with and more directly under the policy guidance of the Be search and Development Board than by continuing 4 its present relationship as a subsidiary of the Army-Navy Medical Procurement Office, 7, After the Secretary of Defense has obtained such concurrence and/or comr.ents from the Eeeearch and Development Board, the three Departments and/or such other elements of the National Military Establishment as he may deem necessary or desirable, approval of the recommendations as set forth in paragraph 5 above is unanimously recommended. 8. This special Interim report constitutes an increment of the report to you on its overall assignment. PAUL H, HAVIET, M, D, Chairman, Committee on Medical and Eoepltal Services of the Armed forces BATMOND V. BLISS Major General, MC, USA The Surgeon General CLUFOEL A, SVAHSON Rear Admiral (MC), U,S. H, J, T, BOONE Hear Admiral (MC), U.S. Navy Executive Secretary MALCOI* C. GBOV Major General, MC, USA. The Air Surgeon MEDICAL PROFESSIONAL SERVICES OF THE ARMED FORCES Recommendations of the Committee in regard to MEDICAL PROFESSIONAL SERVICES OF THE ARMED FORCES (a) That there be established a Coordinating Committee on Medical Professional Services, and that it be composed of the respective Chiefs of the Medical Professional Services Divisions of the Army, Wavy, and Air Force, (b) That the Committee on Medical Professional Services, recom- mended in (a) above, be responsible for the performance of its functions to the Surgeon General of the Army, the Surgeon General of the Navy, and the Air Surgeon acting conjointly, or to some type of an over-all similarly constituted Medical Advisory and Coordinating Board should such be recommended and/or established at a later date at the level of the Office of The Secretary of Defense. (c) That Specialized Diagnostic and Treatment Centers be desig- nated or established in connection with and as a part of selected General or' Naval Hospitals for the hospitalization and definitive cure of patients from all three Services in certain special fields of medicine, where such is considered appropriate and feasible. In this connection, it is to be emphasized that necessity exists for maintaining area general hospital service at each Hospital having such a Specialized Diagnostic and Treatment Center where a concentration of patients of a particular medical category is made. In connection with this recommendation, it is the sense of the Committee that at the present time, sufficient and appropriate indication more definitely exists for such Specialized Diagnostic and Treatment Centers in only a small number of medical fields; for example, for patients in the field of Tuberculosis, for those in the field of Psychotic and Neuropsychiatric Diseases and Con- ditions, for those in the field of Malignant Neoplasms and Associa- ted conditions, for those in the field of Plastic and Neurosurgery, and for those in the field of Amputation Rehabilitation and Pros- thetics . (d) That the principle of joint professional staffing by medical personnel from the participating Departments of the Armed Forces be adopted in the professional staffing of any Specialized Diag- nostic and Treatment Center that may be designated or established along the lines recommended in (c) above. (e) That the interest of more uniformity, and to effect simplification of administrative procedures, one and the same system be adopted by the Armed Forces for appointment of civilian medical professional consultants* The system now in use by the Army is recommended for such adoption* (f) That there be joint or reciprocal use by the Armed Forces of civilian medical professional consultants at all operating levels ■wherever practicable, extending to the coordinated or reciprocal use of civilian medical professional consultants in local geo- graphical areas where separate hospitals or separate medical in- stallations are operated in the same general area by two or more of the Armed Forces* (g) That the.’e be coordinated and reciprocal use by the Armed Forces asprofessional consultants of outstanding medical pro- fessional specialists who are members of the Armed Forces* (h) That the principle of joint professional staffing be adopted where joint utilization of a Hospital is regularly made by two or more of the Armed Forces* (i) That consolidation be effected of certain professional publi- cations which are now prepared, edited, and published separately by the Medical Departments of the Armed Forces but which serve similar purposes* Further that such combined publications be prepared, edited, and published under the direction of a Joint Medical Pubr lications Board having equal representation ftom the participating Services, the members of such Board to be designated by the Sur- geon General of the Army, the Surgeon General of the Navy and the Air Surgeon respectively* In the above connection, the Committee recommends specifically that "THE BULLETIN OF THE U. S. ARMY MEDICAL DEPARTMENTS” and "THE U. S. NAVAL MEDICAL BULLETIN” be combined into one "ARMED FORCES MEDICAL JOURNAL,” with a joint editorial staff, and with the assignment by one of the participating Depart- ments of a qualified Doctor of Medicine as Bditor-in-Chief* Further, that the selection of the individual for nomination as Editor-In- Chief of the ”JOURNAL" be made by the Joint Medical Publications Board; that the period of duty of any one person as Editor-in-Chief not exceed three consecutive years, except with the unanimous agree- ment of the Board; and that unless otherwise agreed to by the Board unanimously at the expiration of each three year period, the position of Bditor-in-Chief be alternated between or rotated among the par- ticipating Services on the basis of effecting a change in Arm 2 of Service identification of the the Editor-in-Ghief at least once every three years* In connection with this recommendation for joint publication of an 11 ARMED FORCES MEDICAL JOURNAL," it is to be pointed out that heretofore and at present the funds utilized for printing and publishing "THE BULLETIN 0? THE U. S. ARMY MEDICAL DEPARTMENT" and "THE U. S. NAVAL MEDICAL BULLETIN," which would be combined into the one "JOURNAL", are not Medical Depart- ment funds but are ddrived from funds of the Secretaries of the Army and Navy respectively, through allocation by the Office of the Secretaries of monies appropriated and available to them for financ- ing the printing and binding of Departmental publications* At the present time, the newly established Department of the Air Forces does not publish a "BULLETIN" of this nature. Approval of this recommendation (i), under the present budgetary and appropriation systems, will therefore require concurrence by the Department Secretaries concerned, and would be contingent upon their agree- ment to make such funds available for joint medical publications of this nature rather than separately financing similar publica- tions serving the same ends* It is the belief of the Committee that the three Department's should share equally the cost of printing and publication of the one "ARMED FORCES MEDICAL JOURNAL," and that the total cost of same will be less than the total cost involved at present in printing and publishing separately conpar- able "BULLETINS." 3 OFFICE OF THE SECRETARY OF DEFENSE WASH I NG 1 ON OOMKITTSS OH MSDIOAL AHD HOSPITAL 3KRVICSS Of THI JIBKXD fOXOH 28 July 1948 Tos The Secretary of Defense Subject! Medical Professional Ssrvlcs in the Ami loreti Reference: (a) Meaorandua fron Secretary forrestal to Dr, faul 1, Hnwley, dated 1 January 1948, subjects "Cosmittee on Medical and Hospital 3err ices of the Arned forces.■ Inclosurei (I) (HW) Report of Subcommittas on Prefessioaal Serrieee 1. By the terms of refer sues contained in Reference (a), you aaked that among other matters the Committee give attention to the p rob leas eft "Methods for improving the organisation, management and administration of the several medical depart- ■onto and the operation of both their hospital and medical programs, including the possibilities of consolidation or coordination of certain activities and functions thsreof, and ths reduction of the com- bined overheads of ths Msdioal Services of ths Arasd forces.■ "Joint preparation of Medical Bulletins and specialised courses.* "Allocation to on# Barrios of ths responsibility for providing all hospitalisation and nodical oars for all Services in certain fields of nsdicins "Development to ths highest practicable degree of common standards, practices and procedures among the msdioal services of ths Armed forces.* "Maxima utilisation of qualified nodical personnel of the Araed forces. Consideration should he siren to the Joint use of highly specialised personnel, te the possibility of interchange of personnel enong the nodical services depending upon the requirmants and facilities for such personnel * "Development ef eeasen programs for ths use ef civilian consultants, and tha Joint usa thsreof by the medical servioas of the Armed forces.* 2. All of the abort matters art inextricably rtinted to each other and art parts of the aort inclusive problem of Proftasional Medical Strrict within the Armed Forces In oarrying out acceptable professional polioiee aad professional programs. It was therefore deemed appropriate by the Cowlttee that pertinent aspects of tho abort nattere bo otudlod aad reportod collectively la connection with the subject: "Medical Professional Serrloee In the Armed forces.” 3. In accordance with Reference (a), a Subcommittee on Professional Serrloee wa# appointed to assist the Committee in itc study of the subject, fhe report of that Subcommittee Is submitted herewith ae Enclosure (1) mad constitutes the beeie on which the recommendsllone of the Committee as set forth below in paragraph 6 hare been erolred. 4. from an historical standpoint there has always been a considerable decree of cooperation and coordination with respect to medical profes- sional polioiee aad praetleas among the Armed Forces. Furthermore, there has always been close cooperation and coordination between the Medical Serrloee of the Armed Forces and the oirillan medical prof tee ion In regard to medical prcfccclonml practice# employed. S. % to the present time, coordination of medical professional polioiee aad practices within the Armed Forces has been purely voluntary, without authoritative direction, end without an established medium for facilitat- ing ouch coordination. It appears that In this particular field, 1. e., of Professional Medical Serrices within the Armed Forces, opportunity exists for oloser coordination to the end that the highest practicable degree of malformlty, efficiency, and economy bo realised. 6. the Commit too concurs la aad recommends approval la principle of the report submitted by the Subcommittee (Enclosure 'hleta of the Library. It oust havu the necessary modern facilities in order to provide shelving for the ever-increasing literature possessed by the Library, and to organise and service these growing collections* The present building at the corner of Seventh Street and Independence Avenue, which the Library shares with the Any Institute of Pathology, has been in- capable of housing the Library adequately for the last thirty years. In recent years the situation has become desperate with the huge increase of medical publication. Within the Library building proper, there is no room to shelve a year's accretion of books without shifting out other useable material. Since 1942 a portion of the Library has been located in Cleveland, Ohio, in leased space, because the Medical Library building In Washington had become so overcrowded that it could no longer accommodate the material* In addition, the Library occupies unsuitable space in two neighboring buildings, with continuing inefficiency and delay in service, and ever-present fire hamard. Such physical divisions of the Library reduce the efficiency and effectiveness of its operation. The present old Library building has not only through the years become inadequate in sise, but is outmoded in design and facilities* Its physical accommodations for the arrangement of books and for thsir use are antiquated; the book " stacks" are obsolete and overflowing, the building is not fireproof by modern standards; its lack of air-conditioning hastens the deterioration of the collections; baser da to the books exist from the elements end from potential failures of water lines and utilities; its mesne of communication and shipping facilities are poor; its lighting is not in accordance with modem library standards; there is no passenger elevator* Personnel are crowded into inadequate work space dispersed throughout the building, making planned work-flow unreasonably difficult* (o) It most have an adequate and competent professional staff, trained and experienced in modem library administration and library management* Sach of the several functional divisions of the Library requires well-trained professional workers in order to properly provide the medical library services which are appropriate for and expected of such an institution* In so far aa possible, personnel of the staff should be of such permanency in aasigHMOt 2 as to insure the highest practicable degree of continuity in rout tor a of policy and administration. This consideration is particularly applicable in respect to the key personnel of the library and most especially in regard to the admlnia tr a tire officers of the Library and of its principal organisational divisions. (d) It must maintain and continue a suitable collection of all literature pertaining to tT»o art and science of medicine. This should include all publica- tions in the field of medicine, and in all languages - books, serials, periodicals, reports and pamphlets. (e) In order to make the Library material readily available to the medical officers of the Armed Forces and to others who need it, it crust main- tain, index, and catalog medical publications in such a manner as is required to serve suitably and promptly the needs of clinical and medical research investi- gations. It must continue to make public the results of its bibliographical organisation and indexing through its existing Index-Catalog and Current List of Medical Literature or similar devises. (f) The Secretary of the Any has approved the introduction of enabling legislation with a ceiling of $l5, 500,000 for the construction of the new Library building and has approved the inclusion of $5,000,000 in the next budget for the acquisition of land and initiations of construction. 5* llm Comaittee unanimously recommends as follows in respect to the Axwor Medical Libraryi (a) That the name of the Library be changed to "THE ARMED FORCES MEDICAL LI3RAHI." (b) That the Secretary of Defense recognise and announce the responsibility of the "Armed Forces Medical Library" as being that of serving the Any, Havy, and Air Forcoj and also that it servo other government agencies and civilian medicine generally in so far as its facilities and capabilities mill permit* (e) That the "Armed Forces Medical Library continue to be operated under the management control of the Surgeon General of the Any. (d) That the role of the Library as an agency of the Military Establishment 1c emphasised by more aggressive action in the collection of medical publications and reports which contribute to medical intelligence} and, through its reference service, in supplying such material to the medical services of the Armed Forces. (e) That the Library function more aggressively and actively in biblio- graphical control of medical literature and reports of interest to the research and development programs of the medical services of the Armed Forces. (f) That the Library's role in the education and training programs of the medical services of the Armed Forces be maintained and accelerated. (g) That positive action be Initiated to meet the urgent requirement for 3 a new Library building. As more fully discussed in the Enclosures sub- mitted herewith, in 1938 the Congress authorized the construction of a now building to house the Library, at a coot not to exceed $3,750,000] in 1940 an appropriation of £l3O, OCX) was made for architect* s plans, which are largely cDeplete j in 1941 the Congress authorised an addi- tional $1,000,000 to include the acquisition of a suitable site and authorised the Secretary of V.ar to condemn and purchase land, subject to approval by the National Capitol lark and Planning Commission] a new site for the Library, on East Capitol Street, was tentatively approved in 19431 the current estimate of cost of an adequate Medical Library building is $17,200,000] this increase over previous estimated costs is due in part to increased building costs during the past ten years and in part to increased space requirements which have developed since the original authorisation was made. Legislative action will be required, therefore, to increase the dollar coiling authorisation for construction of a new Library building from $4,750,000 to $17,200,000 and to obtain appropriation of funds necessary to proceed v;ith the project and to initiate construction. (h) That the matter of selection of the site for the new Library building remain a responsibility of the Surgeon General of the Any work- ing in collaboration with the National Capitol Park and Flaming Coomis- sion, subject to approval of the Secretary of the Arny and the Secretary of Defense. (i) Thai the "Armed Forces Medical Libraryn be directed by a Medical officer in the Armed Faroes| further, that he be permanently assigned and appointed as Director of the Library] further, that Major Frank B. Rogers, Medical Corps, U. S. Any, now undergoing training for this position, be appointed Director at the expiration of hie training period in October 1949 (J) That an Assistant Director of the "Armed Forces Medical Library" be designated and assigned for duty at the Library; further that the Assistant Director be a Medical Officer in the Armed Forces; and further, that the position of Assistant Director be rotated among the three medical services of the Armed Forces on the basis of assignment of each such Assistant Director for a period not to exceod three years in duration. This provision will assist in creating a reservoir of medical officers in the Armed Forces having extensive knowledge of the Library and its opera- tions, and from which an appropriate successor to the permanently assigned Director can bo selected when the services of the Director have terminated for any reason. (k) That the Secretary of Defense assign to the Department of the krmy the primary budgetary and administrative rosponaibllity for the opera- tion, management and maintenance of the "Armed Forces Medical Library" in the manner necessary to insure the performance of its established functions and tne execution of its recognised mission to serve the Armed Forces as a whole* 4 6# This report covering the matter of the "Armed Medical Library" (herein recommended to bo known as the "Armed Forces Medical Library") constitutes an increment of the Committee's report to you on its overall assignment. PAUL R. HARLEY, ii. D, Chairman, Committee on Me lical and Hospital Services of the Aprned Forces RAYMOND W. BLISS Major General, VC, USA The Surgeon General CLIFFORD A. S.ANSON Rear Admiral (MC), U. S. Navy- Surgeon General MALCOIM C. GRO* Major General, MC, USA The Air Surgeon a. T* BOONS Rear Admiral (MC), U. S. Navy Executive Secretary 5 THE ARMY INSTITUTE OF PATHOLOGY Recommendations of the Committee