INVESTIGATION OF THE VETERANS’ ADMINISTRATION WITH A PARTICULAR VIEW TO DETERMINING THE EFFICIENCY OF THE ADMINISTRATION AND OPERATION OF VETERANS’ ADMINISTRATION FACILITIES HEARINGS BEFORE THE COMMITTEE ON WORLD WAR VETERANS’ LEGISLATION HOUSE OF REPRESENTATIVES SEVENTY-NINTH CONGRESS FIRST SESSION PURSUANT TO H. Res. 192 (79th Congress, 1st Session) A RESOLUTION TO DIRECT THE COMMITTEE ON WORLD WAR VETERANS’ LEGISLATION TO INVESTIGATE THE VETERANS’ ADMINISTRATION PART 5 JUNE 26, 27, 28, AND 29, 1945 Printed for the use of the Committee on World War Veterans’ Legislation INVESTIGATION OF THE VETERANS’ ADMINISTRATION WITH A PARTICULAR VIEW TO DETERMINING THE EFFICIENCY OF THE ADMINISTRATION AND OPERATION OF VETERANS’ ADMINISTRATION FACILITIES HEARINGS BEFORE THE COMMITTEE ON WORLD WAR VETERANS’ LEGISLATION HOUSE OF REPRESENTATIVES SEVENTY-NINTH CONGRESS FIRST SESSION PURSUANT TO H. Res. 192 (79th Congress, 1st Session) A RESOLUTION TO DIRECT THE COMMITTEE ON WORLD WAR VETERANS’ LEGISLATION TO INVESTIGATE THE VETERANS’ ADMINISTRATION PART 5 JUNE 26, 27, 28, AND 29, 1945 Printed for the use of the Committee on World War Veterans’ Legislation UNITED STATES GOVERNMENT PRINTING OFFICE WASHINGTON : 1945 COMMITTEE ON WORLD WAR VETERANS’ LEGISLATION Sbventy-ninth Congress J. HARDIN PETERSON, Florida A. LEONARD ALLEN, Louisiana JOHN S. GIBSON, Georgia JAMBS DOMENGEAUX, Louisiana CLAIR ENGLE, California WILLIAM G. STIGLBR, Oklahoma JOE W. ERVIN, North Carolina A. S. J. CARNAHAN, Missouri TOM PICKETT, Texas WILLIAM J. GREEN, Jr., Pennsylvania LEO F. RAYFIEL, New York WALTER B. HUBER, Ohio JOHN E. RANKIN, Mississippi, Chairman EDITH NOURSE ROGERS, Massachusetts PAUL CUNNINGHAM, Iowa BERNARD W. KEARNEY, New York MARION T. BENNETT, Missouri ERRETT P. SCRIVNBR, Kansas JAMES C. AUCHINCLOSS, New Jersey CHARLES W. VURSELL, Illinois HOMER A. RAMEY, Ohio Ida Rowan, Clerk Joe W. McQueen, Counsel II f O N T K N T fe' Statement of— Pa^e Dr. George Morris Piersol. Philadelphia, Pa 1846 Iflftr. Max Cutler, Chicago, 111 1865 Dr. Malcolm T. MacEachern, chairman, administrative board, Ameri- i can College of Surgeons ' \880 Dr. Roy D. Adams, Washington, D. C 2087 Dr. Win. F. Lorenz, Wood, Wis 2108 pdLt. Col. Chas. P. Murphy, medical officer, Veterans’ Administration— 2110 iipppr. Chas. M. Griffith, medical director, Veterans’ Administration 2155 ipUmis H. Tripp, Director of Construction Service, Veterans’ Adminis- tration 2239 Raymond C. Kidd, Director of Supply Service, Veterans’ Administra- * tion 2258 ||p .4! George E. Ijams, Assistant Administrator, Veterans’ Administra- fe, tion 2269 Manual of Hospital Standardization—American College of Surgeons 18^9 Survey—American College of Surgeons—United States Veterans’ Admin- istration Hospitals: Kan Fernando, Calif 2026 HSan Francisco, Calif 2029 /CLos Angeles, Calif 2082 Washington, D. C 2035 Atlanta, Ga 2039 Hines, 111 2041 Indianapolis, Ind - 2044 Wadsworth, Kans 2047 Minneapolis, Minn 2050 Jefferson Barracks, Mo_. 2054 Bath, N. Y 2057 Bronx, N. Y 2060 Oteen, N. C 2062 Dayton, Ohio 2065 Portland, Oreg 2068 Aspinwall, Pa ' 2071 Columbia, S. C 2074 Memphis, Tenn 2077 Kecoughtan, Va 2079 TVood, Wis 2082 III INVESTIGATION OF THE VETERANS’ ADMINISTRATION WITH A PARTICULAR VIEW TO DETERMINING THE EFFICIENCY OF THE ADMINISTRATION AND OPERA- TION OF VETERANS’ ADMINISTRATION FACILITIES TUESDAY JUNE 26, 1945 House of Representatives, Committee on World War Veterans’ Legislation, Washing ton, D. C. The committee met at 10 a. m., Hon. John E. Rankin (chairman) presiding. The Chairman. The committee will come to order. At this point I would like to read into the record a statement of the number of veterans hospitalized since September 1919 through April 1945. Admissions Remaining Discharges World War II .. . .......... 165, 514 2,963, 483 19,922 51, 344 145, 592 All others ... 2, 912,139 Total ... 3,128,997 71,266 3, 057, 731 I would like also to call attention to the fact that yesterday Presi- dent Truman visited the veterans’ facility at Portland, Oreg. I would like to read to you the recommendation that he makes regarding that facility. In his speech to the boys he uses this language: This strikes me as a real hospital, one of the sort we all hope will be the usual thing in the country. I wanted that information to go into the record because there has been some criticism of that Portland, Oreg., hospital. Of all the hos- pitals I have visited since I have been a member of this committee, I have turned in more criticism of that hospital than any other that I went through, and that was because of the lack of equipment. Other- wise, I found it to be in splendid condition. I am glad to know that the President of the United States concurs with me in that opinion now. Mr. Pickett. Have the conditions that you criticized been corrected or did the President have the time to make the examination that you and others made ? The Chairman. I understand the conditions I criticized in 1937, when I was there, have been corrected and they now have the same facilities provided in other veteran hospitals. 1845 1846 VETERANS’ ADMINISTRATION We have met this morning to hear certain members of the medical profession. I am going to ask counsel whom he will have first. General Hines. 1 would like to present to you and the committee at this time Dr, Griffith, the Medical Director of the Veterans’ Admin- istration, who will present these consultants and members of the ad- visory group in such order as you may desire. He has his ideas as to the order, but the committee can, of course, call on any of them. Dr, Griffith, will you come forward? Dr. Griffith. May I introduce Dr. George Morris Piersol, Phila- delphia, professor of medicine, Graduate School of Medicine of the University of Pennsylvania; director of the center for institution and research of physical medicine, University of Pennsylvania; medical director of the Bell Telephone Co. of Pennsylvania; editor in chief of the Encyclopedia of Medicine. STATEMENT OF DE. GEOEGE MOEEIS PIEESOL, PHILADELPHIA, PA. Dr. Piersol. For nearly 20 years I have been able to observe at close range the operation of the Medical Department of the Veterans’ Ad- ministration. The Chairman. You are a practicing physician? Dr. Piersol. I am, sir. The Chairman. General practice ? Dr. Piersol. Internal medicine. The opportunity to do so has been afforded through membership on the Medical Council ever since that body was organized in 1924, In additional, during more recent years, by membership upon a number of special committees appointed by the Administrator of the Veterans’ Affairs to advise him on medical matters. As a result of these various activities it has been possible to come in contact with many of the medical personnel of the Veterans’ Administration both in the central office in Washington and in the field. Personal inspection during the last few years of a number of veter- ans’ hospitals has given ample opportunity to observe at first hand the work that is carried on in these institutions. These years of contact with the Veterans’ Administration’s Medical Department have afforded a basis for certain opinions and impressions concerning this all-important division of the Veterans’ Administration, The impression has been gained that from the Medical Director and the heads of the divisions down, with few exceptions, the medical offi- cers of the Veterans' Administration are an earnest, diligent, conscien- tious, well-trained group of physicians who have been trying to prac- tice satisfactory medicine in the Veterans’ Administration in spite of the many handicaps and restrictions under which they have had to work. It is a tribute to their enthusiasm for medicine and interest in the Administration that under existing circumstances they have ac- complished so much and taken such good care of the sick and injured veterans entrusted to them. Until 1940 the problems were not so acute. Since then, with the outbreak of hostilities, personnel have been steadily depleted until now it is almost impossible to obtain suitable replacements. Every group with which 1 have been connected that has ever investi- gated the medical activities of the Veterans’ Administration is in VETERANS’ ADMINISTRATION 1847 agreement that the medical services given to our veterans could be im- proved and that the medical and hospital functions of the Administra- tion are in need of reorganization. The way in which the reorganiza- tion and improvement can be effected has been set forth in detail in a special report entitled “Proposed Basic Changes in the Medical Serv- ice of the Veterans’ Administration,” submitted to the Administrator of Veterans’ Affairs by the special medical advisory group on May 17, 1945. This report deals with certain defects that are inherent in the organ- ization of the Veterans’ Administration due, in large measure, to the laws and regulations under which the Medical Department of the Veterans’ Administration operates. Until certain faults in the present set-up are eliminated it is doubtful whether any group of physicians can render to our veterans the first-class medical care to which they are entitled. The changes recommended should start with the central office or- ganization. At present the Medical Director of the Veterans’ Admin- istration, who is its chief medical officer, is not even an Assistant Ad- ministrator. The Assistant Administrator who, along with other re- sponsibilities, represents medicine is a layman through whom the Medical Director reports to the Administrator. At present, therefore, the Medical Director is not a member of the policy-making group of the Veterans’ Administration which is com- posed of the Administrator and Assistant Administrators. The Medical Service of the Veterans’ Administration is thereby rele- gated to a subsidiary position not only in theory, according to the organizational set-up, but also in actual practice. The Medical Depart- ment can never function properly until its chief medical officer is ele- vated to the status of an Assistant Administrator, who reports directly to the Administrator and is given full authority and direct responsi- bility for the conduct of the medical and hospital services. It is believed that there should be established within the Veterans’ Administration an organization comparable to the Bureau of Medicine and Surgery of the Navy, composed of the Assistant Administrator in charge of medical services and the heads of the various professional services, such as medicine, surgery, tuberculosis, neuropsychiatry, radiology, pathology, physical medicine, dentistry, research in post- graduate instruction, rehabilitation, and so forth. Such a bureau, made up of the heads of the various divisions of the Medical Department, should have full authority to direct the medical policies of the Administration. Their ability to act in all professional matters should not be inhibited by the necessity of having to report to the Administrator through a lay intermediary. The heads of the various divisions should be men of outstanding ability in their respec- tive fields and should be given compensation sufficient to attract physicians of the highest repute to such posts. Some form of special medical advisory group to the Administrator should be made a permanent part of the organization. Such a group should be charged with the responsibility of critical study of methods and results. Attached to this group should be a full-time medical executive to act as a liaison officer between the advisory group, the Medical Director, the divisional heads, and the Administrator. 1848 VETERANS’ ADMINISTRATION A plan should be established for regional consultants in medicine, surgery, tuberculosis, neuropsychiatry, and so forth. These consultants should be outstanding specialists in their respective fields. The plan to be followed should be patterned along that at present in effect in the Army, where in each service command there are con- sultants in the major fields of medicine and surgery. These consultants should visit each hospital in the region to which they are assigned at frequent intervals and should remain long enough to go over all the cases that come within their particular field. Such a group of con- sultants would be in a position to promptly recognize any professional or administrative faults or abuses that might develop from time to time. These should be reported promptly and directly to the chief medical officer and the Bureau of Divisional Heads so that they could be recog- nized and corrected by the Department at least as soon as they might become evident to the public. The efficiency of central office medical inspection could be increased by more frequent visits to the various hospitals by the heads of the various medical and hospital services. These inspections should be directed particularly to the medical and professional care of the patients. Such central-office inspections should be regular, thorough, and complete, keeping primarily in mind the quality of the care ren- dered the patients and paying less attention to administrative details. Regional offices should be separated from and conducted independ- ently of hospitals. It has been observed that the hospitals operate more effectively when they are divorced from a regional office. When the two are combined the chief medical officer of the hospital is responsible to the manager of the facility, who is almost always a layman and who may or may not be sympathetic with or interested in the medical prob- lems of the institution. The chief medical officer of a veterans’ hospital should be directly responsible to an Assistant Administrator in charge of medical services (now designated as Medical Director). In each medical facility there should be trained administrative assistants to the chief medical officer appointed to take charge of the administrative details in the management of the hospital. Such ad- ministrative assistants could be competent laymen or medical men who prefer administrative work to clinical. Such a group of admin- istrative assistants could relieve the medical personnel of a vast amount of clerical work which at present occupies so much ol the time of physicians that their clinical activities suffer therefrom. There should be appointed to each Veterans’ Administration hospi- tal competent consultants recognized as specialists in their respective fields. These consultants should be obtained preferably from local medical schools or medical centers. They should be adequately com- pensated for their time and professional services rendered, should have regular days for visiting the hospitals and during these occasions they should see all the patients on their respective services, not merely limit their activities to the observation of selected cases. Serious consideration should be given to the training of interns and residents in medicine, surgery, and the allied specialties in at least the larger Veterans’ Administration hospitals. Plans should be made for the graduate training of the senior staff members. Such graduate training should not be confined to veterans’ VETERANS’ ADMINISTRATION 1849 facilities. Properly selected physicians should be sent to those medi- cal institutions in this country where the best type of graduate train- ing in any given field is available. The regulations of the medical department should be changed so that it will be possible for the medical officers to attend important national medical meetings with- out incurring personal financial loss. The medical officers of the Veterans’ Administration should be given the opportunity to be certi- fied by the various national specialty boards and they should be urged to become members of certain outstanding medical organizations. In this way the medical personnel could be stimulated to acquire ad- vanced medical education. By this method the Veterans’ Administra- tion hospitals can be better assured of well-trained, competent medical officers. When new veterans’ facilities are constructed they should not be placed in remote locations but should be established in recognized medical centers so that the medical and scientifie facilities of such centers can be readily made available for the better care of the patients. The present tendency of new facilities to be located wherever the Army stands ready to transfer a hospital or a camp, regardless of its location and accessibility to a medical center, is unsound and is not calculated to improve the medical care of veterans. One of the outstanding difficulties with which the