in regard to THE ARMY INSTITUTE OF PATHOLOGY (a) That the Army Institute of Pathology he designated as the central laboratory of pathology for all of the Armed Forces. (h) That the name be changed from "Army Institute of Pathology11 to "The Armed Forces Institute of Pathology," (c) That the Institute be relocated at a site on the grounds of the Walter Reed General Hospital reservation, Washington, D. C. (d) That the Institute constitute an independent command with separate allocation of funds and personnel and that it be directly under the command of the Surgeon General of the Army. (e) That determination of the broad administrative and professional policies of the Institute be controlled by a Joint Board of Governors composed of the Surgeon General of the Army, the Surgeon General of the Navy, and the Air Surgeon. (f) That the Director of the "Armed Forces Institute of Pathology" be selected by the Joint Board of Governors from among senior officers of any of the Armed Forces Medical Services on the basis of high professional qualifications in the field of pathology and demonstrated medical administrat- ive ability. (g) That the Director of the "Armed Forces Institute of Pathology" report and be directly responsible to the Surgeon General of the Army on all administrative and professional matters in connection with the institute. (h) That financial support for operation of the "Armed Forces In- stitute of Pathology" be provided on an approximately equal basis by each of the three Armed Forces, either* (l) through annual appropriations therefor to be obtained by the Department of the Army, \flth the combined support of the Surgeons General and the Air Surgeon in the budgetary presentations and appropriation hearings before Congress, and with sub- sequent equitable reimbursements by each of the two other Services to the Department of the Army, or (2) that Joint financial support for the Institute be accomplished by contributions thereto by each Service of approximately equal amounts of funds from their own "budgets and appro- priations, in whatever manner is deemed most practicable from an administrative standpoint. (i) That the Army Medical Center provide such housekeeping, utility, and other ancillary services as may be feasible. (j) That the major fields of training to be afforded in the "Armed Forces Institute of Pathology" be in advanced pathologic anatomy, histopathology, advanced pathologic technique, advanced study of disease processes or pathological changes of particular significance in military medicine, and in research methods of importance to the subject of pathology in general. (k) That the facilities of the "Armed Forces Institute of Pathology" for advanced training in the field of pathology be utilized to the full- est possible extent by all the Armed Forces, and that officers so trained be assigned in their respective medical Services where this special trains ing may be most advantageously utilized. (1) That the prerequisite basic training in pathology and related basic sciences be provided medical department personnel of the Armed Forces on a residency level in designated hospitals of the Armed Forces or elsewhere as may be deemed feasible. (m) That the major role in research of the "Armed Forces Institute of Pathology" be in the field of pathology, including clinical correla- tion with such ancillary medical facilities as will enable it to con- tinue its investigation in the realm of experiemental pathological research (n) That the experimental facilities of the Institute be adequate and sufficiently comprehensive to permit any type of Investigation which may be important in the study of morbid anatomy and disease processes. (o) That, the "Armed Forces Institute of Pathology," with all the necessary facilities required for its special work, be a self-contained unit and that it be independent of other established laboratories which may be operated as integral parts of hospitals or which may be otherwise located in the vicinity. (p) That the present arrangement for Joint utilization of the facilities of the Army Institute of Pathology by the Veterans Administra- tion be continued in the "Armed Forces Institute of Pathology"; that this joint utilization be fostered by whatever means are deemed necessary ahd desirable to strengthen this liaison into a truly cooperative effort which will be of benefit both to the Armed Forces and to the Veterans Administration. (q) That similar cooperative efforts between the HArmed Forces Institute of Pathology" and other federal medical services, as well as with the civilian medical, dental, and veterinary professions, be authoriz- ed and encouraged, 2 OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON CGMMITTEB ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES A October 19A& Tot The Scoretary of Defense Subject* The Army Institute of Pathology Reference« (a) Memorandum from Secretary Forrestal to Dr* Paul R* Hawley, dated 1 January 1948, subjects "Committee on Medical and Hospital Services of the Armed Forces*" (b) Ltr to Secretary of Defense from the Committee on Medical and lUwital Services, subject! "Re-establishment of the Axm|h.:liis&tute of Pathology*" Enclosuret ik) (HN) Copy of reference (b) (b) (HW) Report of the Subcommittee on the Army Institute of Pathology. !• In your inatructione to the Committee ae outlined in reference (a) you indlacted your desire fort »• • • a thorough, objective and impartial study of the medical services of the Armed Forces with a view to obtaining, at the earliest possible date, the maximum degree of coordination, efficiency and economy in the operation of these services*" 2. One of the specific problems to #iich you asked the Committee to give attention was that ofs "Establishment of maximum central services of all types uhich might operate for the benefit of the whole of the medical services of the Armed Forces* One of the major facilities coming within this category Is that of the Army Institute of Pathology. 3« On 5 January 1948, by reference (b), the Committee reconnended to the Secretary of Defense the approval of the project #iich had^been sponsored by the Office of the Surgeon general of the Amy and concurred in by the Secretary of the Amy for the construction of new and more appropriate accommodations for the Amy Institute of Pathology, including its Medical Museua, and for its relocation at a place more appropriate than its present site. «*hile the Committee recommended at that time that work proceed on the preparation of preliminary architectural and engineering plans and specifications for the new building from funds appropriated and available for that specific purpose, the Committee indicated ite desire to consider further the matters of the name and location of the institute and to submit Its recommendations at a later date in connection therewith* The proposal to proceed with the development of preliminary plana and specifications for the new Institute of Pathology building was approved by the Secretary of Defense on 18 January 1948* 4* In consonance with paragraph 4of reference (a), the Committee subsequently appointed a "Subcommittee on the Amy Institute of Pathology" to assist the Committee in a farther study of the institute of Pathology as to its prospective functions and relationship to the medical services of the three Aimed Forces and in the development of suitable recommendations as to name and future location of the institute* The report of that Subcommittee is submitted herewith as Enclosure (B)• 5* The Committee has given extensive study as to the most appropriate site for the relocation of the Institute* It has taken into account the number of pertinent factors bearing on the selection of the location and site of the Institute as outlined in Enclosure 6 of the Subcommittee's report) it has also taken into consideration the availability of go/ernment-owned land suit- able for the purposes of the Institute of Pathology, and of the prospective availability of sites which would not conflict with the long-range plans of the National Capitol Park and Planning Commission* The Committee has also weighed the number of differing views and concepts which are entertained by equally competent and qualified individuals in respect to the functions and location of the Institute of Pathology. 6* After long and thoughtful evaluation of all the matters involved, and after further exploration of possible Alternative solutions, the Committee has concluded that the recommendations as submitted by the Subcommittee in itsreport constitute the most acceptable and most practicable basis for solution of the problem* 9* The Committee therefore recoin mends as follows in respect to the Army Institute of Pathology* (a) That the Amy Institute of Pathology be designated as the central laboratory of pathology for all of the Armed Forces* (b) That the name be changed from "Amy Institute of Pathology" to "The Armed Forces Institute of Pathology*" (c) That the Institute be relocated at a site on the grounds of the Walter Reed General Hosoital reservation, Washington, D* C. (d) That the institute constitute an independent command with separate allocation of funds and personnel and that it be directly under the command of the Surgeon General of the Army* (e) That determination of the broad administrative and professional policies of the institute be controlled by a Joint Board of Governors composed of the Surgeon General of the Army, the Surgeon General of the Navy, and the Air Surgeon* 2 (f ) That the Director of the "Aims 4 Forces Institute of be selected by the Joint Board of Governors free among senior officers of any of the Armed Forces Medical Services on the basis of high professional quali- fications in the field of pathology and demonstrated medical adainistrative ability. (g) That the Director of the "Armed Forces Institute of Pathology" report and be directly responsible to the Surgeon General of the Army on all adainie- trative and professional matters in connection with the institute. (h) That financial support for operation of the "Armed Forces Institute of Pathology* be provided on an approximately equal basis by each of the three Armed Forces , el then (1) through annual appropriations therefor to be obtained by the Department of the Army, with the combined support of the burgeons General and the Air Surgeon in the budgetary presentations and appropriation bearings before Congress, and with subsequent equitable reimbursements by each of the two other Services to the Department of the Army, or (2) that Joint financial support for the Institute be accomplished by contributions thereto by each Service of approximately equal amounts of funds from their own budgets and appropriations, in itiatever manner is deemed most practicable from an edelnls- trative standpoint* (i) That the UeonBibility to the Armed Forces, and to p_ssist it in arriving at conclusions and in formulating recommendptions with respect to how the specialised medical requirements of military aviation can best be served. The report of that Subcommittee is submitted herewith as En- closure (1), 3, Several aspects of the broad problem of aviation medicine touch upon other phases of the study which have been or will be covered in other separate reports; for example, in-service medical train- ing programs of the medical services, the possibility of Joint utilization of certain service schools, coordination or consolidation of training and research in specialised fields, physical and mental standards for special- ised types of duty, standardisation of medical examination forms and records, developing cossson and uniform practice and procedures, maximum utilisation of specially qualified ■•dieel personnel of the Armed Forces, and the establishment of maximum central services which might operate for the benefit of the whole of the medioal services of the Armed Forces, She recosjmendntlons of the Subcommittee as contained in its report, in such matters as the foregoing in so far as they pertain to Aviation Medicine, are not in conflict with the views or recommendations of the Comip.lttee in its consideration of these several specifio problems of the medioal services as a whole. 4, The Committee concurs in and recommends approval of the Subcommittee* s report as submitted. Specifically the Committee unanimously recommends approval and implementation of the following recommend a tlonsi (a). That the Air Fores School of Aviation Medicine and the Naval School of Aviation Medicine continue to operate as separate installations for the time being. (b). That the plan for an Aeromedical Center, introduced by repre- sentatives of the Air Pores, be approved and that further planning be tinned with a view of designing a center capable of fulfilling the needs of both servioee. (o). That the courses for training both Navy and Air Force flight nurses be consolidated, to operate under the Air Force School of Aviation Medicine at Randolph Field, Texas, (d). That the Air Force adopt the plan now utilised by the Navy which combines in to one course the training of Air Evacuation Technician, Flight Surgeon1! Assistants, and enlisted technical personnel. (e), Th.-'t all other course* being given at the two schools be cora- tioned as heretofore for the time being. (f). That the U, S, Air Force and the U, S, Navy continue to conduct research and developmental activities in aviation medicine in the installa- tions presently being used and at such others as may be required. (g). That an independent approach to their individual problem* by the aviation medicine research organizations of each service be fostered and encouraged. (h). That the mutual exchange of information and coordination in research in aviation medicine now presently being carried out be continued. (i). That the physical standards for students acceptable for flight training in the Air Force and the Navy be made identical. (j). That no standardization of psychological selection or classifi- cation tests for flying personnel be made at this time. 2 (k). That research and investigation in psychological selection procedures for flying personnel ho continued independently by tho Air Force and tha Nary, (1), That eouraaa for flight surgeons in both tha Air Foroo and tha Nary Include indoctrination in actual flying. (b). That all flight aurgaona of both tha Air Foroa and tha Nary ha required to periodically pur roe postgraduate study. (n). That a snail aunhar of flight surgeons in both sarrioas ha qualified as military ariators. (o). That for planning purposes tha following ha established as tha ideal in qualifications, schooling and aaqparianoa requirement for flight surgeons! (1), One to three yearsl experience (preferably three) as a general medical officer prior to assignment as a student in a school of ariation medicine. (2) A basic course in ariation medicine of at least six to nine months' duration. (3) Inclusion of thorough flight indoctrination in courses in ariation medicine. (4) A minimum of one year's experience while assigned to duty with an actire aeronautical organisation as an ariation medical examiner, plus the acquisition of prescribed flight indoctrination and recommendation by the immediate superior before the indiridual can be rated a flight surgeon. (p). That flight surgeons continue to be rated as flying offiosrs. (q). That studies bs mads to modify the standard form for the recording of the results of physical examinations to facilitate the recording of the findings of ths special physical examinations for flying. (r). That no standardisation be effected of ths following forms which ors utilised for the accumulation of research data! WD AAJ Form( 203 - Care of Flyer Report NavMed 439 Low Pressure Chamber Flight Log NavMed 440 Altitude Training Chit Monthly Report NavMed 589 Monthly Report of Night Vision Training (s). That the decision as to whether a particular form in use by one service should be adopted bilaterally should be left entirely to the discretion of the using service, based on the actual requirement of the respective rervioe. Similarly, reports and forms which would serve to duplicate and/or validate specific statistical data should bo left to 3 the discretion of the ueing service. (t), That there he included in all basic medical department in- struction in the Armed forces, a general indoctrination in the proper utilization, potentialities and limitations of uir evacu tion. (u). That final seleetion and nedioal supervision of air tr.ns- portatlon of patients in eonneotlon with air evacuation be the respon- sibility of the flight surgeons of the Air force and the Navy. (v). Hint necessary action be taken to develop a new standard ulr evacuation unit (light) for first echelon air evacuation. (w), Slat there be included in the basic training of all medical personnel assigned to airborne elements of the Armed Forces, a gcnerJL indoctrination concerning the physiological and psychological effects of flying as applicable to airborne operations. 5, This report on the natter of HAvlatlon Medicine1* constitutes an increment of the report to you on its over-all assignment. hnol. Paul b, haalbt, h, d. Chairman, Committee on Medical and Hoenital Services of the Armed Forcee Raymond w. bliss Major Ganoralt MC, U3A The Surgeon General CLIFFORD A. SWANSON Rear Admiral (MC), USN Surgeon General ma:xolm c, grow Major General (MC), USA lh.B idr Surgeon Hear Admiral (MC), U, S, Navy Executive secretary 4 COORDINATION OF DESIGN OF HOSPITALS AND OTHER MEDICAL FACILITIT3 OF THE ARMED FORCES Recommendations of the Committee in regard to COORDINATION OF DESIGN OF HOSPITALS AND OTHER MEDICAL FACILITIES OF THE ARMED FORCES (1) That a central '’Office of Medical Facilities Planning and Design for the Aimed Forces” be established*, (2) That the location of such an ’’Office” in Washington be selected by the Surgeon General of the Army, the Surgeon General of the Navy and the Air Surgeon acting conjointly, after determination has been made by appropriate authority as to availability of spaces suitable for such an office* (3) That the Office be jointly and approximately equally supported by the three Departments in respect to personnel and funds required for its maintenance and operation in performing its functions and responsibilities ■which are outlined in recommendation 9 below* Each Department to furnish approximately one-third of the necessary civilian employees, supplying the ceiling and funds therefor, and assigning them to duty in this joint office* Similarly, each Department to furnish approximately one-third of the military personnel necessary for the operation of the Office* (4) That the office of the Medical Facilities Planning and Design for the Armed Forces operate under the aegis of the Surgeon General of the Army, the Surgeon General of the Navy and the Air Surgeon acting conjointly at the level of the Office of the Secretary of Defense. (5) That the Surgeons General and the Air Surgeon acting conjointly exercise control over the functions and operations of the Office. (6) That, to assist the Surgeons General and the Air Surgeon in supervising the operation and functions of such an office, there be estab- lished a joint committee to be designated as the ’’Committee on Medical Facilities planning and Design for the Armed Forces.” (7) That the Committee be composed of six (6) members consisting of one representative each from the Office of the Surgeon General of the Army, the Office of the Surgeon General of the Navy, the Office of the Air Surgeon, the Office of the Chief of Engineers of the Army, the Office of the Chief of the Bureau of Yards and Docks of the Navy, and the Office of Air Installations of the Air Force; further, that all members of the Committee be qualified in knowledge of hospital construction planning and design and have had previous experience in that field* (8) That the member of the above recommended Committee who is senior in rank and date of precedence serve as chairman of the Committee and as ex- officio Director of the joint ’’Office of Medical Facilities Planning and De- sign” hereinbefore recommended in subparagraphs (1) and (5) inclusive* (9) That the Office of Medical Facilities Planning and Design for the Armed Forces, under the direct supervision of the Committee recommended in paragraphs (6), (7), and (8) above and subject to the approval and policy guidance of the Surgeons General and the Air Surgeon acting conjointly, be charged with the following principal responsibilities and functions: (a) Coordination among the three Armed Forces of plans for con- struction of hospitals and other medical facilities to provide for the require- ments of the constituent Services of the National Military Establishment in these regards, and to insure their proper integration into the combined long range plans of the three Armed Forces. (b) Coordination of the Planning for construction of all new medical facilities of the Aimed Forces with other agencies, such as the Bureau of the Budget, the Veterans Administration, the U* So Public Health Service, Congressional Committees, and other related federal and civilian agencies* (c) The determination of general standards of design, quality and finish to be followed in the construction and maintenance of all medical facilities of the Armed Forces. (d) The maintaining of a continuing program of study in methods of and advances in modern hospital and medical facilities planning, arrange- ment, construction, and installed fixed equipment, with the view to adoption and effectuation of same to the degree appropriate and practicable in the design and construction of Armed Forces medical facilities. (e) The review of sites for planned and/or proposed new hospitals and other medical facilities of the Armed Forces to determine their adequacy and suitability. (10) That the Office of Medical Facilities Planning and Design, function- ing under the direct supervision of the Committee referred to in paragraphs (6), (7), and (8) above, and under the policy direction of the Surgeons General and the Air Surgeon acting conjointly, be vested with the necessary authority 2 to insure coordination in construction planning and design and in the physical maintenance of Armed Forces hospitals and other medical facilities. Further, that for the foregoing purposes, the term "hospitals and other medical facil- ities," shall include all facilities primarily utilized in providing accommo- dations for the sick and injured, whether of permanent, semi-permanent or temporary construction, and whether fixed or mobile. Further, t hat the term "Planning and Design" shall include final cost estimates and planned final cost limitations. Further, the functions of the Office as to "Planning and design" shall not extend into the sphere of medical supplies or standard medi- cal equipment such as that listed in the joint Medical Supply Catalog of the Armed Forces and that which is normally a responsibility of the medical supply organization. Further, that the functions of the Office shall not extend to procurement, to extending invitations for bids for construction, to the let- ting of contracts for construction, or to the engineering supervision of actual construction, but that these functions shall continue to be the re- sponsibility of the construction agencies of the respective Armed Force. (11) That there be maintained in each of the three Departments a Medi- cal Facilities Planning and Design Section as a part of the Office of the Surgeon General of the Army, the Office of the Surgeon General of the Navy, and the Office of the Air Surgeon, respectively, the functions of which shall be to: (a) Carry out and monitor within the respective Departments the general policies prescribed by the joint Office of Medical Facilities Planning and Design in respect to standards to be followed in each of the Armed Forces in the planning and design of proposed hospitals and other medical facilities. (b) Exercise administrative supervision within the respective Departments over the standards of quality and finish in construction and maintenance of hospitals and other medical facilities in accordance with the standards developed and determined by the joint "Office of Medical Facilities Planning and Design." (c) Coordinate all phases of planning for hospitals and other medical facilities with other appropriate divisions within the respective Armed Force. (d) In accordance with the standards determined and established by the Office of Medical Facilities Planning and Design, exercise technical su- pervision over the planning, functional design and arrangement of all medical facilities required for the medical care and treatment of the sick and injured of the respective Armed Force. (e) Exercise authority for final approval of all plans, functional design, arrangement, and specifications for all new hospitals and other medi- cal facilities of the respective Armed Force. (f) Through the appropriate fiscal agency of and in accordance with the policy to be established by the Surgeon General of the Army, the Surgeon General of the Navy and the Air Surgeon respectively, in consonance 3 with the policy of their respective Departments, prepare the annual budget estimates for and supervise the expenditure of all funds necessary in connec- tion with the construction, repair and maintenance of all hospitals and other medical facilities of the respective Armed Force* (g) Collaborate with the Departmental real estate and construc- tion agencies and other appropriate authorities of the respective Armed Force in selecting sites suitable for the location of all hospitals and other medi- cal facilities. (h) Maintain close liaison with the corresponding Medical Facili- ties Planning and Design Section of each of the other Departments through the Office of Medical Facilities Planning and Design. (i) Review and evaluate new proposals and/or scientific develop- ments pertaining to the design, arrangement, equipment and construction of hospitals and other medical facilities with a view to submitting any recom- mendations deemed appropriate in connection therewith to the Office of Medical Facilities Planning and Design for consideration as to adoption for use by the Armed Forces. (j) Inspect and otherwise maintain current information as appro- priate in respect to the progress of new construction projects and in regard to maintenance of the existing hospitals and other medical facilities of the respective Aimed Force; further, -that the Office of the Surgeon General of the Army, the Office of the Surgeon General of the Navy, and the Office of the Air Surgeon, through -their respective Medical Facilities Planning and Design Sections be specifically authorized to initiate any corrective action indi- cated as a result of the foregoing. (k) Select and train personnel for qualifications in the work of the Medical Facilities Planning and Design Section, particularly as it affects and pertains to the respective Armed Force. 4 OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON COMMITTEE OH MEDICAL AND HOSPITAL SERVICES OF THE AHMED FORCES 3 November 1948 To: The Secretary of Defense Subject: Coordination of Design of Hospitals and other Medical Facili- ties of the Armed Forces, Reference: (a) Memorandum from Secretary Torrestal to Doctor Pe*ul R, Hawley, dated 1 January 1948, subject: "Committee on Medical and Hospital Services of the Armed Forces*■ Enclosure: (l) (HW) Report of Subcommittee on Design of Hospitals* 1* In the memorandum referred to above you asked that among other matters, the Committee devote attention to "Development, to the highest practical degree, of common standards, practices and procedures among the medical services of the Armed Forces*" Tou also asked specifically that among other matters the Committee give at- tention to "Coordination of the current plans of the medical services of the Armed Forces for the construction of any new hospital facilities in the future, * * * and also the possibility of developing Joint criteria for the Design of Hospitals*" 2* In accordance with paragraph 2(h) of your memorandum, a Subcommittee on "Design of Hospitals* was appointed to assist the Committee in a thorough study of the subject with the view of ascertaining and reporting as to the advisability of coordination of plans and the adoption of common criteria for designing hospitals and other medical facilities of the Armed Forces, and to assist the Committee in formulating appropriate recommendations in connection therewith* 3* The report of the Subcommittee on Design of Hospitals is submitted herewith as Enclosure (l). In view of the fact that hospital design and construction planning is a continuing function in the Armed Forces, and one that necessitates frequent changes in consonance with the progressive advancements in modern hos- pital design and construction and in their adaptation to best meet the needs of the Armed Forces, and inasmuch as close coordination among the three Armed forces will continue to ‘be required in the proper performance of this function, the Committee unanimously concurs in the report submitted herewith as *in- closure (1) and recommends its approval in principle* The Committee reconw- mends approval of the recommendations set forth in the following paragraph in reepect to the subject. 4* The Committee unanimously recommends as follows: (l) That a central "Office of Medical facilities Planning and Design for the Armed forces" be established* (2) That the location of such an "Office" in Washington be selected by the Surgeon General of the Army, the Surgeon General of the Havy and the Air Sur- geon acting conjointly, after determination has been made by appropriate authority as to availability of spaces suitable for such an office. (3) That the Office be Jointly and approximately equally supported by the three Departments in respect to personnel and funds required for its mainte- nance and operation in performing its functions and responsibilities which are outlined in recommendation 9 below* lach Department to furnish approximately one-third of the necessary civilian employees, supplying the celling and funds therefor, and assigning them to duty in this Joint office* Similarly, each Department to furnish approximately one-third of the military personnel neces- sary for the operation of the Office. (4) That the office of Medical Facilities Planning and Design for the Armed Forces operate under the aegis of the Surgeon General of the Army, the Surgeon General of the Kavy and the Air Surgeon acting conjointly at the level of the Office of the Secretary of Defense* (5) That the Surgeons General and the Air Surgeon acting conjointly exer- cise control over the functions and operations of the Office. (6) That, to assist the Surgeons General and the Air Surgeon in supervis- ing the operation and functions of such an office, there be established a Joint committee to be designated as the "Committee on Medical Facilities Plan- ning and Design for the Armed Forces*" (7) That the Committee be composed of six (6) Members consisting of one representative each from the Office of the Surgeon General of the Army, the Office of the Surgeon General ef the Havy, the Office of the Air Surgeon, the Office of the Chief of Snglneers of the Arsy, the Office of the Chief of the Bureau of Tarda and Docks of the lavy, and the Office of Air Installations of the Air force; further, that all ambers ef the Committee be qualified in knowledge of hospital construction planning and design and hare had previous experience In that field* (8) That the member pf the above recommended Committee who is senior in rank and date c£ precedence serve as chairman of the Committee and as e*> officio Director of the Joint "Office of Medical Facilities Planning and De- sign" hereinbefore recommended in subparagraphs (1) to (6) inclusive* (9) That the Office of Medical facilities Planning and Design for the Armed forces, under the direct supervision of the Comnittee recommended in paragraphs (6), (7), and (8) above and subject to the approval and policy guidance of the Surgeons General and the Air Surgeon acting conjointly, be charged with the following principal responsibilities and functions* (a) Coordination among the three Armed forces of plans for con- struction ef hospitals and other nodical facilities to provide for the require- ments of the constituent Services of the National Military Istabllshnent In these regards, and to Insure their proper Integration into the combined long range plans of the three Armed forces. (b) Coordination of the Planning for construction of all new medi- cal facilities ef the Armed forces with other agencies, such as the Bureau of the Budget, the Veterans Administration, the U, S. Public Health Service, Congressional Committees, and other related federal and civilian agencies. (c) The determination of general standards of design, quality and finish to be followed in the construction and maintenance of all medical facilities of the Armed forces. (d) The maintaining of a continuing program of study in methods ef and advances in modern hospital and medical facilities planning, arrange- ment, construction, and installed fixed equipment, with the view to adoption and effectuation of same to the degree appropriate And practicable in the de- sign and construction of Armed forces medical facilities. (e) The review ef sites for planned and/or proposed new hospitals and other medical facilities of the Armed forces to determine their ade- quacy and suitability. (10) Chat the Of flea of Medical facilities Planning and Design, function- ing under the direct supervision of the Committee referred to la paragraphs (6), (7) and (8) above, and under the policy direction of the Surgeons General and the Air Surgeon acting conjointly, be vested with the necessary authority to Insure coordination In construction planning and design and la the physical Maintenance ef Arsed Pereas hospitals and other nodical facilities* further, that for the foregoing purposes, the tern ihospltals and other nodical facil- ities,* shall Include all facilities primarily utilised In providing aoeemme- datlons for the sick and Injured, whether ef pernanent, senl-pernanent or temporary construction, and whether fixed er nob lie. further, that the tern "Planning and Design" shall Include final cost estimates and planned final cost limitations, further, the functions of the Office as te "planning and design” shall not extend late the sphere of nodical supplies er standard medi- cal equipment such as that listed in the joint Medical Supply Catalog of the Amed forces and that which Is nornally a responsibility of the nodical supply organisation, further, that the functions of the Office shall not extend to procurement, te extending Invitations for bids for construction, to the let- ting of contracts for construction, or to the engineering supervision of actual construction, but that these functions shall continue to be the re- sponsibility ef the construction agencies of the respective Armed force. (ll) That there be maintained in each of the three Departments a Medi- cal Facilities Planning and Design Section as a part of the Office of the Surgeon General of the Amy, the Office of the Surgeon General of the Havy, and the Office of the Air Surgeon, respectively, the functions of which shall be to: (a) Carry out and monitor within the respective Departments the general policies prescribed by the joint Office of Medical facilities Planning and Design in respect to atandards to be followed in each of the Arsed Forces in the planning and design of proposed hospitals and other medical facilities. (b) Xxercise administrative supervision within the respective Departments over the standards of quality and finish in construction and maintenance of hospitals and other medical facilities in accordance with the standards developed and determined by the joint of Medical Facilities Planning and Design*" (c) Coordinate all phases of planning for hospitals and other medical facilities with other appropriate divisions within the respective Armed Force. (d) In accordance with the standards determined and established by the Office of Medical Facilities Planning and Design, exercise technical su- pervision over the planning, functional design and arrangement of all medical facilities required for the medical care and treatment of the sick and injured of the respective Armed Fores. (s) Xxercise authority for final approval of all plans, functional design, arrangement, and specifications for all new hospitals and other medi- cal facilities of the respective Arsed Force. (f) Through the appropriate fiscal agency of and in accordance with the policy to be established by the Surgeon General of the Army, the Surgeon General of the Xavy and the Air Surgeon respectively, in consonance with the policy of their respective Departments, prepare the budget estimates for and supervise the expenditure of all funds necessary in connec- tion with the construction, repair and maintenance of all hospitals and other medical facilities of the respective Armed Force. (g) Collaborate with the Departmental real estate and construc- tion agencies and other appropriate authorities of the respective Armed Feres in selecting sites suitable for the location of all hospitals and other medi- cal facilities. (h) Maintain close liaison with the corresponding Medical Facili- ties Planning and Design Section of each of the other Departments through the Office of Medical Facilities Planning and Design. (i) Hevlew and evaluate new proposals and/or scientific develop- ments pertaining to the design, arrangement, equipment and construction of hospitals and other nedlcal facilities with a tlew to submitting any recom- mendations deemed appropriate in connection therewith to the Office of Medical facilities Planning and Design for consideration as to adoption for use by the Armed forces* (J) Inspect and otherwise maintain current Information as appro- priate in respect to the progress of new construction projects and in regard to maintenance of the existing hospitals and other medical facilities of the respectire Armed force; further, that the Office of the Surgeon General of the Army, the Office of the Surgeon General of the Vary, and the Office of the Air Surgeon, through their respect ire Nedlcal facilities Planning and Design Sections be specifically authorised to initiate any correct ire action indi- cated as a result of the foregoing* (k) Seleot and train personnel for qualifications in the work of the Medical facilities Planning and-Besign Section, particularly as it affects and pertains to the respect Its Armed force. PAUL H, HAWLIT, M. D, Chairman, Committee on Medical and Hospital Berrices of the Armed Heroes BJLTMOHD V. BLISS Major General, KC, USA The Surgeon General GLIffOBD A, SWAHSOH Hear Admiral (MO), U. 8, lory Surgeon General MALCOLM 0. QBOV Major General. M0V USA Che Air Surgeon j. c. soon Hear Admiral (MO), U. 8. Xstj Bzeoutire Secretary STANDARDIZATION OF MEDICAL