medical depart- ment of the Veterans’ Administration has been confronted and one which more than anything else has militated against the efficiency of medical care is the method by which all medical personnel are selected and the difficulty of obtaining a sufficient number of properly qualified persons. The present system of obtaining medical and other professional personnel through the civil-service organization is definitely unsatis- factory and should be abandoned as soon as possible. Under the pres- ent system the Medical Director has virtually no opportunity to select. Until some method is adopted by which medical personnel can be properly chosen in accordance with their educational background and professional attainments, a first-class, well-trained, efficient group of physicians, nurses, and so forth, cannot be organized. Under the present system of selection through civil service it is impossible to separate a medical officer who personally, temperamen- tally, or professionally is unsuited to the work without instituting complicated legal procedures. Advancement in the service should be dependent upon periodic examinations and should not rest so much upon age, length of service, and the number of patients over which the medical officer is in charge as upon professional efficiency. It should be possible for the proper authorities to drop unsatisfactory or incompetent physicians without resorting to cumbersome and tedious methods. The present salary schedule is too low to attract the right type of experienced physician to the service. All these problems could be largely overcome if the present bill. H. R. 8310, now pending before Congress, should be enacted into law, thereby establishing a corps similar to that of the United States Public Health Service not only for physicians but also for dentists, nurses, and other professional and semiprofessional personnel. The adoption of such a plan would bring about a reorganization of the Medical Department of the Veterans’ Administration which, it 1850 VETERANS’ ADMINISTRATION is believed, would make this service more attractive to the right type of professional men and women. It would provide an incentive for the medical and other professional officers of the Veterans’ Adminis- tration to do better work, thereby improving the character of the professional services which are so vital to the adequate and proper care of sick and disabled veterans. The Chairman. You have made a very splendid statement. I would like to ask you one or two questions. You said that the head medical officer in the Veterans’ Adminis- tration was relegated to a subordinate position. Do you mean by that he is subordinate to the Assistant Administrator? Dr. Piersol. To the Assistant Administrator in charge of medical affairs; yes. The Chairman. And you think that the Assistant Administrator should be a physician? Dr. Piersol. Yes. The Chairman. You said that we should have a medical division such as is provided in H. II. 8310. You have read that bill, have you not? Dr. Piersol. I have. The Chairman. And you approve it? Dr. Piersol. Yes. The Chairman. In that connection General Bradley asked us to hold up consideration of that bill until he returns from Europe, which will be around the 1st of August. I agree with you thoroughly. The bill should be passed. You spoke of the compensation. You said that the physicians are not adequately compensated, but under this bill, H. R. 8310, that deficiency could be met. Dr. Piersol. Yes. The Chairman. You also said that the regional office should be separated from the hospital. Dr. Piersol. I think so. The Chairman. I agree with you on that. In my State that is done. I thought all along it was a mistake to put the regional office in the hospital. You say that the civil-service system of selecting physicians is bad and should be abolished or abandoned. Dr, Piersol, That is what I think. The Chairman. I agree with you on that. I am glad to hear you bring it out and give your reasons for it. The other members of the committee are going to ask you questions. I am called to the telephone, and 1 will ask Mr. Allen to preside. Mr. Allen. Dr. Piersol, I have a question or two that I would like to ask. First, I would like to compliment you on that very constructive statement. I think it is one of the best statements that we have heard. With reference to the manager of the individual facilities, we have some managers that are doctors and some of them who are business- men. Do you have a thought on that, Doctor, what we ought to have? Dr. Piersol. In the facilities that I have visited where the regional office and the hospital are connected they work much better when the director is a physician and understands the medical problems than in those instances wTiere he is a layman and is not familiar with the medical situation. VETERANS’ ADMINISTRATION 1851 Mr. Allen. In other words, you think it is better to have a doctor as manager if you can get the right kind of doctor? Dr. Pier sol. I think that where a hospital and a regional office are combined, as they are in some places, that combination works better under the direction of a medical man as manager. Where the regional office is divorced from the hospital and is in another place, then I do not think it makes so much difference. Where the manager confines his activities to the operation of a regional office and has nothing to do with the administration of a hospital, that is all right. Mr. McQueen. May I ask a question there? In other words, your over-all recommendation, Dr. Piersol, would be that the regional office and the hospital in all instances should be separated? Dr. Piersol. Yes. Mr. McQueen. And the regional office would have such manage- ment as the Administrator would direct, and any hospital or medical center would be under the direct supervision of a doctor ? Dr. Piersol. That is right. That is my idea. Mr. McQueen. And you would separate them in all places? Dr. Piersol. That is my idea. Mr. Allen. Now, with reference to the location of hospitals, or the future location of hospitals, you recommended that they be located in large centers, medical centers, as soon as possible. Of course, the other side of the picture is this: That the Veterans’ Administration has taken into consideration the placement of the veteran, the popu- lation of veterans in the various States, and they have to endeavor to locate the hospitals where the hospitals will be nearer the bulk of the veterans. For that reason it is not always possible and probably it is not always wise to locate the hospitals in large metropolitan centers. A great many of our States, of course, do not have more than perhaps one large city where you would have a large medical center. You are not contending that it would be wise to locate the hospital in a case like that in the one large city ? Dr. Piersol. It is pretty difficult to make a general rule applicable everywhere. My only thought is that in locating any of these hospitals an effort should be made to get them away from some remote place and get them where medical consultation and medical facilities are readily available to the men who are sick, particularly in certain types of cases. Mr. Domengeaux. Doctor, did you read the magazine articles pub- lished in the Cosmopolitan magazine and in PM? The one in Cosmo- politan was written by Mr. Maisel. Dr, Piersol. I did. Mr. Domengeaux, And the other in PM was written by Mr. Deutsch. Dr. Piersol. I have read them. Mr. Domengeaux. Apart from their findings of fact, the conclu- sions they arrived at are more or less similar to the suggestions you are making now. Dr. Piersol. I think in a general way. Mr. Domengeaux. Naturally, the facts on which the conclusions were based are different. Dr. Piersol. That is my impression. Mr. Domengeaux. Your conclusions are about the same as to the corrections that should be made in the hospitals. 1852 VETERANS’ ADMINISTRATION Dr. Piersol. Correct. Mr. Domengeaux. Doctor, in your statement you stated that the average doctor is overloaded with red tape and routine work. Dr. Piersol. Yes. Mr, Domengeaux. And he receives small pay, and that his selection when he comes into the hospital is not the most desirable, in that it is difficult to find qualified people through such a civil-service examination. Would that not indicate that the doctor who went into a veterans’ facility in 1940 is an individual who had difficulty in meeting compe- tition in private practice? Dr. Piersol. That is certainly true of some, Mr. Domengeaux. Is it not true that you did not get the best, or the average medical doctor, to go into the Veterans’ Service? Dr. Piersol. I think that is true. Mr. Domengeaux. Therefore, the Veterans’ Medical Service prior to 1940 was administered by inferior men professionally, as a whole? Dr. Piersol. There are undoubtedly men in that medical group who are not up to the standard of many of these lay physicians out- side. On the other hand, it is my observation that those who have been in charge of the departments, who head up the big divisions and who have been the chief medical officers of hospitals and the chief surgeons, have been exceptionally good men who were thoroughly interested. If you take the rank and file all the way down the line there have been a good many men, I think, that would have been misfits outside. Mr. Domengeaux. The question of their interest and their sympathy toward their patients is not involved. I do believe that they have a conscientious desire to be as kind and helpful as possible, but I am asking you whether their medical attainments were up to the average, as a general proposition. Dr. Piersol. I suppose, taking it broadly and very generally, it probably was not. The Chairman. Do you think that in view of the whole civil-service set-up? Dr. Piersol. I would not know about that. Mrs. Rogers. I am quite troubled about section 30 of the bill before you. It says: The Administrator of Veterans’ Affairs is authorized to appoint, in addition to the Surgeon General, not to exceed five staff assistants, including a general counsel, in the salary range $9,000-$12,000 per annum. I wonder if that does not open the door for very much the same situation to arise that we are in the midst of today. The legal counsel and the staff assistants will have a great deal of power. Dr. Piersol. I am not entirely clear as to what is referred to in that staff section. Mrs. Rogers. There may be a joker in that, and I think it is impor- tant to look into it before we pass the legislation. I think that it opens the door, Mr. Chairman, for the same situation to exist that exists today. I think that we ought to look into that. Doctor, I imagine that you are very much alarmed, just as I am, about the order that the War Department has issued rescinding the transfer of doctors to the Veterans’ Administration. Do you know anything about that? VETERANS' ADMINISTRATION 1853 Dr. Piersol. No; I do not know about that. Mrs. Rogers. I knew about it and spoke about it last week, and I understand that it was made generally public yesterday. The order was that the transfer of doctors to the Veterans’ Administration was to be rescinded. Two groups may be transferred. One is the group of doctors, Army doctors, who formerly served with the Veterans’ Administration. I think that there are about 100 of them. They may serve with the Veterans’ Administration upon request; otherwise, they will be discharged. Also, all men of 64, 1 understand, whether in the Veterans’ Administration or in the Army, will be retired. There is another group that may be transferred from the Army, and that is the graduating man, the man that has graduated from an Army-approved medical school, if they are not eligible for the Army. So you have only two possibilities of men going from the Army to the Veterans’ Administration. With the retirement of a number of Army men in the Veterans’ Administration, the Veterans’ Administration’s cupboard of doctors is going to be very bare. I am extremely sorry that General Bradley has asked us to wait until his return before doing anything. I can see, on the other hand, why he wants that to happen. If the Medical Corps is not started, I think that we are going to lose many fine doctors who are being dis- charged from the Army today. Dr. Piersol. I think that is true. Mrs. Rogers, Are you troubled about that situation ? Dr. Piersol. I think that is true. It is a very difficult and critical situation, this question of medical personnel. Mrs. Rogers. And every day makes a difference. Dr. Piersol. It will take some time. If the corps were started tomorrow, it would be a year or more before jmi could really get the thing in operation and attract good men. Mrs. Rogers. You would know that you were going to be able to attract men. Dr. Piersol. I think so. Mrs. Rogers, The right men. What do you think a consultant should be paid? They can earn very much more on the outside. What would be a fair rate of pay for consultants? Dr. Piersol. That is a pretty hard question to answer. It depends a great deal on who the consultant is and how far away he is. I think it would be very difficult to answer that question just offhand. Mrs. R :gers. $20 is much too low. Dr. Piersol. I think that is too low for the type of consultant that I have in mind. Mrs. 'Rogers. Has the Bureau used your counsel as much the last year as formerly? Dr, Piersol. Well, in the last year the Administrator has called together groups to advise with him much more often than formerly. Mrs. Rogers. Does he follow your advice? Dr. Piersol, I think he always receives our recommendations, and I have no doubt acts upon them as best he can under the circumstances. Mrs. Rogers. But you feel that as a matter of fact your advice has not been carried out? 1854 VETERANS’ ADMINISTRATION Dr. Piersol. Of course, in the last score of years there have been a great many suggestions, including the creation of a medical corps, which have not been followed yet. Mrs. Rogers. It has been a long and uphill fight; has it not, Dr. Piersol ? Dr. Piersol. I think the first recommendation for that was in 1924, Mrs. Rogers. We have not had doctors appearing before this com- mittee either, during that time, which I feel has been very unfortu- nate— The Chairman. We never asked for them. Mrs. Rogers. I beg your pardon. I asked for them. I asked that the Surgeon General of the Army and the Navy appear. The Chairman. I have been on this committee since 1934, and we have summoned everybody before the committee that has been asked for thatT know anything about. Mr. Scrivner. Eighteen months ago one of the first requests I made was to have Colonel Rusk come before the committee. Mrs. Rogers. They are here now, anyway, and I am very glad of it. What did you find in the hospitals that should be changed, Dr. Piersol? Did you find abuses in any of the hospitals? Dr. Piersol. No; I never did—never. Mrs. Rogers. Were any abuses brought to your attention? Dr. Piersol. My personal observation of the hospitals was that the patients were happy, that the doctors were sympathetic, and that they were doing the best they could for them. They labored under the disadvantages of a great deal of paper work and a great deal of routine and regulations which I suppose are inevitable in such hospitals. Their personal care of and interest in the patients in every general hospital to which I have gone, including neuropsychiatric hospital at Coatesville, was in every way satisfactory, Mrs. Rogers. When they had a lay manager, you found oftentimes that the doctors were taken away from their patients ? Dr. Piersol. They were interrupted in their professional work. Mrs. Rogers. That meant lack of care. Dr. Piersol. It made it difficult for the men to carry out their pro- fessional work as efficiently as when they were not interrupted. Mrs. Rogers. And you found a shortage of nurses ? Dr. Piersol. In the last 2 or 3 years there has been a shortage of nurses and attendants and doctors. Mrs. Rogers. In many instances you are absolutely correct, the doctors and nurses have performed a remarkable and unselfish service. Do you feel that the corps bill will attract men of great ambition after it is started? Dr. Piersol. I think after it is started and after it has been well recognized, it should attract a number of able young men coming out of the Army. Mrs. Rogers. They will feel that there is a future ahead of them? Dr, Piersol. Whether they have been in the Army or not The Chairman. You do not confine that to the Army? Dr. Piersol. No. I meant that many