FORMS, RECORDING AND REPORTING PROCEDURES WITHIN THE ARMED FORCES Recommendations of the Committee in regard to STANDARDIZATION OF MEDICAL FORMS, RECORDING AND REPORTING PROCEDURES WITHIN THE ARMED FORCES (a) That as rapidly as possible there ultimately be established within the Armed Forces the maximum standardization in medical recording and re- porting procedures consistent with the inherent differences which exist in the basic missions and responsibilities of the respective Departments. (b) That, pending achievement of maximum uniformity, there be devised a satisfactory cross-reporting procedure which will facilitate the extension of cross-hospitalization and Joint utilization of medical facilities within the Aimed Forces. (c) That the Armed Forces adopt appropriate unifom terminology and definitions for all, or as many as possible, of the most frequently used and generally applicable concepts of medical reporting and medical statistics. (d) That the Aimed Forces establish the highest possible degree of uniformity of items and content of the medical forms used in service-wide re- porting systems, in order to attain as much direct comparability of statistical data as is compatible with the essential differences in mission. (e) That a standard form or report be developed and adopted for use in all cases where separate but similar medical foms or reports serving a common purpose exist in the Aimed Forces. (f) That in all cases where only minor differences exist in the contents of separate forms or reports which are used, or in the administrative procedures governing their use, that every effort be made to compose such differences and devise a standard form or report or administrative procedure which will be acceptable to all the Aimed Forces. (g) That standardization not be attempted in those instances where a form or report either serves a function which is peculiar to one Service or differs from the apparently comparable fom or report of the other Services because of a real difference in the need or function served. (h) That where medical forms or reports have been continued in effect beyond the period during which the need or function served Justifies their continued use, action be taken by each of the Armed Forces to eliminat< from current lists; to rescind pertinent directives, if any, prescribi. their use; to salvage current stocks; and to discontinue their mainten in publication depots* (i) That there be established an inter-departmental continuing **( on Standardization of Medical reporting Procedures, Records, and Medic ■within the Armed Forces,” whose broad missions shall be the accomplish] the foregoing specific objectives and the eventual attainment and main maxzbnum standardization on all matters pertaining to medical recording reporting* 2 OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON METTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARJED FORCES TOs The Secretary of Defense SUBJECT* Standardization of Medical Forms, Recording and Reporting Procedures within the Armed Forces REFERENCE* (a) Memorandum from Secretary of Defense Forrestal to Dr* Paul R# iiawley, dated 1 Januaiy 19A8, subjects "Committee on Medical and Hospital Services of the Armed Forces*•• ENCLOSURE: (1) Report of Subcommittee on Medical Forms, Recording and Reporting Procedures 1* In the memorandum terms of reference given by you to this Committee under date of 1 January 19A8 (reference (a)), you requested that among other matters, the Committee direct its deliberations to the problem ofs "Improvement and standardization of medical records*" It is at once recognized that this problem includes the inseparable matters of medical forms, recording and reporting procedures employed in and among the three Services* 2* In order to fulfil properly their mission of maintaining the health of the Military Establishment at the highest possible level, the medical services of the Armed Forces must obtain and disseminate statistical health data to all echelons of command* The effective implementaion of plans and programs for the prevention of disease, hospitalization of personnel, medical support of combat operations, research on medical problems peculiar to or of especial significance to the Aimed Forces, and the procurement and distribution of medical personnel and supplies, is dependent to a great extent uoon the information gained through the Armed Forces' use of efficient recording and reporting systems* 3* An important additional function served by medical records, forms, record- ing and reporting procedures is that of providing and preserving as a matter of permanent record all available information as to the physical condition, ill- nesses and injuries of all individuals viho are or who have been members of the Armed Forces* Adequate and usable data of this nature are essential in pro- tecting the interests of both the government and the individual in connection with future claims or benefits to which the individual may by law be entitled* 4,. Over many decades the several departments have developed recording and reporting systems adequate for their own needs and consonant with their own administrative practices and procedures* In a unified National Military Es- tablishment, it is essential that these recording and reporting systems be sufficiently coordinated to insure that any differences are justified by corresponding differences in basic missions or needs. While the full accom- plishment of such coordination is a long-range project, it is considered that Immediate steps should be taken to insure that all future changes contribute to the attainment of this objective. 5* In accordance with paragraph 2 h of reference (a), a "Subcommittee on Medical Forms, Recording and Reporting Procedures'1 was appointed to assist the Committee in a thorough, objective and impartial study and evaluation of the subject.and in formulating pertinent recommendations with respect to this problem. Attached hereto as Enclosure (1) is a copy of the report of the Subcommittee embodying its conclusions and recommendationso 6. After careful study of this report, the Committee unanimously supports and concurs in the findings of the Subcommittee and iterates the following tions: (a) That as rapidly as possible there ultimately be established within the Armed Forces the maximum standardization in medical recording and reporting procedures consistent with the inherent differences which exist in the basic missions and responsibilities of the re- spective Departments. (b) That, pending achievement of maximum uniformity, there be devised a satisfactory cross-reporting procedure which will facilitate the extension of cross-hospitalization and joint utilization of medical facilities within the Armed Forces. (c) That the Armed Forces adopt appropriate unifoim terminology and definitions for all, or as many as possible, of the most frequently used and generally applicable concepts of medical reporting and medical statistics. (d) That the Aimed Forces establish the highest possible degree of uniformity of items and content of the medical forms used in service- wide reporting systems, in order to attain as much direct comparability of statistical data as is compatible with the essential differences in mission. (e) That a standard form or report be developed and adooted for use in all cases where separate but similar medical forms or reports serving a common purpose exist in the Aimed Forces. (f) That in all cases where only minor differences exist in the contents of separate forms or reports which are used, or in the administrative procedures governing their use, that every effort be made to comoose such differences and devise a standard form or report or administra- tive procedure which will be acceptable to all the Armed Forces. 2 (g) That standardization not be attempted in those instances where a form or report either serves a function which is peculiar to one Service or differs from the apparently comparable form or report of the other Services because of a real difference in the need or function served* (h) That where medical forms or reports have been continued in effect beyond the period during which the need or function served Justifies their continued use, action be taken by each of the Armed Forces to eliminate them froracurrent lists; to rescind pertinent directives, if any, prescribing their use; to salvage current stocks; and to discontinue their maintenance in publication depots* (i) That there be established an inter-departmental continuing "Committee on Standardization of Medical Reporting Procedures, Records, and Medj.fi£l Forms within the Aimed Forces," whose broad missions shall be/accomplishment of the foregoing specific objectives and the eventual attainment and maintenance of maximum standardization on all matters pertaining to medical recording and reporting* 7» It is further recommended that the Committee referred to in paragraph 6(i) above be composed of one or more representatives each from the offices of the Surgeons General of the Array and Navy, and the Air Surgeon, and that it include chiefs of the divisions of the three Services which are responsible for medical statistics or biometrics function* It is also recommended that this Committee be established at the level of the Office of the Secretary of Defense; further, that it function under the supervision and direction of the Surgeons General of the Army and Navy and the Air Surgeon acting conjointly as a Medical Co- ordinating Board for the Secretary of Defense. 8* It is contemplated that this Cominittee would, when considering the actual revision and redesigning of forms, take into account and be guided by all rules regarding style, format and typography which may have been established by the recently-created Forms Standardization Board;; it is further contemolated that the Committee would subnit the final drafts of revised and re-designed forms to that board for printing and promulgati n* It is not considered,however, that this Committee should operate under or as a part of the Forms Standardization Board, since responsibility for determination of medical and professional con- tent of forms and reports, and the development of appropriate systems of medical recording and reporting will be of even greater importance than the matter of the physical layout or format to be followed in designing such forms* 9* Heretofore, cooperation and coordination in this field among the .edical Services of the Armed Forces have been largely of an informal and voluntary nature, without authoritative direction* By implementing the recommendations contained in this report, authoritative direction will be assured; thus will greeter impetus begiven to such efforts; their effectiveness will be increased, and attainment of the desired objectives will be greatly accelerated* 10* Implementation of the recommendations contained herein requires no legis- lative or executive action, but can be accomplished by an administrative order or directive from the Secretary of Defense* The Committee believes that the 3 recommendations are non-controversial in nature and will result in no encroach- ment on the prerogatives of any authority within the Armed Forces or other government agency* The program proposed herein is considered to be In accord with sound military and medical principles* 11* As discussed more fully in the Subcommittee's report (Enclosure (1)), 165 medical forms now used by the Army, Navy, and Air Force have been considered with the view of determining where possible consolidation, standardization or elimina- tion may be effected* Present considerations indicate that of this number, 110 of the present medical forms are amenable to standardization and can be replaced by 64 forms when so standardized; of this latter number, 25 forms or appear capable of immediate revision and standardization for common use* Three forms are recommended for elimination since their need or function no longer exists or will be served by other recommended changes in forms* The remaining 52 forms constitute those peculiar to and required by the individual Service and those requiring further extended study to determine their amenability to some degree of standardization* 12* The Committee again desires to emphasize the great importance attached to this fundamental problem of medical forms and medical reporting and recording procedures in its relation to the whole matter of achieving more satisfactory common, joint, or cross utilization of medical facilities, medical services and medical personnel in tthe Armed Forces* The Committee urges that intensive efforts be exerted without interruption toward achieving all practicable standardization of medical records, forms, reporting and recording procedures* It is the belief of the Committee that the major portion of such standardization can be attained within a period of two years if the necessary administrative and secretarial staff cna be provided to assist the continuing Committee recommended in paragraph 6(i) above* 13* '■‘•'his special interim report, covering the matter of the "Standardization of Medical Forms, Recording and Reporting Procedures witnin the Armed Forces" con- stitutes an increment of the Committee's report to you on its over-all assignment* PAUL R. HAWLEY, M. D. Chairman, Committee on Medical and Hospital Services of the Armed Forces RAYMOND W. BLISS Major General, MG, USA The Surgeon General CLIFFORD A. SWAIBON Rear Admiral (IIG), U* S* Navy Surgeon General J, T# BOONE Rear Adniral (MC), U# S* Navy- Executive Secretary MALCOLM C. GROW Magjor General, USA The Air Surgeon 4 PROGRAMS FOR HOSPITALIZATION IN THE ARMED FORCES AND FOR IMPROVEMENT IN THE UTILIZATION OF EXISTING HOSPITAL FACILITIES Recommendations of the Committee in regard to PROGRAMS FOR HOSPITALIZATION IN THE ARMED FORCES AND FOR IMPROVEMENT IN THE UTILIZATION OF EXISTING HOSPITAL FACILITIES (1) In the earnest desire and zealous effort to effect greater economy, the programs for hospitalization in the Armed Forces not be so divorced from fundamental military considerations as to abnegate or abrogate the basic principles which have proven sound in the crucible of time and long experience* (2) In consonance with the above recommendation, the programs for hospitalization in the Armed Forces be of such a nature at all times as will insures (a) That the present standard of hospital treatment and medical care now afforded all personnel of the Armed Forces is maintained® (b) That full medical support, including hospitaliza- tion, will be readily available and reasonably accessible for each and every military unit of the Armed Forces* (c) That these programs for hospitalization in the Aimed Forces be ever such as will contribute to and assist in the accomplishnent of the primary purposes and missions of the medical departments 37 of the Armed Forces as enumerated In paragraph 3, page 3 of this report* (d) That the organization, administration and operation of the hospital programs and services of the Armed Forces are in conformity with and workable under the existing organizational structure of the National Military Establishment* (e) That the most efficient utilization is made of the limited supply of medical personnel* (f) That they contribute to the greatest possible conservation of manpower and funds for the Armed Forces as a whole, through minimizing patient transportation costs and by reducing the average time during which patients are absent from their normal military assign- ments by reason of being on the sick list* (g) That a minimum reserve capacity be retained in the Armed Forces1 hospitals (represented by the excess of constructed bed capacities over present capacities now being used in existing hospitals as "authorized operat- ing capacities") sufficient to meet the initial increased hospitalization requirements which will arise as an immediate necessity should sudden armed conflict, rapid expansion of the Armed Forces, or military mobilization occur* 38 (3) Provision continue to be made in hospitals of the Aimed Forces for all military patients requiring hospitalization. (A) Civilian and non-military hospitals continue to be utilized in those instances of an emergency nature •where members of the military forces become ill or injured while on leave, in transit, or are on detached. Independent, or isolated duty at £ location where no military hospital is readily available, and in those exceptional cases when, by reason of the very special or unusual nature of the patient's disease or condition, suitable treatment and care can be more appropriately provided in some selected non-military medical facility. (5) That the full responsibility for providing all hospitaliza- tion and medical care for all Services in certain specialized fields of medicine not be allocated exclusively to any one Service, but that jointly staffed Specialized Diagnostic and Treatment Centers for patients in certain special fields of medicine from all three Services be designated or established in connection with and as a part of selected Azny General Hospitals and U* S. Naval Hospitals as may from time to time be feasible and appropriate* (6) In consonance irith the foregoing recommendation and as the Initial undertaking of that nature, the U* S* Naval Hospital, Houston, Texas, in addition to its continued use as a hospital for general medical and surgical patients, be designated as a Specialized Diagnostic and Treatment Center for Psychotic and Neuropsychiatric Patients from all three of the Aimed Forces, such Center to be jointly staffed by 39 medical department personnel from each Service in relative proportion to the number of such patients being treated therein from each Service* *(See footnote) (7) Wherever and whenever medical facilities are utilised jointly or in common for regularly providing medical services and hospitalization (in-patient treatment and care) for personnel from two or more of the Armed Forces, the following be agreed upon and confirmed by the three Departments: (a) That appropriate medical department liaison and clerical personnel be detailed from the Department or command -whose patients are being provided treat- ment and care in or by the medical facility of another Department, for duty in or at such medical activity of the other Service* (b) That no Interdepartmental reimbursement or transfer of funds shall be expected of or made by one De- pertinent or Service to another for medical atten- tion rendered to personnel of another Service, ex- cept for actual hospitalization (in-patient treatment and care) of ’Hilary personnel of another Service, ♦(Footnote)* Subsequent to the Committee's study of this problem and its unanimous agreement on the recommendations relative to the Aimed Forces? common utilization of the U* S* Naval Hospital, Houston, Texas, the President has by Executive Order directed that this hospital be transferred to the Veterans Administration for the latter's ownership, use, and operation* 40 in which latter case interdepartmental reimburse- ment shall continue to be made at the per diem interdepartmental hospitalization rate which is established annually by the Bureau of the Budget as long as the present requirement exists for such reimbursement to be made between Departments of the Military Establishment* (c) That, for purposes of joint staffing, medical depart- ment personnel - officers, nurses and enlisted - of one Service will be assigned to and detailed for duty in the hospital of a sister Service where such hospital is being regularly utilized for common or joint hospitali- zation* Such assignment shall be Inaugurated and effected on the equitable basis of assigning and detailing medical department personnel of each Service to each such jointly utilized hospital in the same approximate proportion as the number of patients in that hospital from each Service bears to the total combined patient-load in that hospital* (d) That command of and Departmental administrative responsibility for hospitals utilized in common for joint hospitalization of patients from two or more of the Armed Forces shall remain with the owning Department or Service# 41 (8) As a general policy of the National Military Establishment, to be followed wherever practical considerations permit adherence to such a policy, individual hospitals of the Armed Forces for treatment and care of general medical and surgical patients not be operated, or permanently constructed for such operation, at a normal capacity ex- ceeding 1500 beds; and further, that 1000 beds be accepted as the optimum normal bed-capacity of such hospitals in so far as may be practicable in meeting the needs of the Armed Forces. (9) That the plans for future construction of any new hospital facilities in any Department of the Aimed Forces be fully coordinated among the three Departments to insure that, in accordance with the objectives, principles and limitations indicated in this report, any such newly planned hospital will be of such size and location as will best serve the combined hospitalization needs of all three Aimed Forces. (10) Army General Hospitals of a permanent nature located in territories or possessions of the United States be designated as and placed in the category of Amy Class II Installations under the command and control of the Surgeon General of the Amy in a similar manner and to the same extent as now obtains in the case of Amy General Hospitals in the continental United States (Zone of Interior). (11) Wherever station hospitals and/or dispensaries are operated at or primarily in connection with Army, Navy, or Air Force posts, canps, stations or bases and for the principal purpose of providing station hospital type or dispensary level of medical services and 42 hospitalization (in-patient treatment and care) for a particular post, camp, station or base, that such station hospitals and/or dispensaries be operated and administered as activities of the same Service and of the same administrative command as that of the particular post, camp, station or base where they are located and for whose medical support they predominantly function# (12) Within the limitations of existing physical facilities and where administratively and operationally feasible, and where not precluded by other governing considerations, hospitalization (in- patient treatment and care) of patients from two or more separate but nearby military activities or installations, and of whatever Service, be consolidated in one of the two or more hospitals or dispensaries of the Aimed Forces which are readily accessible in the same local vicinity# (13) Where evacuation or transfer of patients to another locality is necessary or indicated for appropriate hospitalization (in- patient treatment and care) at a more suitably staffed and more specially equipped General or Naval Hospital, the evacuation or transfer of such patients be made to a suitable hospital of another of the Aimed Forces if such hospital has facilities available to accommodate these patients and if it is more readily accessible than a much more distantly located hospital of the same Service from “which the patients originate* 43 (LO A continuing study be conducted for the puipose of developing and attaining the highest practicable degree of uniformity in the organization, administration and operation of all hospitals of the Armed Forces. (15) The greater standardization of medical forms and reporting procedures among the three Services be expedited in order to lessen the administrative difficulties attending joint hospitalization and to simplify the problems involved in common utilization of medical facilities. (16) In order to continue central planning in the field of this report, and to insure that constant study and the necessary con- tinuous review of the problem is maintained, a continuing interdepart- mental Committee on Programs for Hospitalization and Utilization of Hospital Facilities in the Armed Forces be formed; that such a Committee be composed of three members, to consist of one representative each from the Offices of the Surgeon General of the Amy, the Surgeon General of the Navy and the Air Surgeon, with the member senior in grade also acting as chairman; and that such Committee work under the direction of and be responsible to the Surgeons General and the Air Surgeon acting conjointly at the level of the Office of the Secretary of Defense* 44 49 isse Hecommendatiohs of the Committee in regard to IMPROVEMENT AND STANDARDIZATION OF COST ACCOUNTING SYSTEMS AND APPROPRIATION ACCOUNTING OF THE MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES A* Cost Accounting Procedures 1* That all Army named General Hospitals, all naval hospitals and selected Amy and Air Force Station Hospitals be required to operate a cost accounting system as hereinafter prescribed* 2* That each reporting hospital maintain books of account conforming insofar as practicable to those prescribed in standard commercial practice, and including the following; (a) General Ledger (b) General Journal (c) Expense Distribution Register (d) Plant and Equipment Ledgers (e) Stores Ledger (f) Such subsidiary records as may be required to furnish complete operating cost data* These books are described in Tabulation A* 3* That the General Ledger provide for the Chart of Accounts shown in Tabulation A* A* That the values of assets to be recorded in the general ledgers at those hospitals not now maintaining cost systems be obtained from current records or realistic appraisals* 1 5. That the accounts in the Expense Distribution Register provide for an analysis of expense that will meet the requirements of the Bureau of the Budget as expressed in its "Instructions for Preparation of Statistical Reporting Forms for Federal Hospitals/' and further provide an analysis which will enable management to evaluate cost of operation by operating departments. The analysis should break operating cost down by those elements of cost and activity functions which may be required by The Surgeons General in order to accomplish the objectives stated above. 6, That all technical equipment and supplies in the custody of the Technical Service Supply Officer at Army, Navy and Air Force hospitals operating under this system be carried on his records at a proper money value. 7. That expenditures from non-appropriated funds which are made for the benefit of hospitals be excluded from the cost of operation, with the one exception of the Army Hospital Fund. 8, That hospital cost reports, together witty a recapitulation of ledger account balances, be submitted quarterly to the Fiscal Director of the Medical Department of each service. 9. That the Fiscal Director of the Medical Department of each service be responsible for auditing and analyzing hospital cost reports to the end that administrative action may be taken to correct un- satisfactory operations. 2 B. Appropriation Accounting Procedures 1. That the Secretaries of each Service assign to the respective Surgeons General responsibility for administration of funds appropriated for the Medical Departments. 2. That the Fiscal Director of each Medical Department, as representative of the Surgeon General, be responsible for fiscal administration and the performance of all accounting and auditing functions per- taining to the appropriations administered by the Medical Depart- ments . 3. That the .Fiscal Director of each Medical Department grant allotments of Medical Department funds to individual activities as required to carry out budgetary programs. Allotments granted will bo limited to budget programs. Those activities engaged in two or more budget programs will be granted two or more allotments as required. 4. That all documents pertaining to the granting of allotments of Medical Department funds and the incurring of obligations against such allotments be referred to the Fiscal Director for approval to determine that they are within the scope of monetary limitations and for any other aption that may be within the scope of his duties as defined by the Surgeon General of each Service, 5. That all allotments to individual installations be issued to commanding officers, who are responsible for fiscal administration and for performance of all accounting and internal auditing functions at the installation. However, the financial records of all Medical 3 Department allotments should be kept by Medical Department personnel including those of installations not under the command of the Surgeon General of the Army, the Air Surgeon or the management control of the Surgeon General of the Navy, Allotment and accounting reports Kirill be submitted to the respective Medical Department Fiscal Directors through the commanding officer of the installation and subject to his approval. 6, That allotments granted field installations be divided into quarterly apportionments corresponding to the quarterly apportionments assigned the respective Medical Departments under the provisions of Budget- Treasury Regulation No. 1 (Revised). 7# That Medical Department installations be authorized to carry forward unexpended balances of quarterly allotments to succeeding quarters of the fiscal year. Whenever it appears that the full allotted funds will not be required, the cognizant Fiscal Director may withdraw the amount in excess. The determination that funds are in excess shall be made by the cognizant Fiscal Director acting upon*the information contained in field allotment reports. The cognizant Fiscal Director shall also have the authority to increase or decrease an allotment at aay time to conform to Medioal Depart- ment programs. 8. That the 3cope of an allotment granted a field installation be limited to the budget program under which it was granted. No transfers of funds between programs should be peknitted, except upon 4 specific authority of the cognizant Fiscal Director. 9. That the Fiscal Director of each Medical Department administer each Medical Department appropriation by maintaining appropriate program ledgers. Reports of obligations and expenditures incurred against appropriated funds shall be submitted to the budget offices of the, respective Services for inclusion in the over-all reports of appropriations which are administered at department level* This report shall conform to the methods currently employed for this function. 10. That activities or installations holding Medical Department allot- ments submit the following monthly reports for each program allot- ment held: (a) A status of allotment report* This report shall be prepared at the close of each month to show in summary form allotment transactions for the month and for the fiscal year to date as well as the current status of the allotment. (b ) An allotment report for management. This report shall provide the cognizant Fiscal Director with accounting details for management purposes. Expenditures shall be summarized on this report by the major object classes prescribed in Budget-Treasury Regulation No* 1 (Revised)* 11, Upon implementation of this plan, suitable blank forms will be provided which will meet the requirements of each of the three Services* It is recommended that these forms be similar to those 5 now in use by the Navy, with some slight modifications as required to fit the needs of all three services. Plan of Implementation 1, That existing directives, memoranda, orders and circular letters be amended to extend the cost accounting system to all Medical Department • installations designated in Recommendation 1, Section V, and to provide the recommended system of appropriation and allotment control accounting to all installations engaged in programs supported by Medical Department funds • 2, That steps be taken to secure authorization for the necessary accounting personnel to perform the additional cost accounting which is recommended. 3. That the necessary accounting instructions covering both cost and appropriation accounting be issued in standard manual form to all Medical Department activities. U. That this accounting manual be a joint publication of the Army, Navy and Air Force Medical Departments, to be written as a joint undertaking of Medical Department accounting personnel of the three Medical Departments, 5* That a program of training in the revised Medical Department accounting procedures be instituted in order to cbtain competent personnel, Facilities for such training of fiscal or accounting officers are available now in existing - 6 - Army and Navy Schools of Hospital Administration* The training of the civilian and enlisted accounting personnel required for this work can be conducted on the job by finance and accounting officers,. Administrative, Executive or Legislative Measures Required 1. Administrative action in the form of official directives to put into effect the recommendations made in Section V in accordance with the plan outlined in Section VI. 2* No legislative measures are considered necessary to the implementation- of these recommendations. 7 TABLE A BOOKS OF ACCOUNT A* General Ledger, The General Ledger is a master or control ledger in which is recorded the debit and credit effect of all receipts and expendi- tures of property and services* Postings to the General Ledger shall be made only from the General Journal* CHART OF ACCOUNTS Assets Current Assets Fixed Assets etc* Liabilities Current Liabilities eto# Capital Account (net worth) The accounts in the General Ledger will be grouped under the conventional headings as outlined in the Chart of Accountsf The detail of the General Ledger accounts will be determined in accordance with Section VI, paragraph 4* B* General Journal* The General Journal is the book of original entry in which is recorded either in detail or summary form the debit and credit effect of financial transactions. Each entry must consist of debit and credit items which in total equal each other, and each entry must be supported by a concise explanation adequate to identify the transaction. Postings to General Ledger accounts shall be made only from the General Journal, - 8 - C. Expense Distribution Register. The Expense Distribution Register is a ledger which provides analysis of the General Ledger control accounts for expenses, as may be determined in accordance with Section VI, paragraph iu D. Plant and Equipment Ledgers. Such Plant and Equipment Ledgers shall ’be provided as may be determined in accordance with Section VI, paragraph iu E. Stores Ledger. A Stores Ledger shall be maintained in which is recorded complete accounting data on each item of supplies received. Separate ledger sheets shall be maintained for each item of supply, and the data to be recorded on each item shall include nomenclature, description, date of acquisition, source from which received, acquisition cost, date and nature of disposition, and quantities remaining on hand by number and value. The total of all items carried on hand must agree with the net debit balance of General Ledger account "Stores," - 9 - TAB A A.a nuo ARY OF DEFENSE COMMITTEE OH MIDI GAL AND HOSPITAL SERVICES OT THE ARMED FORCES WASHINGTON ! 4 APR 1949 TO: The Secretary of Defense SUBJECT: Improvement and Standardization of Cost Accounting Systems and Appropriation Accounting of the Medical and Hospital Services of the Armed Forces. REFERENCE: (a) Memorandum from Secretary of Defense to Dr, Paul R, Hawley, Chairman, Committee on Medical and Hospital Services of the Armed forces, dated 1 January 1948, (h) Report of Committee on subject! "Plan for Uniformity of Medical Department Budgets, dated 4 May 1948, ENCLOSURE: (A) Report of Subcommittee on "Cost Accounting Systems and Fiscal Procedures. " 1. In reference (a), the Secretary of Defense asked that among other matters the Committee on Medical and Hospital Services of the Armed Forces give attention to the matter of: "Improvement and standardization of cost accounting systems." 2. The medical departments of the Armed Forces operate under identical instructions of the Bureau of the Budget, the Treasury Depart- ment and the Comptroller General. Each service furnishes these Agencies with similar but not identical reports, prepared under different admin- istrative procedures. Because of these differences, adjustments must he effected under the present systems to arrive at comparable data on operating costs of the respective medical services. 3* It is recognized that the problem of ” improvement and stand- ardization of cost accounting systems" cannot be colletely divorced from other associated problems. Standardization of "coat accounting systems" is closely related to standardization of "appropriation account- ing systems." Under cost accounting systems currently in use in the RESTRICT Medical Departments of the Armed Forces, costs are not charged to opera- tlon until that time when material, labor or expenses are expended to operating departments of an installation* Under appropriation accounting systems, costs are charged against allotments when funds are obligated for the acquisition of material, labor or expense. Both accounting systems are essential* and though closely related, must be maintained independently* The appropriation accounting studies and recommendations contained in this report are based upon reference (b), the Committee’s report on the subject of "Plan for Uniformity of Medical Department Budgets" which was submitted under date of 4 May 1948* The basic dif- ferences in the underlying budgetary structures, and the related dis- similarities among the three Departments with respect to control and use of appropriations utilised in the operation and maintenance of the medical services of the Armed Forces, were outlined in reference (b)* 4* In accordance with paragraph 4of reference (a)# a Subcommittee on "Medical Department Cost Accounting Systems and Fiscal Procedures" was appointed on 21 January 1948 to assist the Committee in its analysis of subject problem* The Committee concurs in that Subcommittee*s report which is submitted herewith* 5, She Comalt tee unanimously recommends approval of the Recommenda- tioaa set forth In Section Y and adoption of the Plan of Implementation outlined in Section VI of the Subcommittee*s report* which is transmitted herewith as Snclosure "A", Ho additional legislative measures are coiw sidered necessary to the implementation of these proposed administrative actions. of Impl 6* This report constitute# an increment of the Committee’s report to the Secretary of Defense on its over-all assignment* /s/ H. W. Bliss BAIMOHD V. BLISS Major General, MO, USA The Surgeon General /»/ Clifford A, Swanson CLIFFORD A. SWAISOH Rnar Admiral (MC)f TJSH The Surgeon General /•/ Malcolm C. Grow HALCOIM 0. (SHOW Major General, MO, USA. (AI) The Air Surgeon J. T* BOOSI Hear Admiral (MO), USH Executive Secretary COMMITTEE ON MEDICAL AND HOSPITAL SERVICES OP THE ARMED FORCES Report of the Committee on that part of its assignment relative to: ORGANIZATION, MANAGEMENT AND ADMINISTRATION OP THE MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES OFFICE OF THE SECRETARY OF DEFENSE OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON COMMITTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES To: The Secretary of Defense Subject: Organization, Management and Administration of the Medical and Hospital Services of the Armed Forces Reference: (a) Memorandum to Dr. Paul R. Hawley from Secretary of Defense, dated 1 January 194-8. !