of them are in the Army now and there will be a great many more looking for the positions a few years from now than there are now. VETERANS’ ADMINISTRATION 1855 Mrs. Rogers. That is why it is so important to get them coming out of the Army today. Do you feel that it would be helpful to have a medical training school at the medical center that will be established here in Washington? Dr. Piersol. A research center of some kind ? Mrs. Rogers. A research center and a training school. Dr. Piersol. Well, such as they have had at Mount Alto. Mrs. Rogers. More than that; such as they have at Walter Reed, a training center for doctors. I do not see why the Veterans’ Admin- istration should not have a training center also. That would attract a great many men. Dr. Piersol. I think in the large hospitals there should be something done to create educational activity and training. Mrs. Rogers. And that is also true as to nurses? Dr. Piersol. Yes. Mrs Rogers. And the attendants? Dr. Piersol. Yes. Mrs. Rogers. Do you approve of paying the attendants more? Dr. Piersol. I do. Mr. Pickett. I would like to ask you in reference to H. R. 3310, which you endorsed in general terms a moment ago, whether you have studied that bill closely enough to be able to suggest that it be passed without amendment, or do you have some suggested improvement in the bill that could be made? Dr. Piersol. I have never studied it sufficiently to say that it should be passed without amendment. I think one of the objections that has been raised to it by the medical profession at large is that appar- ently it was believed it would make possible the placing of doctors in the Veterans’ Administration whether they wanted to be placed there or not. It would restrict in some measure the ability of doctors to choose whether or not they would go into the Veterans’ Administra- tion. The Chairman, This applies only in time of war, does it not? Dr. Piersol. I guess that is true. Mr. Domengeaux. It would not apply in peacetime. It is volun- tary employment. That would not apply in peacetime. The Chairman. I do not think so. Dr. Piersol. I guess not. Mrs. Rogers. It would not apply in peacetime; I know that. Mr. Allen. It would apply to a physician in the Regular Army, of course. Mrs. Rogers. Not in peacetime. General Hines. The bill is designed so that no one goes in until he passes the board appointed by the President. They voluntarily go in in time of peace. It is a peace organization in time of peace. In time of war the whole set-up of the Medical Bureau of Medicine and Surgery becomes a part of the armed forces. It is not made a part of the Army and Navy, and at that time they are commissioned and held, of course, like officers of the Army and the Navy. Likewise, personnel can be selected through the Selective Service to fill vacancies and avoid the troubles we have had, but in times of peace anyone who joins joins of his own volition. 1856 VETERANS’ ADMINISTRATION The Chairman. Do you have any objection to it under those cir- cumstances, Doctor? Dr. Piersol. No. It was not my own personal objection. I think it Avas something that was misunderstood by the medical profession at large, and I doubt if they understand the situation. Mr. Pickett. You asserted in your original statement that the vet- erans’ facilities be located adjacent or near to some already established medical center. I take it you mean some city or town where there is a clinic recognized as of high caliber. Dr. P IERSOL. Yes. Mr. Pickett. Did you mean to suggest that it should be confined to the largest cities such as Philadelphia and NeAv York, or towns of 40,000 or 50,000, or just any reasonably good-sized town that possessed medical men of some caliber and attainments avIio could be consultants ? Dr. Piersol. That is right; not necessarily big cities like San Fran- cisco, New York, and Philadelphia. Mr. Pickett. It might apply to towns of 10,000 or 15,000 to 25,000 in given cases ? Dr. Piersol. Yes. Mr. Pickett. You understand the general policy the Veterans’ Ad- ministration follows with reference to the location of those hospitals? Dr. P iersol. I think so. Mr. Pickett. There would be nothing in your suggestion that Avould be counter to their established policy in that connection ? Dr. Piersol. No. Mr. Pickett. Do you make any distinction along that line ? Dr. Piersol. No. Mr. Pickett. One further question with reference to the articles that haA7e been published recently criticizing the Veterans’ Adminis- tration hospitals in various sections of the country. Have you, since those articles were published, had an opportunity to visit any of the facilities that have been criticized in those articles? Dr. Piersol. No; not this winter I have not; I have not since the articles Avere published. Mr. Pickett. I believe that is all. Mr. Scrivner. Doctor, in your statement you criticized the Veterans’ Administration for taking over Army and Navy hospitals. Was that criticism directed toward adopting that as a permanent policy or would you criticize taking them over as a matter of emergency during a period of building? Dr. Piersol. My thought Avas in reference to their geographical location. Many Army hospitals are in fairly remote spots as far as medical facilities are concerned. If you took them over you would be no better off than if you put up a veterans’ hospital in a remote spot. Mr. Scrivner. Then it is your suggestion that doctors should be the managers of all these hospitals. Have you not found in your A7isits that some of the best hospitals that we haA7e have been managed by laymen? Dr. Piersol. There are lay managers and there are medical direc- tors, also. Mr. Scrivner. So it is a matter largely of a man’s personal mana- gerial ability that determines Avhether he is better fitted to manage a hospital; is that not true? VETERANS’ ADMINISTRATION 1857 Dr. Piersol. I think as a general principle—and this applies to civilian hospitals—the best hospitals in the United States are man- aged by medical directors and not by lay directors. Mr. Scrivner. You made the suggestion that the medical officer was not now an assistant administrator with full authority. Is there any- thing under the present existing law that makes that impossible? Dr. Piersoe. Not that I know of. Mr. Scrivner. You do not need to pass a law to get that job done. Dr. Piersol. Oh. no; I do not think so. Mr. Scrivner. Then we will come down to the question of the pa- tient load that we now have. I think the figures shown here previously indicated that about 60 percent of the veterans in hospitals were non- service-connected cases. We are faced now with a shortage of doctors and attendants, and incidentally, as far as the Army’s order is con- cerned, I am not much alarmed about it after having seen some of the things that have happened under it and some of the doctors we will see. Getting back to the 60 percent of non-service-connected cases, is there not an indication that there might be a necessity in order to give the service-connected cases the care and attention they deserve and should have the non-service-connected cases will have to be handled in some other way ? Dr. Piersol. If the service-connected load gets so great—and that will be the first thing to handle—then the non-service-connected cases would have to be taken care of some other way. Mr. Scrivner. The disabled men will have to come first, and if our hospitals are overcrowded due to non-service-connected cases, by cur- tailing somewhat our non-service-connected cases we will be able to give more attention to the service-connected cases. Dr. Piersol. I think so, Mr. Scrivner. You mentioned the handicaps and restrictions under which these doctors have to work. Would you care to specify in some detail these handicaps and restrictions to which you referred? Dr. Piersol. I was referring particularly to the amount of clerical work, the paper work, that they have had to perform every day. Also, to the fact that they frequently have to go through a good deal of administrative red tape before certain things can be done. Mr, Scrivner. Has yonr committee made any suggestions to the Veterans’ Administration about eliminating some of those handicaps and restrictions? Dr. Piersol. Yes. Mr. S crivner. And have any of your suggestions been adopted? Dr. Piersol. Yes. Mr. Scrivner. How many have not ? Dr, Piersol. I would not know mathematically. I think that all our suggestions recently have been acted upon as best they could under the circumstances. Mr. Scrivner. What do you mean by recently? Dr. Pi ersol. In the last year. Mr. C arnahan. You spoke of the membership of the veterans’ doc- tors in professional organizations as though there might have been some restrictions, or is it more difficult for members of the veterans’ facilities to belong to these organizations than other doctors? 75183—45—pt. 5 2 1858 VETERANS’ ADMINISTRATION Dr. Piersol. Yes; it is. Mr. Carnahan. What is the set-up? Dr. Piersol. I think largely because they are moved around from place to place so that they have difficulty in establishing membership in county medical societies, because they are not in any one place long enough, and that means if they cannot get into a county medical society then, of course, they are in a position automatically where they cannot become members of the American Medical Association. Then there are some of these other organizations such as the American College of Physicians and Surgeons where the question of residence is not so important, but where the question of professional attain- ments is, these men have often not had an opportunity to carry on enough professional work of a high order to qualify. Mr, Carnahan. Of course, that would be a matter for the Medical Association to take care of, would it not, the arranging of their rules by which the membership could be had? Dr. Piersol. As far as the American Medical Association is con- cerned, that is true. Mr. Carnahan. In the location of training camps, as I understand it, you realize that the military training camps are located in isolated places on purpose. That is the type of place that they need. Dr. Piersol. That is right. Mr. Carnahan. Certainly that is not a proper location for a veter- ans’ hospital. Dr. Piersol. No, sir. Mr. Carnahan. Even though those hospitals are already built and at a considerable expense, do you think that we should still perhaps forget the idea of locating veteran hospitals in the training camps and relocating the veteran hospitals to the best advantage for the years to come? Dr. Piersol. I think if the proper object is to give the veterans the bes4- medical care, that is the thing to do. Mr. Carnahan. You have a private practice; is that right? Dr. Piersol. That is right. Mr. Carnahan. And you have had considerable connection with private hospitals? Dr. Piersol. Yes. Mr. Carnahan. As well as veteran hospitals? Dr, Piersol. Yes. Mr. Carnahan. What, in your opinion, is the relationship between the two ? How do they rate ? Dr. Piersol. The veterans’ facilities that I personally inspected, as I have said in reports to the Administrator, compare very favorably with the clinical work, the records they keep, with any private hospital, Mr. Ramey. In the ethics of your profession the doctor stands out at the head, of course, and the nurses are taught to respect your profes- sion so they obey you. Now, in the eight hospitals that I visited I found that the great problem was the problem of attendants. Here is what they said: They said that the doctors just spent a moment with the patients, or gave the order to the nurses. In some hospitals, especially like the one in Dayton, Ohio, you have the nurse in her room with the medicines. Someone rings the buzzer and she directs an at- tendant to go to that patient. The attendants say that after all the VETERANS’ ADMINISTRATION 1859 doctors see them for just a minute. The patients are treated by some of the outstanding physicians. In Dayton, Ohio, one of the greatest surgeons in the country is in charge. The veterans feel safe about an operation there. The veteran gets no recognition from the physician, professional recognition. He does not get to see him. That is the reason that the veteran occasionally complains and says that, after all, when we were overseas, we were treated like kings, but when we get into a veterans’ hospital we are the forgotten man. He feels that he does not have personal recognition from the physician. He would like to talk things over with the physician. About the only person that sees him is that attendant. They are under the nurse. At present wages we can hardly get attendants. So the nurse will get her bottle of mendutol and give him something to put him to sleep so that he will not ask questions. Now, I am disturbed about the situation of attendants. If we have a surgeon general and his decisions are controlling, and if we work out something that the attendants will be all veterans, all brothers, dignified with the title of technicians, so he, too, is recognized as a professional, so the attendant is not one of a group that does not get the recognition ? When the doctors work out something like that, so that that attend- ant will be professional, too, the same as the nurses and the doctors— that is, recognized as that by the veterans—can something like that be worked out ? Dr. Piersol. He is practically an orderly. Mr. Ramsey. Yes. Dr. Piersol. And it is very difficult in the best civilian hospitals to get good orderlies now. That problem is not peculiar to the veterans’ hospitals; it is prevalent in all hospitals. Mr. Ramey. Yes; but so many will be in our veterans’ hospitals, and I found the real situation of the veterans; he wants to talk to someone, and the only one he can talk to who can give a good deal- of time is an attendant. If that was a veteran of this war and that was made a profession, would that veteran in the hospital not feel then, well, I am not just shoved around; I am recognized? Dr. Piersol. He probably would. It would be a good psychological approach to the thing. All patients feel just like these boys do. And you can go into the wards of any big hospital. It is the same thing. The surgeon sees them. He does a professional job well enough, but, after all, the pa- tient, whether he is a veteran or not, wants a personal human touch. Mr. Ramey. Yes. Dr. Piersol. To sit down and talk an hour does him a lot of good. Mr. Ramey, Yes. Dr. Piersol. Now, you have a hundred people in the ward, and you cannot sit on the side of the bed and hold their hands and listen to them all day long. You have to go along, and it is the problem of finding the people for attendants in hospitals who have the proper psychologi- cal approach and sympathy in dealing with patients. What you find in the veterans’ hospitals you will find in Massachu- setts General, or any other hospital today, patients being the same the world over. 1860 VETERANS' ADMINISTRATION What they want is attention and persons fussing over them. The Chairman. What is that, Doctor? Dr. Piersol. Well, I say, whether they are in the veterans’ hospitals or in a private hospital, they want attention. The Chairman. You say the orderlies are no better in private hos- pitals? Dr. Piersol. That is right. The Chairman. Is Dayton an NP hospital ? Dr. Piersol. No; Chillicothe. They have an outstanding surgeon there. But the persons who do complain say they just do not get the treatment. When the recognition is not there, they kind of feel, well, kind of pushed around. Mr. Cunningham. Dr. Piersol, may I interpose a question right there? Dr. Piersol. Yes. Mr. Cunningham. What would be the situation if we would dis- pose of these hospitals and then give them money, let them select their own doctors? What would be the result? Or would you care to express an opinion ? Dr, Piersol. That would involve a pretty big question, would it not ? Mr. Cunningham. Yes. Dr. Piersol. I suppose it would have the same results as with all private patients, some would go to good doctors, some would waste their money with poor doctors. Mr. Cunningham. Well, would the veterans, as a whole, be any better off ? Dr. Piersol. He would probably be worse off. Because now he is in a place where they have good facilities and excellent men at the head of the service, and where he is going to get legitimate scientific medicine practiced on him and does not have the opportunity to do all sorts of fool things that he would have if he would go off for himself. Mr. Cunningham. Then the statement that they are not getting the treatment