• By the terms of reference given to the Committee in (reference a), the Secretary of Defense stated: "In general what I wish is a thorough, objective and impartial study of the medical services of the Armed Forces with a view to obtaining, at the earliest possible date, the maximum degree of coordination, efficiency and economy in the operation of these services," He also asked that among other things the Committee give attention to the problem of: "Methods for improving the organization, management and administration of the several medical departments in the operation of both their hospital and medical programs, including the possibilities of consolida- tion or coordination of certain activities and functions thereof, and the reduction of the combined overheads of the medical services of the Armed Forces," He further asked that the Committee study and recomnend as to; "The development of an organization or mechanism for the continuing, examination of the type of problems mentioned in the terms of reference given to the Committee," 2. The Committee has, since the date of its formation, given much consideration to this problem. It has maintained an open mind as to possible organizational plans. With the assent of the Office of Secretary of Defense, it has deferred formulation of its conclusions and submission of its recommendations in this matter until detailed studies of the many factors involved had been made and the numerous facets of the problem fully examined. This was considered as being not only desirable but also necessary in order that the suitability and feasibility of possible solutions could be thoroughly and realistically weighed* • 3* The Committee has assumed that although some modification may be made in the National Security Act of 1947, the basic concept of that Act will be preserved for a long time* The Committee has considered that it would not be appropriate or reasonable to assume that within the foreseeable future the three military Departments (the Amy, Navy and Air Force) would lose their identities and be merged into a new single military Force. The Committee has therefore been guided by a realistic consideration of the apparent fact that, under unified broad policy direction and coordination of effort, there will continue to be three separate but coordinated combatant Arms with each performing its appropriate functions, and with each of these three Departments operating its own facilities and shore establishments as required to carry out its assigned mission and to assist the other two Aimed Forces in performing their missions. 4* Subject problem therefore resolved itself into one of devising an organizational structure of the medical services which will be com- patible with the above over-all basic concept of a three-Department 2 organization of the military establishment for operational purposes* 5* In analyzing the several methods of organization for the medical services which might be considered, they appear to fall into one of two general categories: viz., (l) an amalgamation and fusion of the three medical services into a single medical service to serve and operate with all three of the military Departments (Army, Navy and Air Force); or (2) a coordinated team of three medical services, - one to be an integral part of each of the three military Departments - with common utilization of medical facilities wherever practicable and/or Joint performance of certain functions wherein community of effort is feasible* 6* The two general categories of concepts Just mentioned can each in turn be more specifically considered from two viewpoints as to the methods of operation, as further analyzed in the following discussion. 7• If the medical services of the Armed Forces are combined into a single amalgamated medical service which would serve and operate with all three of the military Departments, such a thesis would appear to require either: (A) That the amalgamated (single) medical service of the Armed Forces be established as an autonomous Medical Service in the nature of a fourth Department of the National Military Establishment and separate from the Departments of the Army, Navy, and Air Force; 3 or (B) That the amalgamated (single) medical service of the Armed Forces be established under one of the three existing Departments of the Military Estab- lishment (Army, Navy or Air Force), and that this one Department (either the Army, the Navy or the Air Force) be assigned the responsibility for providing all three Departments of the Military Establishment with all the medical services required by each. $• If each of the three Military Departments has its own medical organization - as integral parts of the respective Armed Forces - mechanisms would appear to be required to insure their unification through effective coordination, either by; (A) An interdepartmental coordinating agency or agencies functioning under the three Secretaries at the military staff level, or by (B) A joint coordinating agency or agencies functioning at the level of the Office of the Secretary of Defense. 9. Whatever the nature of the concept which may be decided,upon in regard to organization of the medical services, it is evident that it must be one which is so devised as to function with the statutory agencies of the National Military Establishment. These statutory agencies, such as the Munitions Board, the Research and Development 4 Board, the Joint Chiefs of Staff (and its Joint Staff) are, by the National Security Act, charged by law with specific duties within the respective spheres of their assigned responsibilities. It is incon- ceivable to the Committee that the medical services of the Armed Forces could be expected to function effectively except as a part of and in conformity with the statutory organization pattern of the National Military Establishment* 10. To establish and operate an amalgamated (single) medical service separate from the Army, Navy and Air Force would require: (a) That the existing medical services of the Amy, Navy, and Air Force be combined into and replaced by an independently administered "single" medical organization, involving transfer to the new "Single Medical Service" of present medical personnel, facilities, material and installations of the three Departments. (b) That, from such a new "Single Medical Service," medical personnel and facilities be assigned to the operating (combatant) forces of the Army, Navy, and Air Force to serve with these forces in the manner of "attached" medical troops. Medical personnel so assigned for duty would need be under the military direction and control of the respective military commanders of the three Armed Forces while so at- tached, but subject to the professional supervision 5 of the "Single Medical Service" organization* (c) Not only would it be necessary for appropriate per- sonnel from the "Single Medical Service" to be i assigned for adequate liaison in the staffs and planning agencies of the three Aimed Forces, but it would also be necessary that similar working groups from the "Single Medical Service" be maintained in the agencies of the National Military Establishment (such as the joint planning staff, the Munitions Board organization, the Research and Development Board, the Personnel Policy Board, etc*) if the separate "Single Medical Service" is to be able to intelligently plan and provide for the medical support required by the Aimed Forces in peace and war* (d) To establish,-operate and administer the "Single Medical Service" in the nature of a separate small new Department of the National Military Establishment and separate from the Army, Navy, and Air Force, a number of central administrative offices independent of the three Departments would be essential to enable it to function* These would be necessary in a variety of fields, such ass budgets and appropriations, the 6 procurement and assignment of personnel; legis- lative and legal matters (JAG); medical records and reports; construction and maintenance planning; etc., to perform in the “Single Medical Service” those administrative and supportive services now perfomed for the medical services by the appropriate headquarters offices of the respective parent Armed Forces. 11. The Committee does not share the opinion expressed by some advocates of a separate "Single Medical Service" that substantial economies in personnel and/or funds would be realized if such an organization were established. The Committee is convinced that any savings or economies which would appear to accrue from some sources would in fact be overbalanced by the requirements for additional funds and personnel which would be required for other purposes in order for the new separate "Single Medical Service" organization to exist and function in the manner of a "fourth Department" of the National Military Establishment. Furthermore, the Committee earnestly believes that separation of the medical Services from the Departments which they serve and sustain, and with which they intimately operate each day at every post, camp, station and ship of the Aimed Forces, would greatly reduce the efficiency and the effectiveness of the medical services in rendering medical support to the various departments and 7 agencies of the National Military Establishment. In this connection, the Committee on the National Security Organization (Eberstadt Committee) of the HHoovern Commission in its studies of the medical services and hospitalization in the military services gave considera- tion to the feasibility and practicability of a single medical department with relation to unification within the Aimed Forces. In its report to the Commission, that Committee stated as follows: ’•Great Britain has recently faced this same problem with a defense establishment composed of three depart- ments similar in many respects to ours. Their national medical resources seem even more limited than our own. On March 10, 194-8, the Minister of Defence of Great Britain was asked in the House of Commons to give the principal reasons for the rejection of a proposal to amalgamate various services (including the medical) common to the armed forces. He replied as follows: ’’This question has been thoroughly examined by the normal process of Interdepartmental discussion, both official and ministerial. The amalgamation of common services would, in view of the Government, result in: M(a) loss of contact with the forces they serve; 11 (b) divided responsibility for the forces and for their auxiliary services; ”(c) the establishment of a new headquarters organization to deal with such matters as pay, transport, clothing, accommodations, etc. for the amalgamated services; rt(d) an increase in the detailed liaison work between the amalgamated services and forces. ’’These are the main reasons which led the Government to the view that the practical difficulties which the tasks of unification would bring with them outweigh the advantages. In present circumstances we are not satisfied that amalgamation would lead either to 8 increased efficiency or to economy in manpower and money.” No clearer answer to the -question of a single medical department can be presented*” Similarly, an extensive study of this subject has recently been con- ducted in Canada* The Minister of National Defense of Canada, Mr. Brooke Claxton, in addressing the Defense Medical Association of Canada on 5 November 194-8 at Ottawa, discussed the matter of unifica- tion of the Aimed Forces medical services of that country. In that address, he stated that no agreement could be arrived at by the Interservice Combined Functions Committee in regard to the amalgama- tion of the medical services of the Armed Forces into a single service. He further stated that ”it is exceedingly difficult to tie in an interservice or combined service me'dical service when you have three Services.” He pointed out that to set up a 4-th Service, which would be a combined service, would necessitate the setting up of additional housekeeping and bookkeeping functions. It was concluded that duplication and competition better could be eliminated through coordination of the three medical Services, and a plan based upon this conclusion has been placed in effect. 12. To establish and operate an amalgamated (single) medical service under one of the three existing Departments of the Military Establishment (Amy, Navy, or Air Force), and the assignement to this one Department (either the Amy, Navy, or Air Force) of the responsi- bility for furnishing all three of the Amed Forces with the medical services needed by each, would require: 9 (a) Transfer to the one Department (either the Army, Navy or Air Force) selected to operate the medical services for all three Departments of all medical personnel, facilities, material and installations of the other two Departments. (b) That from the ’’Single Medical Service” controlled and operated by one Department to furnish all the medical services required by all three of the Armed Forces, medical personnel and the necessary facilities would need be assigned to the other two Armed Forces, as from a separate ’’Single Medical Service” discussed above, to serve with these Forces at posts, camps, stations and on board ships in the manner of ’’attached” medical troops. (c) As with the separate ’’Single Medical Service” discussed earlier, in order to maintain a ’’Single Medical Serv- ice” under one of the three existing Departments, control of medical department personnel with respect to assignment to and reassignment from duty with the client Armed Forces would need be lodged in the parent Department under which the ’’Single Medical Service” would be placed. During the period of their assign- ment for duty with other than the parent Department, 10 medical department personnel would need be under the military control and direction of the respective client Armed Forces while so attached, but at all times would be under the professional and technical supervision of the parent "Single Medical Service•" 13• The concept of a "Single Medical Service" to be operated by one of the Armed Forces for the medical support of all three Armed Forces would have the seeming advantage of pooling medical department personnel and medical facilities, as does the concept of a separate "Single Medical Service" described earlier. Transfer to one of the three existing Departments (Armed Forces), of this combined "Single Medical Service" would also appear to obviate a part of the additional overhead which would be required in both funds and personnel if the "Single Medical Service" were to be established as a separate Depart- ment independent of the Army, Navy and Air Force. However, the Committee firmly believes that any supposed savings in funds and/or personnel which might be expected to accrue as a result of combining the three medical services into an amalgamated "Single Medical Service" under one of the existing three Departments of the National Military Establishment would be more apparent than real. The Committee has concluded that any small savings in funds and personnel which might result from the establishment of a "Single Medical Service" under one of the three Military Departments would be so insignificant in relation to the over-all medical activities and other problems involved that 11 they do not justify or warrant such a radical reorganization. This is more fully appreciated when it is realized that adequate medical support in full coverage would still have to be provided throughout the three Aimed Forces. The size or deployment of the three Armed Forces would not be materially changed by the establishment of a "Single Medical Service," since the three Arms would continue to operate their numerous posts, camps, bases, stations and ships to process military personnel and to train for and carry out their assigned missions in the national defense effort. However organized, the medical services must provide the necessary medical support in the day-to-day operations of the widely-spread military establishment. No reduction in the total medical work load which must be performed would be accomplished by the act of shifting the total medical re- sponsibility to one Department. Moreover, such a plan has inherent disadvantages and faults which more than offset any small advantages which might accrue therefrom. Among the additional faults of a "Single Medical Service" which would be operated by one of the three Departments, the following are cited; (a) The "Single Medical Service" would inevitably become responsive primarily to the parent Arm* Especially in times of scarcity and stress, it would be only natural that the parent Department would be more responsive to its own impelling urgencies than to the medical needs of the sister Departments of which it has less intimate knowledge 12 and less understanding. Decisions reflecting the dominant interests of the controlling Depart- ment would tend to the enforcement in all three Armed Forces of procedures and methods which are peculiarly suited to and used by the controlling Service. Such would arise from a superficial conception that all the Armed Forces are so similar that, as far as the medical services are concerned, there is little need to conform to principles and procedures which nevertheless are of substantive importance to the client Departments. (b) The "Single Medical Service,n if established and operated as a responsibility of one of the three Departments, has the defect of creating an organiza- tion -which is even more inimical to the morale of a large part of the personnel of which it would be composed than if the "Single Medical Service11 were established as a separate Department independent of the Army, Navy and Air Force* 1A• The Committee members all share what is believed to be the common desire of everyone in that, so far as possible and especially during peacetime, the Armed Forces (including the several Corps which constitute the medical departments) consist of personnel who are 13 serving voluntarily in the Military Establishment. The estab- lishment of an amalgamated “Single Medical Service” would deprive at least two of the Aimed Forces of a medical department as integral and permanent parts of the respective Armed Forces. It must be accepted as a fact that many professional medical department personnel, which are the categories of personnel most difficult to maintain in adequate supply in the Armed Forces, are strongly influenced in their decision to voluntarily join and continue to serve on a career basis in the Armed Forces by a definite desire to serve as a permanent and full-fledged member of some one particular Armed Force. Yilhile the numbers involved cannot be estimated, the Committee believes that there will be a considerable wave of resignations submitted, or requests for retirement if eligible for retirement, by medical department personnel now serving in whatever two of the Armed Forces would no longer have a medical service as an integral and permanent part of that Force. Since the controlling Department would presumably perform all the major professional functions from the strictly medical view- point, most personnel (both those remaining in and those choosing to enter the military service) would seek to obtain continuous assignment in this one Force where the greatest opportunity would exist for ad- vancement in a medical professional career in the Armed Forces, and with which the principal accomplishments of the medical services of the Armed Forces would be associated in the public mind; if not so 14 assigned, many medical department personnel would become acutely dissatisfied. It cannot be denied that many prospective replacements from civilian life would be unwilling to voluntarily enter the mili- tary establishment, fearing they would not be assigned for duty in the Armed Force of their choice. 