they should get in private hospitals is a little far- fetched ? Dr. Piersol. That is not true. The same situation pertains to any hospital in the world. The Chairman. What is that question ? Mr. Cunningham. Will the reporter read it? (The question was read.) Dr. Piersol. My answer is that it is far-fetched. Mr. Cunningham. Now, your private—you are a private physi- cian ? Dr. Piersol. Yes, sir. Mr. Cunningham. And you gentlemen are a little concerned as to whether there is ever going to be socialized medicine ? Dr. Piersol. Some of them are. Mr. Cunningham. Is it your opinion that the wider the veterans’ hospitals get the closer we are getting to socialized medicine ? Dr. Piersol. Yes. I mean the more people who are taken care of in Government hos- pitals, veterans, or otherwise, is a big entering wedge for socialized medicine. VETERANS’ ADMINISTRATION 1861 Mr. Cunningham. If we would have another war like the one we are in, eventually all hospitals would be Government hospitals, would they not, Doctor ? Dr. Piersol. I guess many would be Government hospitals; I do not think all of them would. The Chairman. That would not be the case if these hospitals were confined to service-connected cases, tubercular and neuropsychiatric cases, would it ? Dr. Piersol, If they were—if they would confine their efforts to service-connected disabilities. The Chairman. Well, now the neuropsychiatric and tubercular have to be taken care of in some kind of institutions, do they not? Dr. Piersol. Most of them—many of them do. The Chairman. Excuse me, Mr. Ramey. I believe we are on your time on this. Were you through ? Mr. Ramey. I believe so, for the present. The Chairman. Mr. Auchincloss? Mr. Auchincloss. Doctor, I believe you answered a question of Mr. Ramey or Mr. Scrivner about the excess duties that the manager of a hospital has, so that it circumscribes his ability to operate. Is the cure to that the decentralization of the general system of management in the Veterans’ Administration, giving the manager of a hospital greater latitude, greater power, authority? Dr. Piersol. You mean so that he would not have to appeal to central office ? Mr. Auchincloss. If he wanted to get a typewriting machine, he would not have to apply to the central office for it. Dr. Piersol. I think on general principles that is true. I think now they are held down. They are subject to a good deal of delay, on the other hand, there are many things that can be settled better by competent administrators in the central office than men in the field. But I think they should have more latitude than they have now, personally. Mr. McQueen. Now, I would like to ask a question or two. The Chairman. Yes. Mr. McQueen. Doctor, you stated the changes should start with the central office, and in response to questions, and in your statement, your main point is that authority should be in a medical director on a level with the Assistant Administrator. Is that your main Dr. Piersol. That is the first basic principle. Mr. McQueen. And from the medical standpoint that would take care of, you believe, the situation from a medical standpoint, that is, if he were placed on that level. Now, in response to other questions, you stated that you believed that every hospital should be managed by a physician; and then you stated that there was a great deal of paper work. Is it your opinion that a hospital could be better operated with a lay manager, with a medical head who reports to him, or would you have a doctor actually in charge of the administration of the hospital ? Dr. Piersol. I would have a doctor in charge with properly quali- fied lay people under him reporting to him, and the corps administra- tive men such as they have in the Army, Administrative corps for example, could take care of the paper work, the matter of supplies, buying food, all that sort of thing. 1862 VETERANS’ ADMINISTRATION Mr. McQueen. Well, is it not a fact that a great many of the well- operated and managed civilian hospitals have a lay manager and the staff merely looks after—of course, the medical staff takes care of the medical end; but the hospital is under the charge of the lay manager. Is that not true? Dr. Piersol. That is true of some hospitals. Mr. McQueen. Well, do you believe those hospitals are more effi- ciently operated than the other hospitals, or would you say the reverse ? Dr. Piersol. I think the ones where the best professional work is carried out are those under the direct charge of the medical director. Mr. McQueen. And the lay personnel is under him? Dr. Piersol. Yes. Mr. McQueen. As to the management of the hospital and all of that ? Dr. Piersol. Yes. Mr. McQueen. Now you spoke of the fact that it is very hard for some of these medical men to belong to the societies that they probably wanted to belong to, and so forth. There has been some testimony here that the personnel, the medical personnel, the professional personnel in veterans’ hospitals, should be rotated, the same as in the Army, on a 2-year tour. What are your ideas about whether or not the doctor should be located in New York or Fort Lyons, Colo., and stay there, or should he be rotated—where should he be located? Dr. Piersol. I think they should be placed in the position where they are able to do the particular kind of work they do best. In other words, if you had a fine chest surgeon and he was in New York City and had a set-up there where he did this work for example, he ought to be allowed to stay there. The same way with the Mayo Clinic surgeons, who do not want to rotate them to San Francisco or Chicago. And they ought to be allowed to build up an organization that is adapted to carry on the special thing they are qualified for. Mr. McQueen. Then as a matter of policy, you would not recom- mend a rotation of medical personnel, at least, among the hospitals, at a given period ? Dr. Piersol. I would not be in favor of a fixed policy of that kind. I think that is all an individual matter. Mr. McQueen. Now, you spoke of the fact that the records were very well kept, and you also spoke of the fact that there is a great deal of paper work. What would be your suggestion which might help the records which must be kept in veterans’ hospitals, probably kept in private hospitals, and yet give the same service to the veteran ? What would be your suggestion on that? Dr. Piersol. Better organized and greater secretarial help, the introduction of time-saving devices such as dictaphones, and so forth. Mr. McQueen. Is it feasible for the highly professional men in taking care of patients to delegate this work of records to someone else? Dr, Piersol. No ; the doctor has to be the man to install—to initiate the records, but if he sits down and in longhand has to write it all out, it is a laborious thing. Whereas if he can dictate it to a secre- tary or administrative assistant or dictaphone, he saves time. VETERANS’ ADMINISTRATION 1863 Mr. McQueen. And the record would be just as good and would answer the same purposes, you say, as if he wrote it all out? Dr. Piersol. That is the way the records are kept and written out in most of the big civilian hospitals. Mr. McQueen. Now, as to inspection of hospitals which you spoke of in your dissertation there, what would be your suggestions The Chairman. Mr. McQueen, how many more questions have you ? Mr. McQueen. Just one more. The Chairman. We want to meet that roll call. Mr. McQueen. What would be your suggestion about the inspection of hospitals, whether that should be done by an outside board ? Dr. Piersol. I think there should be fewer types of inspection. I think the professional group should make more frequent inspection and pay more attention to the professional side. In addition to that, I think they should make definite systematic visits at which time they direct their attention to that particular group in which they are interested ? Mr. McQueen. In other words, they should be independent of the administration altogether and make their reports to the administra- tion of their inspection? Dr. Piersol. Make their reports to the medical director. Mr. McQueen. What would be your suggestion as to the kind of set-up that should be, in the form of this advisory group? Or some- thing else? Dr. Piersol. If you had an advisory group—I think they should make their report to the Chief of the Medical Service. Then he can bring that up to an advisory group. Mr. McQueen. That is all, Mr. Chairman. Mrs. Rogers. I have just one question. You spoke of the veterans’ hospitals which are well run. Which are the best? Dr. Piersol. I think the best veterans’ hospital I was in was the one at Aspinwall outside of Pittsburg. I think the one at the Bronx is a well-run hospital. Mrs. Rogers. How about Hines? Dr. Piersol. I have never been there. Mrs. Rogers. What kind of contribution do you think the Veter- ans’ Administration has made to medicine and surgery ? Dr. Piersol. They published a bulletin which, if not widely read, should be, because it contains a great deal of very excellent medical observation. Mrs. Rogers. I think that should go in the record, Mr. Chairman. I think it would be helpful. The Chairman. His statement may go in the record but it is not necessary to put the pamphlets in there. Mrs. Rogers. Oh, no. His statement along that line. The Chairman. Mr. Domengeaux ? Mr. Domengeaux. On that particular question, do you know of any particular contribution that the doctors of the Veterans’ Administra- tion have made toward the advancement of medicine or science out- side of treatment in osteomyelitis and treatments in cancer at the Hines foundation? Do you know of any other contribution that doctors in the Veterans’ Administration in 30 years have made toward the advancement of medicine ? 1864 VETERANS’ ADMINISTRATION Dr. Piersol. I think so. I cannot specify the various articles right now but I have read a great many of them. I think they have done outstanding work in cancer. Mr. Domengeaux. Yes. Dr. Piersol. I think they have done good work in neuropsychiatry. And there have been a good many surgical contributions made. That is all offhand. I would have to look it up. Mr. Domengeaux. Doctor, do you know in your inspections of these hospitals whether these activities toward making it possible for the doctor in the veterans’ facility to keep up with his profession were made available to these doctors by the central office, and does the doctor in the veterans’ hospital keep up with his profession, and is he encouraged to do so ? (Mr. Domengeaux assumes the chair.) Mr. Domengeaux. Doctor, is he en couraged to do so by the central office? Dr. Piersol. He is encouraged to do so, and in most of the hos- pitals, or all that I have ever visited, they have periodical weekly and bimonthly conferences at which they get their professional groups together, which are scientific meetings, in which they assign subjects and go over the clinical material. I think possibly they may not have been urged as much as possible to go to some of the national meetings, and I think that it is due to the fact that it is hard for them to get the time, and there are certain arrangements about their pay and allowances, and so forth, that puts some financial burden on them, Mr. Domengeaux. I had this experience, Doctor, when the oppor- tunity to look at some of these hospitals, one at Biloxi, Miss., where the head surgeon, who had been there since the Veterans’ Adminis- tration was organized, had come right out of medical school and from that time to the present time, the fact that he had requested to attend certain clinical schools that he had never been allowed— I will not say allowed—but he has never attended any clinical school or refresher course notwithstanding the fact that he was head sur- geon, since commencing some 21 years ago. Do you consider that a desirable situation? Dr. Piersol. No; I think that is one of the things that should be corrected, and an opportunity should be given these men to go to postgraduate courses, to be paid, let them take the time out to go, even though it takes months or years, if necessary. Mr. Domengeaux. But there has been no attempt on the part of the Veterans’ Administration to do that, has there? Dr. Piersol. No. I think not. Mr. Domengeaux. And that is absolutely essential in an organiza- tion of this kind? Dr. P iersol. I think so. Mr. Domengeaux. How else can a doctor keep posted in his profes- sion unless such a movement prevails ? Dr. Piersol. He cannot. Mr. Domengeaux. Now, have you not found this also, Doctor, that in many instances doctors were assigned to certain specialty where they had no aptitude or training or inclination for that particular type of work? VETERANS' ADMINISTRATION 1865 Dr. Piersol. I imagine that has happened. Mr. Domengeaux. You do not know that of your own knowledge? Dr. Piersol. I could not specifically cite the instance. Mr. Domengeaux. You have made no study in that direction to find whether the doctors were properly fitted to carry on their work? Dr. Piersol. I think some of them have been assigned to do things for which they had never had enough professional training in certain lines. Mr. Domengeaux. Nowt, is it not a fact that in the tuberculosis hospital, a doctor, irrespective of his previous tuberculosis training, is given a very short course, most of which is paper work, that there- after he is considered a tuberculosis specialist ? Dr. Piersol. I do not know wdiether he is considered a tuberculosis specialist, but he is often assigned to take care of tubercular patients. Mr, McQueen. Will you announce now’ at 1: 30 Mr- Domengeaux. Yes. We are going to stand adjourned to meet again at 1: 30. (Whereupon the committee recessed until 1:30 p. m. of the same day.) AFTERNOON SESSION The committee met at 1: 30 p. m., Hon. John E. Rankin (chairman) presiding. The Chairman. The committee will come to order. Dr. Griffith. Dr. Max Cutler, former director, Michael Reese Hos- pital, Chicago; a former instructor in pathology, Cornell Medical School and Memorial Hospital, New York; former director, New York City Cancer Institute; associate in surgery, Northwestern Uni- versity; past president, American Association for the Study of Neoplastic Diseases. STATEMENT OF DR. MAX CUTLER, CONSULTANT IN CANCER, AT HINES HOSPITAL, CHICAGO, ILL. The Chairman. Doctor, give your name and address. Dr. Cutler. Dr. Max Cutler, Drake Hotel, Chicago. The Chairman. Dr, Cutler, you are a practicing physician ? Dr. Cutler. Yes, sir. The Chairman. Where do you practice ? Dr. Cutler. Chicago. The Chairman. How long have you practiced ? Dr. Cutler, Since 1924. The Chairman. What school are you from? Dr. Cutler. Johns Hopkins. The Chairman. Where did you take your literary course ? Dr. Cutler. University of Georgia. The Chairman. University of Georgia. You graduated from Johns Hopkins in 1924? Dr. Cutler. 1922. The Chairman. What did you do from 1922 to 1924? Dr. Cutler. I was resident house surgeon in Johns Hopkins Hospi- tal. I was there 1 year: then I was at Michael Reese Hospital in Chicago. 