15* The Committee rejects the concept of combining the medical services of the Armed Forces and the formation of a nSingle Medical Service”. The Committee unanimously recommends against the adoption of such an organizational plan, whether the "Single Medical Service” would be controlled and operated by one of the three Departments of the National Military Establishment, or established as a separate "Service” which would be independent of all three of the Armed Forces. 16. The Committee has concluded that until the three Armed Forces are themselves merged and combined into a singly-administered and singly-operated Armed Force, the only practical organization of the medical services for achieving the objectives stated in paragraph 1 above is one of unification of the three medical services through effective coordination. This solution recognizes that the true mission of medical service in the Amed Forces is not an entity unto itself. Standing alone it would have no purpose, since its sole reason for existing lies in operating intimately with and sustaining the fight- ing strength of the Army, Navy and Air Force. 17. In examining the mechanisms whereby the policies, procedures. 15 activities and operations of the medical services of the Army, Navy and Air Force could be unified through effective coordination, the Committee is convinced that reliance should not be placed for accomplish- ing this end upon an interdepartmental medical coordinating group or committee which would function under the three Secretaries at the military or special staff level. It is believed that such a coordinat- ing agency or Committee placed at this level would soon deteriorate and that only an occasional and ineffectual between-Department con- ference on medical matters would be the ultimate result. Lacking the constant stimulus inherent in coordinating agencies which function at the level of the Office of the Secretary of Defense, it is felt that attainment of the objectives indicated in paragraph 1 above -would be retarded if nothing more than a mechanism for interdepartmental col- laboration existed. Further, the establishment of a medical coordinat- ing agency or Committee at this Departmental level would result in unnecessary duplication and overlapping of certain coordinating func- tions already prescribed by law or assigned to existing statutory and administratively created agencies of the National Military Establishment, such as the Joint Staff of the Joint Chiefs of Staff, the Munitions Board, the Research and Development Board, and the Personnel Policy Board. It is the opinion of the Committee that an attempt to coordinate the medical services by a mechanism placed below the level of the Secretaries of the- three Departments would prove unworkable in practice. 16 and therefore recommends against adoption of such a plan. 18. The professional and administrative aspects of the medical services of the Armed Forces demand a close working relationship with a large number of non-govemmental medical and dental organiza- tions and bodies such as, The American Medical Association, The American Dental Association, The American Hospital Association, The Association of American Medical Schools and Colleges, The Council on Medical Education and Hospitals, The Council on National Emergency Medical Services, The Advisory Board on Medical Specialties, etc., as well as with other governmental medical agencies such as those in- cluded within the Veterans Administration, the Federal Security Agency and the Office of Civil Defense Planning. The Committee has con- cluded that coordinated relationships between the medical services of the National Military Establishment and such groups and agencies can be more effectively and efficiently maintained by a mechanism functioning at the level of the Office of the Secretary of Defense. Moreover, the Committee considers that the objectives outlined in paragraph 1 above can also best be obtained by such a mechanism located at this level and as outlined in succeeding paragraphs. The plan advocated herein would more fully utilize the existing agencies of the National Military Establishment in their respective spheres of assigned responsibilities as applied to the medical services5 and would provide a medical coordinating agency at the same level to coordinate those professional and other medical matters which are 17 not included in the specified functions and duties of these statutory and administratively created coordinating and planning agencies, such as the Joint Staff of the Joint Chiefs of Staff, the Munitions Board, the Research and Development Board and the Personnel Policy Board* 19* The organizational plan proposed by the Committee has the following aims in accomplishing the objectives stated in paragraph Is (a) Operation of the medical services on a level comparable with the highest standards of contem- porary American medicine* (b) Ready responsiveness of the medical services to the necessities of the Armed Forces which they support. (c) Integration of medical planning in the planning activities of the three Armed Forces and of the over-all joint planning agencies* (d) Maximum utilization of existing medical facilities. (e) No under-employed medical personnel, and maximal utilization of the skills of all such personnel. (f) Treatment of patients at the nearest suitable Armed Forces medical facility. (g) Accomplishment of the entire operation of the medical services with the smallest possible overhead con- sistent with efficient performance of their missions. 18 (h) Maintenance of best relations and close liaison with civilian medicine and other Federal medical agencies# (i) Making the medical services of the Armed Forces sufficiently attractive as to enable them to secure and retain the required medical department personnel on a voluntary basis in so far as possible# 20. The proposed plan has been constructed on the following principles: (a) To recommend organizational changes only where we believe that an important objective would not be secured under the existing structure# (b) To pattern the recommended changes with respect to medical affairs as closely as possible after the general design of the National Military Establish- ment# (c) To avoid seeking new legislation until it has been clearly demonstrated that new statutory changes are necessary to accomplish important objectives# 21. In recommending the proposed plan ive have taken into account the following considerations: (a) Although there exists at present a considerable stringency in respect to professional medical department personnel in the Armed Forces, we hope 19 that with the assistance now being rendered we will be able to discharge our major responsibilities in providing medical service to the Armed Forces* (b) We recognize that many opportunities exist for the more effective coordination and integration of medical activities among the Armed Forces. However we are impressed with the fact that several major efforts to contribute to this desirable end have only recently been instituted, the fruits and ultimate results of which have not yet had time to develop and become evident* 22* The Committee earnestly believes that the following plan if accepted and implemented would be the constructive and practical next move in furthering the accomplishment of the objectives indicated in // paragraph 1, and in achieving the aims outlined in paragraphs2B above: THE PLAN. (a) That the Secretary of Defense designate an Assistant Secretary of Defense (if provided for by law) or continue the present plan of a Deputy to the Secretary of Defense for Medical and Allied Professional Matters * whose duties in whole or in part will be to act for the Secretary of Defense in all matters affecting medical affairs; and further that said Assistant Secretary or Deputy serve as Chairman of the Aimed Forces Medical Council outlined below* 20 (b) That there be established by the Secretary of Defense an Amed Forces Medical Council composed of a Chairman as outlined above, the Surgeon General of the Army, the Surgeon General of the Navy and the Air Surgeon. On all matters affecting dental affairs, the Medical Council would be assisted and advised by a tri-partite dental committee consisting of the Chiefs of the Dental Divisions in the Offices of the Surgeons General of the Army and Navy and the Air Surgeon. Further, that there be established a Secretariat of the Council composed of one medical officer from each of the three Services in the grade of Colonel or Captain (Navy;, and a Chairman of general or flag rank selected from one of the three medical services, and such secretarial and office personnel as may be required. The Chairman of the Secretariat would also serve as Executive Secretary to the Council. (c) That the Aimed Forces Medical Council be established as a staff agency in the Office of the Secretary of Defense to assist the Secretary of Defense and other agencies of the National Military Establishment at that level in matters affecting medical affairs of the National Military Establishment. (d) That the Armed Forces Medical Council be authorized to designate tri-partite subordinate groups from appropriate personnel within the three medical services to continue the work and studies in specific fields or of selected aspects of the medical services as has 21 been initiated by the ad hoc Committee on Medical and Hospital Services of the Armed Forces ('‘Hawley*l Committee). (e) That the functions and activities of the Aimed Forces Medical Council be limited primarily to policy, planning and organ- izational matters, with operational activities carried out through existing established channels within the three Departments. In conformity with approved national defense policies and directives, it would exercise, through the three Departments and appropriate agencies of the National Military Establishment, general supervision of and be responsible for: (1) Medical professional matters in all echelons of the National Military Establishment* (2) The formulation, development and implementation under the general direction of the joint Chiefs of Staff of over-all medical plans for the three Departments• (3) Furnish medical planning guidance to all echelons of the three Departments* (4.) Coordination of medical policies, plans and programs of the three Departments in such matters as: a. Personnel requirements, deployment and utilization* b* Medical supply requirements, procurement 22 and distribution. c. Hospitalization. d. Medical Research and development (in accordance with the policies and approved procedures of the Research and Development Board). e. Preventive medicine. f. Professional services. g. Medical forms and reports. h. Physical and mental standards. i. Classification and diagnostic nomenclature of diseases and injuries. j. Medical and bio-statistics. k. Programs for construction and utilization of medical and hospital facilities. l. Training of medical department personnel. (5) Insuring that established policies, plans and programs of the medical services are being properly implemented by appropriate and timely field inspections. (f) That for the most effective operation of this Council, each of the three medical services have the same degree of autonomy, and that in so far as possible they operate under standardized policies as well as uniform regulations with respect to the medical departments. 23 (g) That a legally authorized Service-identified medical com- ponent of the United States Air Force b£ established by appropriate action of the Secretary of Defense, acting under existing legal authority of the National Security Act, and embodying the actual principles already agreed upon within the Department of the Army and the Department of the Air Force. 23. Implicit in the implementation of the foregoing plan is the following assignment of responsibilities: (a) The previously mentioned Assistant Secretary or Deputy to the Secretary of Defense will have as his sole duty, or at least one of his principle duties, the accomplishment of the objectives and aims set forth in preceding paragraphs of this report. It would be his specific task to follow through on the implementation of the various plans, programs, and procedures worked out by the Armed Forces Medical Council and approved by him after appropriate processing through the National Military Establishment. (b) The Aimed Forces Medical Council would be charged with working out the various plans, programs and procedures which when implemented would assure the accomplishment of the desired objectives and aims previously outlined herein. In doing its work the Council would place a high degree of responsibility on its Secretariat, which would in turn be authorized to proceed with its work in collaboration with other agencies of the National Military Establishment in whatever 24 manner appeared most constructive, either by enlarging its resources through requesting the detail of officers from the three services to work with it on a particular problem or plan; or to give responsibility for the planning to one of the three Services; or to proceed in any other appropriate manner -which it might see fit. The Aimed Forces Medical Council would act in the nature of a composite Surgeons Generals’ Office in medical department professional matters of common interest to the three Armed Forces. It would serve as the appropriate medical agency to which the Secretary of Defense, the Joint Chiefs of Staff and the Munitions Board organization would look for assistance in coordinating medical planning in support of broad strategic and logistic plans, the utilization of medical facilities, and in arriv- ing at statements of combined requirements of the Aimed Forces not otherwise provided by existing joint agencies. Conversely, it could, on its own initiative and after preparation of suitable studies dealing with specific problems in the medical field, submit its pro- posals and recommendations in the premises to the Joint Chiefs of Staff, the Munitions Board, the Research and Development Board, the Personnel Policy Board and the three Departments as would be appropriate in the particular matter being given consideration* The Aimed Forces Medical Council would also perform those functions not otherwise pro- vided for which were suggested for the continuing military medical coordinating board previously proposed by the Committee in its mem- orandum to the Secretary of Defense on 18 January 19A9. 25 24* The foregoing plan is put forth at this time as being the most constructive and practical next move, without prejudging the possible need for changing or modifying it at a later date. More- over, it is not unlikely that as specific actions are contemplated to achieve a progressively higher degree of unification, requests for legislative changes may subsequently be found necessary. In view of the fact however that there have already been substantial undertakings initiated in the National Military Establishment to accomplish the desired objectives and aims, and since the plan outlined in paragraph 22 above contemplates additional changes toward this end, it is considered definitely inadvisable to put forward recommendations for extreme or revolutionary organizational changes at this time and until a reasonable opportunity has been had to assess the efficacy of the changes and programs already in effect or recommended to be put into effect* 25* It is our considered and objective opinion that the organ- izational plan proposed above will enable the Aimed Forces to accomplish the desired objectives and achieve orderly unification of the medical services. Schematic charts are attached as Enclosures I and 11. Adoption and implementation of the plan proposed herein is unanimously recommended. It is believed that this plan, if approved, can be fully implemented by administrative action within the National Military Es- tablishment without recourse to any additional legislation. 26. It is recognized that the Secretary of Defense may desire 26 to also have a Civilian Medical Advisory Committee. It is considered that the question of the appointment, composition and organization of such an Advisory Committee is discretionary with the Secretary of Defense and is a policy matter for determination by him; it is not considered as being a matter coming within the terms of reference or prerogative of this Committee. 27. This report constitutes an increment of the Committee’s report to the Secretary of Defense on its over-all assignment as given in reference (a) . 28* The views and proposals outlined herein are our own and do not necessarily represent those of the three Departments. (pvkk*' RAYMOND W. BLISS, Major General, MC, USA, The Surgeon General. Jmtest Rear Admiral (MC), U.S. Navy, Surgeon General. (fyt o9^ MALCOLM G. GROUT, Major General, MC, USA, The Air Surgeon. JV4T. BOONE, Rear Admiral (MC), U. S. Navy- Executive Secretary. 