1866 VETERANS’ ADMINISTRATION The Chairman. So you have been a practicing physician in Chicago since that time? Dr. Cutler. No, sir; between 1930 and 1934 in New York, and then in Chicago. The Chairman. Are you a specialist? Dr. Cutler. Yes, sir; in cancer. The Chairman. You are a cancer specialist? Dr. Cutler. Yes, sir. The Chairman. That is what I want to get around to. We are glad to have you. The other members of the committee will come in as we proceed. Dr. Cutler, before you start in, are you a consultant at the veterans’ hospital in Chicago? Dr. Cutler. Yes, sir; I am consultant in cancer at the Hines Hos- pital. The Chairman. How long have you occupied that position? Dr. Cutler. Since 1931. The Chairman. Thank you. You may proceed. Dr. Cutler. For the past 14 years it has been my privilege to serve as consultant in cancer and director of cancer research in the Edward Hines, Jr., Hospital of the Veterans’ Administration. Dur- ing this same period I have been director of the tumor clinic of the Michael Reese Hospital—1931-38—and since 1938 director of the Chicago Tumor Institute. Throughout this period I have engaged in private practice in Chicago. Within several months after my arrival in Chicago in 1931 I was invited to visit the Hines Veterans’ facility with a view to accepting the position as consultant in cancer. When I began my work as consultant in 1931 there were approximately 100 beds set aside for cancer patients. Today there are almost 600 cancer beds. My work has consisted of regular weekly visits to the Hines Hos- pital and numerous visits to central office in Washington for con- ferences with the Administrator and Medical Director and their staffs. Also, before the war, annual inspection visits to the subsidiary cancer units, at Washington, I). C., Bronx, N. Y., Atlanta, Ga., Port- land, Oreg., and Sawtelle, Calif. The Chairman. Doctor, will it disturb you to interrupt you at that point? You say when you began there were 100 patients, I believe you said 90. Dr. Cutler. About 100. The Chairman. About a hundred cancer patients and now there are 600? Dr, Cutler. Yes. The Chairman. Will you explain why that increase ? Dr. Cutler. Because the Hines Hospital is the one hospital in the Veterans’ Administration that is especially interested in cancer. The Chairman. In other words, it is because their treatment of cancer has attracted these men there. Is that it? Dr. Cutler. I think so. 1 lie Chairman. Would you say that has caused this increase? Dr. Cutler. Well, they are also sent there by the Director from the central office. Mrs. Rogers. Is it not true that you have a very fine record of cure of cancer of the thorax at Hines? VETERANS’ ADMINISTRATION 1867 Dr. Cutler. What form? Mrs. Rogers. Cancer of the thorax. Dr. Cutler. Cancer of the throat, yes. Larynx, yes; we have been doing special work. Mrs. Rogers. It has been very successful. Dr. Cutler. Yes. Mrs. Rogers. And is it not true, also, that, due to the very fine wmrk of the cancer society that cancer is recognized earlier than it Avas formerly? Dr. Cutler. Yes. The Chairman. Would you say there is a general increase or de- crease in the United States? Dr. Cutler. We know that cancer is on the increase, but we are not absolutely certain of the reason Avhy. Mrs. R gers. Is it because they discover it earlier? Dr. Cutler. One reason is that people are being saved by the new de\Telopments from deaths from other causes, so they live to be older and the older one gets the more likely he is to develop cancer. There are also other cancers, as for example, cancer of the lungs. I think there is no question but that there is an increase in incidence of cancer of the lungs. I have also directed the treatment of veterans in the Chicago Tumor Institute. In a constant effort to maintain and advance the stand- ards of treatment I havTe made numerous Ansits to cancer centers in this country and abroad. In view of the fact that until the outbreak of the present war, the most advanced work in the X-ray and radium treatment of cancer came from the Curie Institute in Paris, I made annual \Tisits to Paris for many years in order to familiarize myself thoroughly Avith these advances. I also arranged for members of the staff of the Curie Institute to come to this country for conferences and lectures, and finally Dr. Henri Coutard. chief of the X-ray department of the Curie Institute, joined the staff of the Chicago Tumor Institute for a period of 3 years, during which time he made numerous visits to the Hines Hos- pital and assisted Avith the deArelopment of new methods. The results in the treatment of cancer in 1931 Avere most discourag- ing. The great majority of the cases were advanced and cures were so few as to be in the realm of medical curiosities. In this respect the conditions Avere precisely similar to those in the Ncav York City Cancer Institute, Avhich I directed in 1930 and 1931. The patients A\diose cancers were not too advanced were treated sur- gically with limited success and Avith certain exceptions (cancer of the skin and lip) X-rays Avere—and radium— Avere used largely for the relief of pain. BetAveen 1924 and 1931 I had spent considerable time in the Curie Institute of Paris with Madame Curie and the medical staff where I had an opportunity to learn a special method of X-ray treatment deAnsed by Dr. Courtard and widely known as the Courtard technique. This new X-ray method was then the only one that offered any real hope for the cure of cancer of the mouth and larynx. When I arrived, in Chicago in 1931 I at once instituted this method in the tumor clinic in the Michael Reese Hospital and in my private practice, and when I began my work in the Hines Hospital, I in- 1868 VETERANS’ ADMINISTRATION structed the chief of the X-ray department to institute this new method, the details of which I outlined to him. Now a word about the new technique. In order to have any chance at all of destroying a cancer of the larynx, for example, it is necessary to administer a dose sufficient to destroy the superficial layers of the skin. This reaction produces a moist lesion which looks like an X-ray burn, but it is not a burn because the dose is so finely graduated that the rays destroy the superficial layers of the skin and leave the blood vessels and connective tissue intact, hence the area heals. Generally speaking, when such an effect on the skin is not produced by X-rays or radium it is an indication that the dose is inadequate to cure the cancer. Because the skin effect resembles an X-ray burn, the chief of the X-ray department refused to carry out this technique, claim- ing that he was legally liable and unprotected. I would like to, if 1 may, pass around a photograph, showing the skin reactions. May I do that? The Chairman. Yes. The clerk will do that for you. Dr. Cutler. This is before and after, the skin at the height of a reaction, and then after they are cured, the two cases. Here, then, was a new method which, when executed with proper care, was safe, yet without which the cure of cancer of the mouth and larynx was practically impossible. I insisted upon its use in the Hines Cancer unit. There followed many conferences, both in Chicago and in Wash- ington, and finally I appealed to the medical director and to the Ad- ministrator directly. Lawyers from the legal department in central office were finally sent to the Hines Facility to hold conferences on the medico-legal aspects of the problem. At last permission was granted, technicians were trained, and the local radiologists were in- structed. The new technique was installed and with it cure of cancer of the mouth and larynx among veterans in the Hines Hospital began to appear. I have cited this incident in detail because the Veterans’ Admin- istration has been criticized recently for its lack of interest in research. Here is an example to the contrary. In order to make these new advances available to patients in other veterans’ hospitals, five subsidiary cancer units were organized to which veterans suffering from cancer could be sent. The parent unit at Hines, 111., trained most of the members of the staffs of these units in special cancer surgery and in the newer methods of X-ray and radium treatment. At this time one of the trainees in cancer surgery in the veterans’ facility, Bronx, N. Y., and the other in the vet- erans’ facility at Sawtelle, Calif., are so outstanding in ability and experience that I look upon them as two of the very leading cancer surgeons in this country. After 7 years’ experience with the newer methods of irridiation, 1931 The Chairman. One is at Hines and one at Sawtelle? Dr. Cutler. They were both trained at Hines but one is at the Bronx Facility, Mrs, Rogers. Did von give their names? Dr. Cutler. Dr. Horace Smith, at Sawtelle, Calif.; and Dr. Mote- land, at Bronx, N. Y. VETERANS’ ADMINISTRATION 1869 After 7 years’ experience with the newer methods of irradiation, 1931-37, the results were so encouraging that a further elaboration seemed urgent. In order to execute the new ideas a separate and independent organization had to be formed, and this led to the foundation of the Chicago Tumor Institute in 1938. To organize the surgical aspect of the problem, one of England’s great surgeons, Sir G. Lenthal Cheatle, of London, came; and for the X-ray work, Dr. Henry Coutard, of the Curie Institute of Paris, came. Dr. Ludvig Hektoen, one of America’s leading pathologists, became president of the institute. From the very beginning an intimate collaboration was established between the Chicago Tumor Institute and the Hines cancer unit. Sir Lenthal Cheatle, Dr. Coutard, and Dr. Hektoen have visited the Hines cancer unit on numerous occasions, and members of the staff of the Hines unit have visited and observed the work of the C. T, I.—the Chicago Tumor Institute. I mention this particularly because of the criticism that has been Iveled against the Administration of lack of cooperation with other institutions. Here was a work of collaboration, patients are taken by bus daily from the Hines Institute to Chicago for the treatment of cancer. Here was an incident of collaboration with the chief of the X-ray department of the Curie Institute in Paris; here was collaboration with the great cancer surgeon in London, bearing directly upon the care of the veterans. The Chairman. Doctor, would it have been possible for the veterans to have obtained better cancer treatment anywhere else in the world ? Dr. Cutler. I tried to make it the best. The Chairman. Do you think it is the best? Dr. Cutler. There is room for improvement. I think it is as good as anywhere. Mrs. Rogers. I think the Cancer Control Institute has admitted what a fine record you have there. Dr. Cutler. Well, it is the result of the friendly and understanding collaboration. It could not have been attained otherwise. As newer and more effective techniques were developed, especially for cancer of the larynx, it became imperative to test these methods on earlier and more hopeful cases. That is on what we call operable cases. The Chairman, Doctor, before you get onto that, I want to hand you a case, and will you look over it ? Dr. Cutler. Shall I do that now? The Chairman. Yes. Mr. McQueen. Do you want it now or later? The Chairman. Right now, while he is talking from these pictures that have been passed around. Dr. Cutler. Of course, it is impossible to tell, from looking at the photographs what we are dealing with, but looking at the photograph and reading the letter, it would seem that this patient has had an ex- tensive amount of X-ray treatment and claims he has X-ray burns. Now, as I look at the photograph, it looks as if there might be some recurrent cancer there too. I would have to have more of the details to know whether we are dealing with X-ray effect, or cancer and X-ray effect. 1870 VETERANS’ ADMINISTRATION The Chairman. He said he had those treatments at Hines Hospital. Dr. Cutler. Yes. The Chairman. I thought maybe you were familiar with this. Dr. Cutler. No ; I did not see this particular patient. The Chairman. What effect did the burns have? Dr. Cutler. Well, in the first place, there is a good deal of ques- tion as to whether this is an X-ray burn. It may be a combination of X-ray effect and cancer. The Chairman. I thought probably that was a duplication of the effect you showed in these pictures. Dr. Cutler. They look very much alike, the difference being that the lesions of the skin in the picture which I passed around follow within 2 or 3 weeks of treatment. We know almost to the day when they are going to heal. The Chairman. Thank you very much. Dr. Cutler. In the beginning the only early cases of cancer of the larnyx we treated with X-rays were those in which the operation of removal of the larnyx was contra-indicated by some general condition of the patient, such as heart disease or high blood pressure, and those who simply refused to permit removal of the larnyx and who preferred to take their chances with the new X-ray treatment. After we had cured a group of such cases we were in position to advise X-ray treat- ment as the method of choice in certain favorable cases. Personally, I was convinced that this new X-ray method was superior to surgery in cancer of the larynx which was not too advanced, but in order to prove this highly important point it was necessary to treat an adequate number of comparatively early cases and compare the results statistically with those of surgery. In this connection I went to Washington and explained the problem to the medical director and to the Administrator with the result that a directive was issued to all veterans’ hospitals to send all patients suffering from cancer of the larynx to the Hines cancer unit. This resulted in a concentration of cancer of the larynx in such numbers that this important test could be made for the first time. In the beginning, before the X-rays staff at the Hines Facility understood the new technique, selected patients were treated in the Chicago Tumor Institute, and as the skiff of the Hines unit became more experienced with this method, the treatment is being undertaken more and more by them. As a result of this collaboration, it was possible in 1014 to publish in the JAMA the results of treatment of a series of 413 cases of cancer of the larynx with 83 percent 3-year cures in the comparatively early cases. A table here which was published in the journal gives the statistics : There were 30 very early cases, 20 fairly early, 50 that could be called comparatively early, and 25 out of the 30 early ones, or 83 percent, were well and without disease and with normal voices at the end of 3 years. The Chairman. What percentage was that ? Dr. Cutler. There were 25 out of 30 very early cases, that is 83 percent; and 40 out of the whole group of 50, or 80 percent, well, 3 years, without evidence of recurrence, and with normal voices. Now, this is the most important contribution for this witness, that no other institution in the world has been able to get together 50 cases. VETERANS’ ADMINISTRATION 1S71 The largest hospitals in the country will have 2 or 3. Here we had 50 cases. We would have had to wait 10 or 15 years to get that many together in any other organization. Mr. Allen, Yon mean you did not get cancer patients formerly as early ? Dr, Cutler. Yes, sir. Out of the 400 cases only 50 were early. Mr. Allen. Is that because people hesitate to consult medical advice ? Dr. Cutler. It is because cancer has such a reputation that when a patient fears he has cancer, he has fear that he might learn the truth, and he immediately imagines a mutilating operation, and an unsuc- cessful one, and he does not come. That, in my opinion, is the most important reason for delay. When people begin to understand that, if they go early enough, they can cure it without mutilation, we will have more. Mrs. Rogers. That is why you introduced the education in it? Dr. Cutler. Yes. Mrs. Rogers. And do you think that is why they go to Hines Hos- pital ? Because they hear of these cures ? Dr. Cutler. Definitely. And we are getting more cases there than in any other hospital. Here, then, is a major contribution to the treatment of cancer which advanced this problem by many years. It was made possible by a com- bination of factors: The availability of large numbers of cases, inti- mate collaboration with other institutions, and complete cooperation on all sides. I must add that it would not have been possible without deep personal interest, encouragement, and support of General Hines. I break many rules, I do not go through channels at times, but I went to General Hines directly because‘we were concerned with serious problems. It has been my constant aim to provide for the veterans the very best care in the treatment of cancer at all times, but even this is not enough. The availability of such rich clinical material and the very best of equipment imposes an obligation on all of us for the advance- ment of medical science is a recognized function of medical organiza- tions, a responsibility which the Veterans’ Administration cannot escape. At no time in these 14 years have I failed to receive the whole- hearted cooperation of General Hines and Dr. Griffith and their staffs as well as the local officials in the Hines Hospital in my efforts to ad- vance the treatment of cancer among veterans and I think it is fair to say that the treatment of cancer in the Hines Hospital compares favorably with that in the leading clinics and university hospitals in this country or abroad. During the last 3 years members of the medical staff and the con- struction department of the Veterans’ Administration in Washington have been working intimately with the staff of the Hines Hospital, formulating plans for the construction of a 630-bed cancer hospital to be attached to the present Hines Hospital. The final plans are completed and construction is scheduled to begin at any time. This cancer hospital will embody our latest knowledge in facilities for the diagnosis and treatment of cancer. Advice of leading experts in various departments has been obtained and this unit will undoubtedly constitute the very best in construction equip- 1872 VETERANS’ ADMINISTRATION merit to be found anywhere, including provision for 2,000,000-volt X-ray unit. It goes without saying that far more important than the physical unit is the calber of the personnel and the organization of the work. In this connection I want to say that from those deliberations there arose the question of whether or not to put in a 2,000,000-volt X-ray machine. Now, a 2,000,000-volt X-ray machine has been constructed, but with very few exceptions it has not been used in cancer, and after numerous conferences with men in different parts of the country, authorities, es- pecially on the safety of this apparatus, I recommended to General Hines that the construction of the new hospital be such as to be able to receive this very high-powered unit. It took concrete walls about 6 feet in thickness, 5 or 6 feet in thick- ness. I had to convince the general that the apparatus was safe. I was convinced by the engineers that it wTas safe, and the final con- clusion was to build a unit for that at the Hines Hospital, and after further deliberation probably accept the unit and use it in clinical research. I will point that out again as an example of the fact that so far as cancer is concerned, we have kept in the foreground of research. Mr. Allen. Would you mind indicating about how expensive this high-powered unit is? Dr. Cutler. $75,000. The Chairman. How does an X-day volt compare with an electric volt? Dr. Cutler. It will be 2,000,000 volts. The Chairman. Is that equal to 2,000,000 electric volts? Dr. Cutler. I think so. The Chairman. The largest high-powered line in the United States I think is less than 300,000 volts. Dr. Cutler. I am not sure. The highest used so far is 2,000,000 volts. We are told that we can effect the skin effects. That, of course, will be very large, and we are planning to use it, of course, with the greatest care. Mr. Allen. But you have actually tried this machine on human beings and it is working ? Dr. Cutler. It has not been tried on human beings except there has been one report on the human beings so treated, but there has been no comprehensive study for it yet. Mr. Allen. They can take the treatment from that machine and still live? Dr. Cutler. Oh, they have to be safe, and they will be safe. The thing is entirely a matter of dosage. We use the entire backlog of many things—of many years of ex- perience before we make a new step, and this is simply another step, based on experience. The Chairman. Doctor, what is the voltage of the machine that is used? Dr. Cutler. 400,000. The Chairman. So this will be about five times as strong as that? Dr. Cutler. Yes. VETERANS’ ADMINISTRATION 1873 Mr, Huber. There is no comparison between this and the so-called Mexican use; that is low amperage ? Dr. Cutler. Low amperage. Mrs. Rogers. What type of case will yon use it on first? Dr. Cutler. We believe cancer of the lungs. Cancer of the lung is very prevalent and on the increase, the results of surgery are not too good, although there has been tremendous progress in surgery for cancer of the lung. We believe that is one place this should be tried. Mrs. Rogers. You are not using radium much now. This com- mittee helped to get some radium a few years ago. Dr. Cutler. Yes. This leads me to speak of some of the deficien- cies in the organization and operation of veterans’ hospitals as I have observed it during my 14 years’ association with it. The main difficulties that I have encountered revolve almost en- tirely on the problem of personnel. (Mr. Allen assumes the chair.) Dr. Cutler. The Veterans’ Administration has simply not been able to attract to its medical service the very highest type of physicians. I add at once that there are many physicians in the medical service as highly qualified and experienced as can be found anywhere. One great difficulty is related to the regulations of civil service which are not compatible with the free selection of scientific and technical per- sonnel. It is obvious that the purpose of the medical service of the Veterans’ Administration is to give to the veterans the very best possible medical care at all times. It is equally obvious that the standards of medical service are almost wholly dependent upon the training and experience of the physicians who direct and perform the work. In order to attract physicians of the highest caliber, the medical service must create conditions of work and offer opportunities com- parable to those in university hospitals. It must be in a position to offer careers to physicians to give them an opportunity to advance by merit to an adequate income and some degree of security by pension. Opportunities to work in a scientific atmosphere, under such condi- tions, free from the worries and hardship of private practice would surely attract to the service many of the best graduates of the medical schools. The present system of selection of personnel through civil service fails totally to accomplish this purpose. The last quarter century has witnessed unprecedented advances in all branches of medicine, and specialization in various fields has reached an all-time high. New methods and intricate technique are under intensive study and constant change. Hence, it is to be expected that in the postwar period many changes will be encountered. These constantly changing conditions render it essential to reevaluate the medical service and make such service—make such changes as are necessary to maintain the highest standards of service to the veteran. As a member of the special medical advisory group of the Adminis- trator I have had an opportunity to study this problem in some detail. The following recommendations are based upon mv own experience as consultant and upon the study now under way by the special com- mittee : 75183—45—pt. 5 3 1874 VETERANS’ ADMINISTRATION 1. There should be established within the Veterans’ Administra- tion a department of medicine and surgery comparable to that of the Bureau of Medicine and Surgery of the Navy, the personnel of which should be appointed without regard to civil-service laws. 2. A greater use of the services of consultants should be made with adequate authority to carry out their responsibilities. 3. There should be established a plan of regional consultants in medicine, surgery, and the major specialists patterned on the Army plan. These consultants should visit each hospital in the region several times a year. 4. The administrative and medical activities of the hospital should be separated as much as possible in order that the medical personnel may have the time and opportunity to concentrate on the purely medical and scientific aspects of the work. 5. The chief medical officer and the chiefs of the clinical services should be highly qualified for their respective positions. 6. A system of training of interns and residents should be organ- ized comparable to that in university hospitals. There should also be established a system of graduate training in medicine and surgery and the specialties. Only through this means can the medical service of the Veterans’ Administration be assured of well-trained and com- petent medical officers. 7. There should be an upward revision of the compensation schedules for medical officers. 8. The Veterans’ Administration must accept its full responsibility toward medical science by continuing to encourage clinical research and thus contributing not only to the better care of the veteran but to medical science in general. Mr. Allen. Are you through with your statement ? Dr, Cutler. Yes. Mr. Allen, Are you familiar with the bill introduced by Chairman Rankin of this committee with reference to a Medical Corps in the Veterans’ Administration? Dr. Cutler. In a general way, sir. Mr. Allen. Do you approve of the bill ? Dr. Cutler. Yes, sir. Mr. Allen. Let me ask you your opinion with reference to man- agers of facilities. Do you feel that the managers should be laymen, or should they be doctors ? Dr. Cutler. That is an administrative problem which I really do not feel qualified to answer. Generally speaking I feel, naturally, that all medical activities should be supervised by a medical man. I realize the complications and the other side of the problem. The Chairman. We are very grateful for your statement, Doctor, and it is a very splendid statement, and it deals with a field that very few of us have any knowledge of. We can always see the very evil effects of cancer, but we know nothing about it, and, as you pointed out, it scares most folks. And I appreciate the fact that the medical profession is educating people to make known those conditions and to seek early treatment. VETERANS’ ADMINISTRATION 1875 Any questions from the gentlemen of the committee ? Mr. Domengeaux? Mr. Domengeaux. I do not have anything. Mr. Allen. Mr. Carnahan ? Mr. Carnahan. You have a private practice? Dr. Cutler. Yes, sir. Mr. Carnahan, In your opinion, how do you think the veterans’ facilities compare with the private facilities, hospitals ? Do they com- pare favorably or unfavorably ? Dr. Cutler. I believe that the patients—are you speaking of cancer patients ? Mr. Carnahan. Yes, Dr. Cutler. I would prefer to answer that because I am more familiar. Mr. Carnahan. Yes. Dr. Cutler. Why certainly the cancer patient in the Hines receives good care and treatment at the Chicago Tumor Institute, as good as any private patient. Mr. Allen. Mrs. Rogers? Mrs. Rogers. Doctor, you mentioned some other hospitals where cancer is treated. Do you feel that they are having the excellent care in these other veterans’ hospitals ? Dr. Cutler. Yes; I believe that the cancer patients in those other units receive very good care. Mrs. Rogers. You did not make any investigation after the Deutsch articles, because your specialty is cancer? Dr. Cutler. I was asked to go to the Atlanta Facility and look into the cancer work there, and I found it highly satisfactory. Mrs. Rogers. They are getting good results ? Dr. Cutler. Yes. Mrs. Rogers. What results do you have with cancer of the eye ? Dr. Cutler. Of the lid, or the eye itself ? Mrs. Rogers. The eye itself. Dr. Cutler. Well, we have cured those cases with rather remarkable permanent results, cancer of the cornea. We have treated several of those cases at Hines. Mrs. Rogers. Are you treating Hodgkin’s disease ? Dr. Cutler. Yes. Mrs. Rogers. Have you any cure for that ? Dr. Cutler, No ; Hodgkin’s is very bad. Mrs. Rogers. And you feel that one of the contributions the Vet- erans’ Administration has made is in cancer ? Dr. Cutler. Well, I think it is an example in a special field of one unit, obtaining the adequate treatment, and their personnel is an exam- ple of what can be done in other fields in the Veterans’ Administration. Mrs. Rogers. I gather from your testimony you do not feel just the transfer from General Hines to General Bradley will cure the medical and surgical situation unless that medical department be given power. Dr. Cutler. I think in reading these really critical articles, if I may comment on them ? Mr. McQueen. Go ahead. Mr. Allen. Yes. 1876 VETERANS’ ADMINISTRATION Dr. Cutler, I should say, I feel that the remarkable thing is not that somebody found a patient who was unhappy about his treatment, the remarkable thing is that so many patients have been treated so well. There is no medical organization in the world that begins to com- pare in scope with the Medical Department of the Veterans’ Admin- istration, and it is simply amazing what good treatment so many patients have received over so long a period of time. That does not mean there is no mom for improvement, and any doctor is constantly looking for methods of improvement, but certainly as I see it, the program, the medical care that the veterans have had, has been very good indeed. Mrs. Rogers. You feel then that the promises of care for the vet- erans have been lived up to? Dr. Cutler. I certainly do, and I think that constantly wTe have to keep our eyes open as to how we can improve them. Mrs. Rogers. That is our obligation. Dr. Cutler. That is our important obligation. Mr. Carnahan, Doctor, you would not recommend the Govern- ment selling the veterans’ facilities and allowing the veterans’ atten- tion and letting him get his medical treatment wherever he wants? Dr. Cutler. I think he would get far less care than he is getting. Mr. Vursell. Doctor, in your 14 years in the service and from your knowledge of the work of the organization—the veterans’ organiza- tions, I take it that you are of the opinion that in this very large! •organization with soldiers generally, in all walks of life, we might say in their treatment generally for various diseases, that the work of the Veterans’ Administration under General Hines and the present staff lias been most commendable? Dr. Cutler. Yes, sir; definitely. Mr. Vursell. Realizing, of course, that in any great organization of this kind, there will be a certain amount of maladministration, and, because of the lack of help and personnel and with the war on, that that will aggravate the situation, but, notwithstanding that, you would think that the veterans’ organization and administration has done a wery remarkable job, a remarkably good one, too? Dr. Cutler. I think so, and with emphasis on how remarkably well they have been able to do since the war, realizing that they have been loaded with more patients, while at the same time their medical and technical personnel has been taken away from them. Mr, Vursell. You think it would be an improvement, I take it, uf we could put the appointment of the medical staff on a merit basis and, I might say, on a business basis, in their employment, rather than through the Classification Act and the Civil Service ? Dr. Cutler. I believe we must have a freer selection of personnel in order to build up the medical and technical staff to a very high caliber, .as free as the law will permit us. Mr. Vursell. I agree with you perfectly. Mr. Huber. Doctor, assuming the Civil Service safeguards are re- moved, what would you have to effect that ? Dr, Cutler. I’m not so familiar with that, but the United States Publ ic Health Service seems to have a satisfactory medical depart- ment, and I am not thoroughly familiar with that, but I think of that in connection with your question. VETERANS’ ADMINISTRATION 1877 (Mr. Rankin resumes the chair.) The Chairman. Doctor, would you care to discuss the cause of the growing prevalence of cancer throughout the country? You stated a while ago that it was on the increase, and of course, it has been for some time. Can you give any reason for that increase? Dr, Cutler. There are a number of reasons, some of which we think we understand, and others we do not. One important reason is that we live longer. Penicillin and the other new drugs save us from infection and we live longer, and the longer we live the more likely we are to get cancer, because the inci- dence of cancer varies with age, and we are more likely to get cancer in our older age. Second, exemplified by cancer of the lungs. It has been definitely established that there is an absolute increase, not a relative increase but an absolute increase of cancer of the lung, and that came from the Veterans’ Administration and was published and it has been quoted in literature and accepted. Now, the reason cancer of the lung is increased we do not knowr but we have some ideas. Some people believe the increase in smoking ; others believe gasoline fumes on the streets have something to do wdth it. The Chairman. I read a scientific article some years ago that there was a connection between the increased use of inferior animal products and the increased prevalence of cancer. Do you agree with that ? Dr. Cutler. Between what products ? The Chairman. Dairy products, animal. Dr. Cutler. I believe there is no clear evidence on this point, sir. The ChairmxVN. No clear evidence. Dr. Cutler. But I would like to say the current research on this whole problem of the causation of cancer is taking diet into account very seriously, and it may prove to be that certain things we take in our food—we do not know wdiat those things are, yet—may play a very important part in the development of cancer. There was at one time a suspicion that certain dyed substances, such as butter yellow used in margarine, might cause cancer and, in factr the Food and Drug Administration now is looking into that question. It is all an open problem. The Chairman. This article