27 (see note) ♦NOTE: Would be assigned duty as Assistant to the Secretary of Defense for Medical Affairs, and would serve as Chairman of the Armed Forces Medical Council. ASST, '■-Armed- forces;] ,/ MEDICAL A-: 7//y COUNCIL^'' ASST. DEPARTMENT OP THE AIR FORCE / MEDICAL DEPARTMENT/ / s /At / //' ASST. PERSONNEL POLICY BOARD MEDICAL ORGANIZATION IN THE NATIONAL MILITARY ESTABLISHMENT SECRETARY OF DEFENSE [RESEARCH ft DEVELOP. BOARD k* ■■■i—■■ ■ii— UNDER SEC. DEFENSE DEPARTMENT OF THE NAVY MEDICAL DEPARTMENT MUNITIONS BOARD CIVILIAN MEDICAL ADVISORY COMMITTEE MEDICAL DEPARTMENT DEPARTMENT OF THE ARMY WAR COUNCIL JOINT CHIEFS OF STAFF JOINT STAFF COORDINATION OF MEDICAL POLICIES, PLANS, and PROGRAMS OTHERS ♦NOTE: On all matters:'affecting dental affairs, the Council would be assisted and advised by a tri-partite committee consisting of the Chiefs of the Dental Divisions of the Offices of the Surgeons General of the Army and Navy and the Air Surgeon* Liaison and planning coordination with other medical agencies of the Federal government and with non-governmental medical agencies COMPOSITION, FUNCTIONS and ORGANIZATION OF THE ARMED FORCES MEDICAL COUNCIL DIAGNOSTIC NOMENCLA- TURE AND STATISTICS I TRI-PARTITE SUBORDINATEj STUDY AND WORKING GROUPS (Part-time)J MEDICAL FORMS AND REPORTS PROFESSIONAL SERVICES ARMED FORCES MEDICAL COUNCIL CHAIRMAN (Asst, to Sec Def,) SURGEON GENERAL OF THE ARMY SURGEON GENERAL OF THE NAVY THE AIR SURGEON *(see note) S E C R E t|a R I A T PREVENTIVE MEDICINE MEDICAL DEPARTMENT PERSONNEL Coordination and collaboration with established agencies of the National Mil-V itary Establishment MEDICAL i SUPPLY j HOSPITAL- IZATION Recommendations of the Committee in regard to MEDICAL DEPARTMENT PERSONNEL (a) That Medical Department Personnel Requirements of the Aimed Forces should be a continuing study* (b) That an office operated by and for the three depart- ments of the Armed Forces, be established for joint Medical Department officer procurement* (c) That the system of classification of Medical Depart- ment officers used by the Army and Air Force be adopted for Medical Department officers of the Armed Forces. (d) That utilization and assignment and deployment of personnel of the Medical Departments of the Armed Forces should be a continuing study. That special- ized personnel be used jointly where feasible* (e) That no change be made at this time in the established personnel records of the Medical Depariment of the Aimed Forces* (f) That the promotion system currently applicable to personnel of the Medical Departments of the Aimed Forces be a continuing study* 1 (g) That the established strength of the enlisted Hospital Corps of the United States Navy be increased by legis- lation* (h) That there be established in the United States Army and Air Force a Medical Department Enlisted Corps by legislation* (i) That no change be made in the present systems of pro- curing enlisted personnel for duty with the Medical Departments of the Armed Forces* 2 OFFICE OF THE SECRETARY OF DEFENSE WASHINGTON CCM6ITTEE ON MEDICAL AND HOSPITAL SERVICES OF THE ARMED FORCES % 0 MAY 1949 TO* Secretary of Defense SUBJECT* Medical Department Personnel of the Armed Forces REFERENCE: (a) Memorandum from Secretary of Defense to Dr. Paul R. Hawley, Chairman, dated 1 January 1948, subject: "Committee on Medical and Hospital Services of the Aimed Forces"• ENCLOSURE: (1) Report of Subcommittee on Medical Department Personnel of the Aimed Forces, dated 27 April 1949 1* By the terms of reference (a) you asked that among other matters, the Committee on Medical and Hospital Services of the Aimed Forces give attention to the following: "Maximum utilization of qualified medical personnel of the Aimed Forces. Consideration should be given to the joint use of highly specialized personnel, to the possibility of interchange of medical personnel among the Medical Services depending upon requirements and facilities for such personnel, to the relief of quali- fied doctors from administrative responsibilities and to providing them with greater opportunity for exclusive attention to the practice of their profession, etc." It was further indicated in reference (a) that a thorough, objective and impartial study of the medical services of the Armed Forces was desired with a view to obtaining the maximum degree of coordination, efficiency and economy in the operation of these services; further, that the terns of reference of this Committee embodied any and every question whose solution may tend to further this broad objective. 2. In accordance with the provisions of paragraph 4of reference (a), the Committee on 22 January 1949 appointed a subcommittee on Med- ical Department Personnel to assist it in its study of this aspect of the Committee's assignment* The final report of the above mentioned subcommittee is attached hereto as enclosure (1) • The Committee unan- imously concurs in the report of the above-mentioned Subcommittee* 3* During the past fifteen months the many and varied aspects of this general subject of "Medical Department Personnel" have been made matters of separate studies which have been continuously conducted by the Committee, assisted by the above-named Subcommittee and a number of special task groups designated by the Subcommittee to further aid it in analyzing this complex personnel problem# This has led to the develop- ment of an intimate and mutually helpful working relationship among the three medical services with respect to all medical department personnel matters# As a consequence, it has been possible, within the individual medical services themselves, to arrive at common approaches to similar personnel problems and to adopt and follow practices and policies with respect to medical department personnel on a more nearly uniform basis than has been done heretofore* 4* The many facets of the subject have undergone marked and contin- uous change during the period of time covered by this Committee's work# At the same time, notable progress has been made in effectuating the common utilization by the three medical services of medical department personnel in a number of fields wherein such common employment is prac- ticable and in the common interest# Joint use of medical professional 2 personnel and joint staffing of Armed Forces Hospitals -which are regularly utilized in common by two or more of the Armed Forces has already been instituted as a result of the work and studies of this Committee on Medical and Hospital Services during the past several months and the approval of certain recommendations made by it with reference to medical department personnel in connection with reports on other portions of its assignment. It is anticipated that this adopted policy of joint staffing and joint use of medical professional personnel will be pursued and progressively implemented in an increasing number of appropriate medical installations and activities. 5. Some of the features of the personnel problem, such as require- ments and availability of medical department personnel, will continue to be of a constantly changing nature, and specific figures with respect thereto fluctuate from month to month. No statement as to specific requirements or prospective availability of medical department personnel is therefore included in this report* inasmuch as any such ever-changing figures would become obsolete within a period of a few days. It is known to this Committee that the Armed Forces Medical Advisory Committee (Cooper Committee) in the Office of the Secretary of Defense has for the past few months been kept advised of the spec- ific current and prospective requirements and availability of medical department officers, particularly Doctors of Medicine and Dentistry, in connection with that Committeefs study of this same problem. Periodic formal presentations in this regard have been made before the Armed Services Medical Advisory Committee by the offices of the 3 Surgeons General of tne Army and Navy and the Air Surgeon. 6. The Committee is impressed by the necessity for continuation of studies in the medical department personnel field in such matters as requirements (present and prospective), availability, procurement (short range and long range), utilization, assignment, qualifications, military career management, promotion, selection, classification methods, etc. 7. The Committee recommends approval of the recommendations contained in the above-mentioned Subcommittee’s report. For conven- ient reference, these recommendations are quoted as follows: (a) That Medical Department Personnel Requirements of the Armed Forces should be a continuing study, (b) That an office operated by and for the three departments of the Armed Forces, be established for joint Medical Department officer procurement, (c) That the system of classification of Medical Department officers used by the Army and Air Force be adopted for Medical Department officers of the Armed Forces. (d) That utilization and assignment and deployment of personnel of the Medical Departments of the Armed Forces should be a continuing study. That special- ized personnel be used jointly where feasible. 4 (e) That no change be made at this time in the established personnel records of the Medical Departments of the Armed Forces* (f) That the promotion system currently applicable to personnel of the Medical Departments of the Armed Forces be a continuing study* (g) That the established strength of the enlisted Hospital Corps of the United States Navy be increased by legis- lation • (h) That there be established in the United States Army and Air Force a Medical Department Enlisted Corps by legis- lation* (i) That no change be made in the present systems of pro- curing enlisted personnel for duty with the Medical De- partments of the Armed Forces. 8* This report constitutes another increment of this report to the Secretary of Defense on its overall assignment as given in reference (a)* /•/ RAYMOND W. BLISS, Major General, MC, USA, The Surgeon General* A, SHANSON, Rear Admiral (MC), U. S. Navy, Surgeon General. /s/ J. T. BOONE, Rear Admiral (MC), U. S. Navy, Executive Secretary* /»/ MALCOLM C. GROW, Major General, MC, USA, (AF), The Air Surgeon. 5 22 June 1949 Summary of comments on and present status, as of above date, of reports and recommendations submitted to The Secretary of Defense by the Committee on Medical and Hospital Services of the Armed Forces (Hawley Committee) COMMITTEE’S REPORT ON SUBJECT GIST OF COMMENTS BY: MUNITIONS ACTION TAKEN BY THE TAB OF: ARMY NAVY AIR FORCE R&DB BOARD SECRETARY OF DEFENSE A. • Joint Armed Forces Med- ical Supply- System. Believes either Army or Navy could perform medical supply fundi ons for other two Departments, Recom- mends decision be deferred, and that report be returned to -Committee for further study. Thinks proposed plan in oresent form not wholly sound. Contends program violates Declaration of Policy of National Security Act, Re- commends apnroval be withhold pending recommended revis- ion of reuort. Concurs; believes plan is sound; only reservation is that proposed method of funding be adjusted. Re comm, ended on 22 Feb 1949, that the Plan not be placed in effect; that the Medical Supply problem be recognized as an integral part of the over-all distribution problem in any future study. The Army member. Assistant Secretary of the Army Dray, dissents from a.bove; be- lieves plan does not go far enough and indicated ho would develop recommenda- tions for consideration of Munitions Board relative to charging one Service with responsibility for distri- bution of all medical supply. Under consideration by Armed Forces Med- ical Advisory Com- mittee and other groups in the Office, of the Secretary of Defense, tab I COMMITTEE'S REPORT OH SUBJECT OF: 1 ARMY NAVY AIR FORCE GIST OF C BY: R&DB OMIfENTS MUNITIONS BOARD ACTION TAKEN BY THE SECRETARY OF DEFENSE B, Classification and Diagnostic Nomenclature of Diseases, In- juries, etc. Concurs Concurs Concurs •‘ipprovcd and implementation directed 7 June 1948, C. Uniformity of Medical Depart- ment Budgets. Does not concur. Concurs Docs not concur. t Under consideration in the Office of the Secretary of Defense. (NOTE - Action being deferred since OSD believes recommendation can not be implemented at this time, nor until changes are also made in budgetary pro- cedures of the three Departments having no reference to the mcdica.1 services;. D. Hospitaliza- tion and Medical Service in the Panama Canal Zone area. Concurs Concurs Concurs Approved, and implementation directed on 7 June 1948. Aimed Forces Hospital facil- ities at Guam, M.I. approved, and implementation directed on 21 Fob, 1949, as part of approved recommendations conta.incd in Report on Programs for Hospitalization, F. Inter-Service Reciprocity in Medical Caro of Dependents of Militarv Personnel Concurs Concurs Concurs 2 Annrovod, and implementation directed on 12 August 1948, TAB COIGIITTEE1 S REPORT ON subject OF; ARMY GIST NAVY OF COMMENTS BY: AIR FORCE MUNITIONS R & DB BOARD ACTION TAKEN BY THE SECRETARY OF DEFENSE G. Standardization Concurs in oh- Concurs with Concurs Concurs Approved recommendations of Preventive jeetivo, hut only slight (aj and (d), and implo- Medicine Prac- questions mat- modification. mentation directed on 21 tices and Pro- ter of cstab- Feb, 1949, Decision on cedures within lishment of co- recommendations (b,) and the Armed ordinating com- (c) withheld pending Forces, ,mitteo on Pre- further consideration. ventivo Medicine, H, Medical Research (Departmental vie vs coordinated by RADB) Concurs in Approved recommendations of the Armed recommenda- (A., (C), (E), (F) and (G) Forces tions A, C, of original report; rccom- F, G, E, mendation (B) approved as Made amend- amended by R&DB; and monts for recommendation (H) approved others in Itr as amended by the AFIiAC, of 22 Dec 48 to Implementation directed on Sec of Dcf. 21 Feb, 1949, Recommendation (D; disapproved. I. Medical Profcs- Concurs in Concurs, In re: Concurs, Recommendations (d>, (c;,(f), sional Services basic concept Recommendation Will make (g;»(k) &nci (i) "the original of the Armed of further un- (iI is willing share of report approved, Recommonda- Forces ification in to make funds funds avail- tion (c) approved as omendod this area, but available for able for by AFMAC, Implementation questions matter printing and printing and directed on 22 Mar 49, of estae, of binding up to publications coord. l/3 cost if provided same committee on Med- other Depts is agreed to ical Professional agree to furnish by other Sec- Services. cquc.1 share# retarics, 3 TAB COMMITTEE»S REPORT ON SUBJECT OF: ARMY GIS1 NAVY . OF COiiliENTS BY; AIR FORCE R&DB * MUNITIONS BOARD ACTION TAKEN BY THE SECRETARY OF DEFENSE J. Medical Intolli- Opposed, Recom- Opposed, Feels Opposed, Request (NOTE: Alternative proposal wh Lch would be acceptable gonco of tho mends no action medical officers report be return- to the Medical Services is being explored with Amod Forces. to ho taken; should assign** od for further CIA, ONI, G-2, afid A-2 fools such on od to existing study, because Organization Intelligence Ag- report disregards would remove di- encies to co- existing depert- rection from tho ordinate work. mental intolli- control of tho Present budgets gonce activities. Intelligence will not allow including their Division of tho Navr- Assgmts, of relationship to Army and from lied Offs as Asst CIA t JIG. control of Sur- Naval attaches. oon General, Recommends coor- Propose objoc- dination Bd of tivo be satis- Surgeons General fiod through CIA and Air Surgeon to or Joint Intolli- work in consulta- gonce Group of tion with tho 3 Joint Staff, Services intolli- § gonco chiefs. K. Physical and Concurs, No com- Concurs Concurs Report has been re- Montal Stan- mitmont as to ferred to and is under dards. establishment of review and considcra- a permanent commi- tior. by tho Personnel ttco on Physical Policy Board, and Mental Stan- dards. I*, Graphic Repre- (Factual re tort, no action requi rod. Essentially for use as a No action required or sontation of background working d< cumont. contemplated tho Principal Medical Facili- ties of Ar. Fs, 4 COMMITTEE1S GIST OF COMMENTS IE PORT ON BY; SUBJECT MUNITIONS ACTION-TAKEN BY THE TAB OF: ARMY NAVY AIR FORCE RADB BOARD SECRETARY OF'DEFENSE M. Training and Educa- tion Programs of tho Medical Depart- ments of the Armed Forces, Concurs in general, but questions ad- visability of es- tablishment of Co- ordinating Com- mittee as recom- mended in tho original report. Concurs Corourb ■ | Recommendations (a; and (c; of the original re- port, as amended by tho AFMAC, approved; imple- mentation directed on 22 March 1949, N. The Army Medical Library, Concurs, Requests funds for new building be carried in Dept, of Army- Civil Functions Ap- propriation Bill, Concurs Concurs 0. Tho Army Institute Concurs in general Concurs, Prefers Concurs, Re- Concurs in Approved, and implementa- of Pathology, principle, but re- commends this matter be referred to the Par, 7(h) of ref (b) as method of financing arrang- commend ap- propriations be obtained toto. tion directed on 21 Fob, 1949, Recommendation (h) referred to Mr, Me Armed Forces Mod, monts (rcimburs- by Army, Neil to work out some Adv. Committee, able basis;. mutually agreeable fiscal arrangement. 5 COMMITTEE1 S GIST OF COMMENTS REPORT ON I BY: SUBJECT MUNITIONS ACTION TAKEN BY THE TAB | OF: ARMY NAVY ! AIR FORCE R&DB BOARD SECRETARY OF DEFENSE P. I Aviation Modicino Concurs in rocom- Concurs, Rocom- Concurs. Is Concurs Concurs with certain re- Recommendations (a). in tho Armed For- mendation ro: Train- mends strong on- prepared to in gen- sorvations. (c),(d;,(o),(ij,(j;. cos. ing in connection doresoment of joint implement the oral. (l),(n),(o),(p),(q). with Aviation Mod- Aeromodical Center recommendations. with re- (r;,(s),(t),(u) and icino. Unable to program. serva- (w) of original re- question or endorse tions as port approved. Re- the separate diroc- to certain commendations (b). tion and conduct of suggested (f)#(g)*00»(k)#(n) research and inves- modifica- and (v) approved as tigation in tho tions of amended, Implementa- field of aviation rccommcnda- tion directed on 24 medicine as embod- tions (b/. March 1949, icd within rocom- (f),(g). mondation. and (h) Q. Coordination of None ommi 11al, Ro- Not yot received. Concurs in aim Recommends that; (a) Dotor- Design of Hos- commended report of Committee, raination of needs for addi- pitals' and other bo referred to but states A,F, tional medical end hospital medical facili- Armed Forces Mod- cannot budget facilities and general loca- ties of tho Armed ical Advisory for funds for tion -thereof bo assigned to Forces Committee medical con- struction. an interdepartmental body consisting of personnel re- sponsible for medical matters; (b) No change in existing rc- sponsibili tics of the Chief of Engineers, Chief of Bu, of Yards & Do cks and tho Direc- tor of Air Installations with respect to execution and ap- proval of: design and construc- tion of new facilities, main- tenance and repair, prepara- tion of cost and budget es- timates, and review and se- lection of sites; (c> No (OONT•D.^ TAB COT ITTEE'S RE ■CRT ON SUBJECT OF: ARMY GIST NAVY OF COMTIENTS BY; AIR FORCE R&DB MUNITIONS Bair® facility be set up to dup- licate continuing studies of working groups of the Construction Standards Sub- committee of the Munitions Board organization in deter- mining common standards for hospital requirements, space allowances a nd construction standards. ACTION TAKEN BY THE SECRETARY OF DEFENSE Q. Coni: ‘d. ■ H R. S, Standardization of Mocical Ferns Recording and Re- porting Procodures within the -untied Forces, Programs for Hos- pitalization in the Armed Forces. (Not referred t Special ..ssist- Concurs, with :: ceptio of oars 59(1Cj, 29(15) 32G(2). > the three Dopartmei mt to the Secretary Concurs in prin- * ciplo, tnd its, but considered I of Defense; Concurs y Office of 1 ir. HcNcil, Concurs in general prin- ciples. Approval withheld pending further co- ordination as to details of implement- ing the Committee's recommendations, Approved, with ex- ception of pars 29(irt, 29(16) and 32G(2,, and implementation direct- ed on 21 February 1949, T. Improvement and Standard! - at! on of Cost Aocour.t- ing Sys terns and j.opropriation Accounting of the -Adical end hosoit*- al Services of the Armed forces. (noti • >c-ar tr.v ccived. submitted to Secrotai ;ntal or HIE Agency c y of Defense on 14 / lOmments thereon have ' 7 oril 1949, ] yet boon re- Jo C 01,21 IT TEE* S GIST OF COMMENTS REPORT ON BY: SUBJECT MUNITIONS ACTION TAKEN BY THE TAB t OF: i ARMY NAVY AIR FORCE R&DB BOARD SEC MS TAINT OF DEFENSE u. Organization, Manage- (NOTE: Rot Dort submitted to Secretary I of Defense on 3 liny 1949. * I On 12 May 1949 the mont and administration No [Departmental or Nl.TE Agency comments thereon have yet i Secretary of Defense of the Medical and Hos- bee on received.) 1 1 established a Modi- pital Services of the cal Service Division, Armed Forces, with a Director of Medical Services as the head thereof. 1 within the office of the Secretary of Defense, and set forth in outline the authority, re- sponsibility and dut- ics of the Director of Medical Services, V. Medical Department i (NOTE; Renort submitted to Secretary o ’ Defense on 20 May 1949, Personnel No Departmental or NHE Agoncr cements thereon have •'’’Ct been received,; 8