went on to say in those areas where people were largely vegetarians—for instance, I think it probably mentioned an area in the Himalayas—perhaps there was less cancer than where they feed on animal products, like beef and butter. Mr. Scrivner. Well, if beef causes it there will be a considerable drop in cancer. The Chairman. I was wondering if that contributed to the causes of the disease. Mr. Scrivner. I have no questions. The Chairman. Any other questions? Mr. Caranahan, Is there and development, or tendency on the part of the medical organizations to discriminate against the doctors con- nected with the Veterans’ Administration facilities, so far as mem- bership in the organization is concerned? Dr. Cutler. I do not think so. You know of the general feeling of some physicians against socialized medicine, but I do not believe that 1878 VETERANS’ ADMINISTRATION goes so far as to express itself in that way. I believe competent doc- tors are accepted. There may be some exceptions; I do not know. Mrs. Rogers. Are you finished ? Mr. Carnahan. Yes. Mrs. Rogers. Doctor, I infer from your testimony that you did not expect the veterans’ hospital to just go into the clinical part of it on cancer cases. Is that right? You have not made an inspection of all of the hospitals, going right through the hospitals from the very beginning? Dr. Cutler. No. I have never been asked to do that. The Chairman. Doctor, eating meat from a cow that had tubercu- losis, would that cause the person eating it to contract tuberculosis? Dr. Cutler. I do not think I am qualified to answer that. Gen- erally speaking as a physician, it has been my impression that that is the case, and that is the reason for the inspections that we have, but I do not think I am qualified to answer that, sir. The Chairman. Of course, Public Health Service is in the field of preventive medicine; they are trying to find what causes the various diseases and prevent their spread, the infection. For instance, 40 years ago, we had a tremendous amount of malaria and typhoid where I live, and in 1905 our Gulf coast was swept with typhoid fever and yellow fever, but due to the geuius of Walter Reed, who discovered the cause of yellow fever, we got rid of it, and, as a result of that, they went a step further and found the cause of malaria and then the cause of typhoid. And those three diseases have been practically eliminated. But I was wondering what is being done in this field of cancer pre- vention, to stop the spread of that. Dr, Cutler. Well, in that field I feel that the medical department of the Veterans’ Administration has unequaled opportunity, because they have the largest number of patients under perfect control and therefore a wonderful opportunity for clinical research. The Chairman. Does thyroid trouble usually result in cancer? Dr. Cutler. No ; the general thyroid disease—we think of goiter, for instance—is not related to cancer. However, there is one, what we call edema of the thyroid, which in numerous instances becomes cancerous. The Chairman. It is because of lack of iodine in the food ? Dr. Cutler. Yes. Mr. Vursell. Now, any development of the cancer work in the Vet- erans’ Administration, do you care to say whether you were aided or deterred by the lay manager of Hines Hospital or by the Assistant Administrator, or the Administrator? Dr, Cutler. I should say not in the slightest. I have had nothing but help and encouragement from all of them. Mr. Vursell. That is all. Mr, McQueen. Along that line, I would like to ask you, Doctor, we will say in the handling of cancer hospitals or cancer centers, would it be your idea that these hospitals should be managed by lay people or medical people ? Dr. Cutler. I am assuming now you are speaking of a hospital and not associated with any regional office. Mr. McQueen. That is right. Just the hospital. VETERANS’ ADMINISTRATION 1879 Dr. Cutler. Frankly speaking, I do not think that I am qualified to answer it, but in a general way I would say that it depends largely on the individual. There are some medical men wTith administrative training who, I think, would be ideal to direct a hospital. Conversely, a lay director with no knowledge of medicine would be comparatively at a disadvantage. So, of the two systems, I would say that a medical person with ad- ministrative—some administrative experience—I think, would be a better director. Mr. McQueen. Well, would you say that the medical administrator would have to give too much time to the average clinic or hospital to take away from his clinical work in the management? Dr, Cutler. That depends entirely on his having enough trained administrative assistants, which would solve that problem at once. Mr. McQueen. The over-all answer would be, it would be more successful if it would be under the absolute direction of the medical man ? Dr. Cutler. I think that is so, unless there were some administrative problems with which I am not familiar. The Chairman. Doctor, may I ask you a question? We have sep- arate hospitals for neuropsychiatrics; we have separate hospitals for the tubercular patients. Do you think we should have an entire separate hospital for cancer patients ? Dr. Cutler. Yes, sir. We are planning that, as you know. The Chairman. That would enable us to staff that hospital with cancer specialists, would it not ? Dr. Cutler. Yes, sir. The Chairman. And that is what you are driving at at Hines ? Dr. Cutler. Yes, sir. The Chairman. Is that to be under separate management, separate and distinct from the Hines Hospital ? Dr. Cutler. We have not yet discussed—I have not yet known of any discussion about the details of the organization, I do not know what the plans are. The Chairman. Do you think the cancer patient should be sepa- rated entirely from other patients and placed in a separate institu- tion ? Dr. Cutler. Yes, sir; I do. The Chairman. Instead of having one great sprawling institution with patients of all kinds in it ? Dr, Cutler. No, sir; I think there are important advantages to hav- ing a separate cancer institution, as proved by the Memorial Hospital in New York, the Institute in Paris, and Stockholm. The Chairman, Location does not mean anything in cancer hos- pitals ? Dr. Cutler. No, sir. Mr, Huber. How about the diagnosis in the early stages? Where one particular hospital might not be able to diagnose it without trained technicians ? Dr. Cutler. I think it should be the duty of the cancer hospital to give courses in early diagnosis to members of Veterans’ staff in other hospitals. 1880 VETERANS’ ADMINISTRATION That should be a center of education. Mr. Carnahan. Well, many of your cancer patients have other dis- eases besides cancer, do they not? Dr. Cutler. Yes, sir. Mr. Carnahan. Then you would have to provide for these other diseases? That is, unless you put on able staffs in all of the major things they have ? Would not your patients get then an inferior grade of treatment for diseases other than cancer? Dr. Cutler. In the cancer unit at the Hines Hospital, where we en- counter a condition other than cancer, we at once call in a consultant for that condition. If the patient has diabetes, we call in the consultant for diabetes. That is more satisfactory than having the patient in a general hos- pital. The Chairman. Well, thank you very much, Doctor. You have been very selpful. We are grateful indeed for your contribution. Dr. Griffith. Dr. Malcolm T. MacEachern, associate director and chairman, administrative board, American College of Surgeons; professor of hospital administration, also associate professor of medicine, Northwestern University; former general superintendent, Vancouver General Hospital; member, committee on hospitals and memorial commission on physical rehabilitation, National Defense Advisory Board; advisory board of American Dietetic Association; advisory council, Association of Medical Social Workers. STATEMENT 0E DR. MALCOLM T. MacEACHERN, ASSOCIATE DIREC- TOR AND CHAIRMAN, ADMINISTRATIVE BOARD, AMERICAN COL- LEGE 0E SURGEONS The Chairman. Doctor, are you a practicing physician? Dr. MacEachern. No, sir; administrative medicine, I guess, is my field. The Chairman. Have you ever practiced medicine? Dr. MacEachern. In a hospital, yes. I was in a hospital for 3 years in which I specialized in that particular field, but I did not practice outside of the hospital. The Chairman. What medical school are you from? Dr. MacEachern. McGill, Montreal. The Chairman. When did you finish that? Dr. MacEachern. 1910. And I finished my graduate training in 1913. The Chairman. Where did you take your literary course, literary schooling, academic ? Dr. MacEachern. I took my academic work in Ontario. I was born in Canada and I took it in Canada—McGill. I am a naturalized American for several years. The Chairman. All right, Doctor, you proceed. Dr. MacEachern. My contact with the Veterans’ Administration dates from 1924, I happened to be taken in the American College of Surgeons as an associate director, and my chief work at the beginning was director VETERANS’ ADMINISTRATION 1881 of the hospitalization standardization movement for the United States, Canada, and for foreign countries where we had interests: We are international, in a sense; our organization includes surgeons of North and South America and some foreign countries. We have 14,000 members who are surgeons who have qualified after 7 years or longer out, and who are recognized surgeons in general surgery or in a surgery specialty. We set up our qualifications at camp but found that many of our men could not meet that because they did not have the right kind of environment in hospitals to get the right kind of experience, and so, by common consent, we started a hospitalization standardization movement in 1918, which will asure the best diagnosis that treatment— best diagnosis and treatment to every patient who conies in as far as scientific medicine will permit. That is from setting down certain standards, physical plant, and equipment, organization, personnel, medical staff organization, case records, clinical findings, X-rays, and the like. When we started this only 89 hospitals had any kind of acceptable organization or laboratories or X-rays, and so it fell our lot to take all hospitals with 25 beds or over and list hospitals as approved. This was going on a few years and proved successful and General Hines and his group in the Administration asked us if we would make surveys of veterans’ hospitals in the United States, as they wanted a disinterested organization beyond their own inspection to get them the facts on what they found, bearing on the care of patients. So we undertook this. The Veterans’ Administration—it was then the Veterans’ Bureau—asked us first. That was followed rapidly by the Army and Navy and Public Health Service. So they are all on our annual survey list as to meeting those basic requirements. We put on this survey ever since we started our most experienced two men, and we have—in our files at our organization, we have 324 surveys of the 89 hospitals, of the 80 hospitals—the 89 hospitals that have been made, repeatedly, of course. All that material in files like this [indicating] is available for your committee if they want it. The Chairman. How many years does it cover ? Dr. MacEachern. Since 1924. We started the survey in 1924 and have been carrying it to the present time. And we have made other surveys and very critical ones, and we have sent back to the Veterans’ Administration immediately our find- ings and the criticisms. We still have to wait for the time when these recommendations are not carried out promptly. We have never on record one instance of where they did not carry out our recommendations. I will admit that we did not find very many things wrong with them as compared with most civilian hospitals. At present, we have difficulty getting pathologists and radiologists in every hospital, because they are not obtainable, but the Adminis- tration has been trying to keep them up as well as they can. In 1925 when we finished we found of the 50 hospitals only 14 met the association requirements at that time, but the Veterans’ Bureau asked us to wait 6 months before publishing the list. 1882 VETERANS’ ADMINISTRATION You see, we make public every year a list of hospitals that meet the requirements in the United States and Canada and it is quite natural we would wait 6 months, because we always give our hospitals 6 months a year The Chairman. You said “meet requirements.” Dr. MacEachern, Yes. The Chairman. Meet what requirements ? Dr, MacEachern. We publish a list every year in October The Chairman. What organization? Dr. MacEachern. The American College of Surgery. You see, we take the basic requirements, the American Medical takes the educational aspects. After the first survey, it was necessary to recommend in one letter 28 radiologists and 32 pathologists, and that was back in 1925, and which they filled as quickly as they could. Coming now to the present situation, during all these years the Veterans’ Administration endeavored to maintain competent men. They developed their nursing staff and dietary staffs and other staffs and laboratories just as well as they could. We found it was impossible to get the high-powered specialists in hospitals because, as jmu realize, a stipend of $3,800 to $4,200 would not get them. We recommended, and it was accepted, consultants, men outstanding in their special fields, and that was taken up quite widely. These were men who were recognized in all the specialties, tuber- cular, orthopedics, and the like. It cost the Veterans’ Administration a considerable amount of money. Some were on fee basis, some on salary. The fee basis did not work out as well because the consultant was not called, perhaps as frequently as he would have to go, if he was on salary. In the Chicago area where I live, these men go out and spend 1 day a week. As we went along the specialists began to go into these long drawn- out cases. They did not present the problems and they were not so interested—they were not so interesting to these high-powered con- sultants, so therefore, there came a time when their services were not needed as much as when they were running the acute group. Some say the consultants are not used as much as they should be. Maybe that was the reason. It was a great contribution to the medical service. Another thing we recommended is not to put the neuropsychiatrics here and the TB here and separate them, get them together in one hospital; and that was done by making it a facility, combining—having the regional office there, too. We felt that in "this way they would have the advantage of the specialists, by getting them closer together, there would be a better system of contact—contact and consultation. Another thing we have recommended on several occasions, and I think it is something everybody is sympathetic to, is that these hospi- tals in the future should be near the medical centers where the men could go to the medical centers and keep up with the times, and also get into research as much as possible. Now, in our medical group, the Medical Advisory Group, which you have heard about, and I am not going to repeat too much, it is all VETERANS’ ADMINISTRATION 1883 written out here—it fell to my lot to write out the original recom- mendation of what we would recommend for the Veterans’ Admin- istration. Now, I want you to get this: You are not having this reorganization because of a whole lot of stories which we do not have much knowledge about. You are having it as a trend of the times. Every major hospital is now getting a new line because of this post- war period. We believe now that all hospitals will have to come into a new level on account of the advances in medicine. Every State in the United States from one coast to the other, there is a survey being made of the State hospitals and the facilites, and there is a Commission sitting on hospitals, headed by the president of the Uni- versity of Pennsylvania, and Dr. Blackmeyer, of the University of Chicago, is the director of study and they are making a complete study of the hospitals of this country. In other words, we recognize that we must get on a new level. In the last four years there has been difficulty in every hospital, their personnel has been pulled away, industry offers their personnel bigger salaries, the best doctors were taken away, the best nurses were pulled awTay. Some were kept home. But there is not a hospital in this country that has not had its prob- lems in the last 4 years. There is no question that many of their best doctors were taken into the wTar, and their best nurses. Now, it is true that was helped by the Army assigning some of their reserve men to the veterans’ hospitals. I do not doubt but what these men were disappointed because they had enlisted for service for the acute cases. In the veterans’ hospitals most of them were the long- drawn-out cases with very little philanthropic interest. Now, doctors are attracted by one thing, scientific medicine. How I can learn more medicine—how can I improve myself, and, secondly, my salary. Those two things draw them to veterans’ hospitals. Many of our Army doctors will be disappointed when they have to take on this work. It was something we had to bridge over. Now, in regard to the administration of veterans’ hospitals in the future, our committee discussed the question of the central office having a medical director to be made an assistant director of the Veterans’ Administration, and that he be charged with full responsi- bility to the Administrator for the medical services concerned with the care of veterans. (Mr. Allen assumes the chair.) Dr. MacEachern. It is also suggested that his designation be that of Director of Medical Services, United States Veterans’ Administra- tion. It is believed by the Medical Advisory Group that there should be established within the Veterans’ Administration an organization of the medical services comparable to that of the Bureau of Medicine and Surgery of the Navy, thus giving the medical services of the Veterans’ Administration a more definite and recognized status than at present. Such a Bureau of Medicine and Surgery, or whatever the organi- zation might be designated, would include the Director of Medical Services and the assistant directors in charge of the various profes- sional services—that is, medicine, surgery, tuberculosis, neuropsychia- try, dentistry, radiology, pathology, research, and postgraduate in- 1884 VETERANS’ ADMINISTRATION struction—and the liaison officer of the special Medical Advisory Group of the Administrator. As far as the central office inspection was concerned, the Medical Advisory Group believes that the efficiency of the central office inspec- tion would be increased by more frequent visits of the heads of tha various medical and hospital services to the extent of every 6 months or twice a year. This inspection should involve particularly the medical or profes- sional care of the patients. It might mean the cutting down of the customary period of time now spent on each station and possibly lessen- ing the details of the reports or limiting them chiefly to deficiencies in the service and their remedy. Central office inspection should be regu- lar, thorough, and complete, keeping primarily in mind the quality of the care rendered the patient. For obvious reasons it would be advan- tageous for the Administrator of the United States Veterans’ Admin- istration to visit as many institutions as possible from time to time. We also recommended regional consultants. The Medical Advisory 'Group recommends to the Administrator of Veterans’ Affairs the establishing of a plan of regional consultants in medicine, surgery, tuberculosis, and neuropsychiatry who are specialists of recognized standing in their respective fields. The proposed plan would follow the pattern of the Army in each service command where there are ■consultants in the major fields of medicine and surgery. These consultants would visit each hospital in the region or assigned area at regular intervals, possibly three or four times a year, and re- main long enough at the station to see all the cases in his particular service. It is our understanding that this plan is working well in the Army, and we believe it could be applied equally well to the medical service of the Veterans’ Administration, provided there is a careful selection of the regional consultants. This type of regional consultants is very valuable. Now, in addition to the regional consultant, there will be the local consultant—that is, men who can be called on in the community who are probably teachers in the university or who were fellows of the College of Physicians, College of Surgeons of Diplomates of the 15 boards. These local consultants would be available for certain periods of time at the hospital, preferably a day a week or something like that, and they should be remunerated for it. In the plan we discussed and which I am interested in, it was pro- vided for the consultants, local and regional. The regional ones who spend sufficient time in the hospitals to cover all the cases which might be in his particular line—his particular specialty in that hospital. That would give the veterans, we feel, the advantage of the very best there is. We also discussed who shall administer the veterans’ hospitals. We felt that there was a movement on—I understand there is a movement on—to separate the regional office from the hospital and this may be called a hospital again instead of a facility. We think that would be a very good move, and that the chief medical officer of the hospital should be responsible to the Director of Medical Services of the Veterans’ Administration. The Medical Advisory Group recommends that the chief medical officer of each United States Veterans’ Administration hospital be in VETERANS’ ADMINISTRATION 1885 effect comparable in authority to the commanding officer or head of the hospital in the Army and Navy, and be responsible to the Director of Medical Services—or assistant director in charge of medical and hospital services. This officer should be selected with due care as to- his professional status in the type of work for which he is prepared— that is, general medicine or surgery, tuberculosis or neuropsychiatry,. Te should be a well-recognized specialist in the type of work which is carried on within the hospital which he administers. He should have an adequate number of clinical assistants and administrative assistants, depending on the size of the institution. His responsibili- ties in general would be the entire institution and in particular the professional care of patients, with adequate provision to relieve him of the detail of administrative duties. His time should be conserved! for the medical policies and medical services of the institution rather than being taken up with administrative detail. Now, when we come to the administrative assistants, the Medical Advisory Group recommends that in each hospital one or more com- petent, trained, administrative assistants be appointed to look after all the administrative details in the management of the hospital working through well organized departments with competent heads for'the carrying on of the various activities incident to the care of the patient. Such administrative assistants to the chief medical offi- cer could very well be trained, competent laymen or medical men who- have a preference for administrative work rather than clinical. It is essential, however, that such person or persons be properly trained to carry on the administrative duties of the hospital. In this con- nection, it is learned that there are some 18,000 men in the Medical Administrative Corps of the Army. This could well be a source of supply. These men would need special training for the work and it is suggested that a course or courses of training be set up. Looking forward to postwar needs and at the request of the president of Northwestern University and the dean of the medical school, a pro- gram in hospital administration in connection with the school of com- merce and in cooperation with the medical school and the university college on the Chicago campus has been in operation for the past 2 years. It is believed that this university would be prepared and willing to give training to a group as suggested who thus might become trained administrative assistants for Veterans’ Administra- tion hospitals. There may also be other places where such courses? could be given. The Medical Advisory Group believes that this plan would greatly enhance the administrative efficiency of the Administration hospitals. These men through a specially prepared institute or longer course could well be organized in the basic prin- ciples of hospital organization and management and their practical application to Veterans’ Administration hospitals. Such a course or courses would consist of lectures, seminars, conferences, round- table discussions, field trips to other hospitals, and demonstrations. Our group also recommended, and we agree on the thing that the heads of the services in the medical service should be recognized specialists. The medical advisory group recommends that so far as it is prac- ticable and possible the heads of the various services in Veterans?7 Administration hospitals should be fellows of the American College 1886 VETERANS’ ADMINISTRATION of Physicians, fellows of the American College of Surgeons and/or diplomates of the various American specialty boards now numbering 15, or medical officers of equal standing. There may be found in every community certain highly qualified physicians and surgeons who are not fellows of either of the colleges of diplomates of the boards but who are highly proficient in their respective fields. Through examination or a credentials committee the eligibility of these men could be determined before an appointment is made. However, it is understood that all the medical officers in the Vet- erans’ Administration cannot acquire the standing of recognized specialists, but the younger members of the medical staff should aspire thereto and be encouraged to obtain their recognition in the various fields as soon as prepared. Possibly, after setting up grad- uate training in general surgery and the surgical specialties and in general medicine and the medical specialties, opportunities for train- ing will be available for the younger medical officers in the Veterans’ Administration hospitals so that they can advance into fields of rec- ognized specialties. We believe that these hospitals are able, in many instances, to have interns and residents. We believe that they should particularly train younger men in 3 to 4 years to grow up into the service to carry on the work. I am going to mention in a minute the plan which we are carrying out now in this respect. We know the vet- erans’ hospitals are now taking on nurses. They have probably 300 or 400 of the cadet nurses. I know Hines has 140 nurses finishing their training, 100 or more cadet nurses and others that come in for evaluation. The veterans’ hospital offers excellent training for nurses in that stage. They will have to come perhaps later but they are ready for evaluation and the heads of nursing services that are here today will appear, but what I say is these that are coming here are getting very excellent training in their work. Now, another thing I would like to discuss with you is the fact that we can relieve medical officers of some paper work by a proper system of medical secretaries or dictaphones. We have the same problem in civilian hospitals, only to a much greater degree. The Medical Advisory Group believes that the medical officers of the Veterans’ Administration hospitals have too much paper work under the present system and that the addition of medical secretaries and dictaphones would be most advantageous. There are now trained medical secretaries available. Dictaphones are very helpful in writ- ing medical records. There will be a large number of these machines available after the war and the obtaining of an adequate number for Veterans’ Administration hospitals it is believed would not be diffi- cult. At any rate, some plan should be set up within each Veterans’ Administration hospital in order to relieve the medical officers of a large amount of paper work thus allowing him more time for his clinical duties. There are 9 or 10 colleges today turning out medical secretaries for this purpose. We are trying to introduce them in civilian hospitals as fast as we can, A year ago we were asked by the Veterans’ Admin- istration to look over a number of their hospitals for the purpose of training in surgery and the surgical specialties. They listed with us some 20 hospitals and we have made a very extensive survey of 20 of VETERANS’ ADMINISTRATION 1887 their hospitals to find out how far they could go on a 4-year training in general surgery and surgical specialties and that survey has been completed. There is a complete report here on these 20 hospitals. They have been surveyed by experts, outstanding men in the field, with a con- sulting—the consulting services of Major General Reynolds, former major general in the United States Army, who is now on our staff. He and Dr. Ferguson finished 2 weeks ago, going over this 20-hospital group to see in which could be established 4-year courses for the train- ing of younger officers for surgery and the surgical specialties. Now, according to the statistics of the American Medical, there are 18,000 men coming back when the war is over whose education and training was interrupted; that is, they could not complete their 3 or 4 years’ training. (Mr. Allen assumes the chair.) Air. Allen. Off the record. (Discussion off the record.) Mr. Allen. We will have a recess for just a few minutes. (Short recess.) (Mr. Rankin resumes the chair.) The Chairman. We will proceed. All right, Doctor. Dr. MacEachern. When we adjourned I was speaking of educa- tional activities in veterans’ hospitals. I mentioned to you earlier that the educational standards have increased as medicine has become more complicated. In the Veterans’ Administration today and for many years you will find a number of outstanding men. The general con- sensus of opinion is that men who head departments should be recog- nized specialists. They may not be always fellows of the colleges or diplomates of the boards but ones with equal proficiencies. It is not possible that all highly qualified physicians and surgeons can take these boards and all that. There are many capable men in the field who are not, but, generally speaking, these are the ones of proficiency, the heads of departments. The younger men should aspire to pre- paring themselves for the various fields anyway. When the older ones graduated with medical education and years internship and perhaps a year’s residence, he was pretty good, but now the young men must look forward to 3 or 4 years’ training in the field he desires to enter. The men who have not had that have gained that by long years of experience. We believe that in the Veterans’ Administration now—I believe it— now there will be a better chance for the training of our younger doc- tors ; there will be a chance for intern training—now well established on a definite basis in civilian hospitals; and for graduate training which we speak of as residences. By that I mean going on new work you want to follow, and then taking 2, 3, 4 years. As I said, the Veterans’ Administration called on the College of Surgeons to look over 20 of their hospitals, and that same pattern is established. After the selection of these hospitals they were surveyed by very competent medical men of long experience. They were looked at from the standpoint of training surgeons and training specialists in the various fields of surgery. A report of the finding and summary is here. Two of our staff, Major Reynolds, for- mer major general of the United States Army, and Dr. Ferguson spent 1888 VETERANS’ ADMINISTRATION the greater part of a week here with the Medical Director and the heads of divisions, going over carefully each of these hospitals and seeing wherein they were fitted to train for the various fields. And that work has now been completed and we are working with the staff at headquarters in bringing up to the required level for training these different hospitals for different specialties. Some will take general surgery, some urology, orthopedics, opthal- mology-otolaryngology, and the like. Now, the teaching hospital is better for a hospital in the sense of scientific care of the patient, because you assemble there the groups interested in teaching. Out of your own Veterans’ Administration grew the urge to have this training. Now, the young medical officers coming back from war will want this training and should find the place in the veterans’ hospitals. That is the spirit that activated General Hines. Now, as Ave survey veterans’ hospitals, we make no charge. We assume all costs of this survey. We have 3,911 hospitals, and we have 3,132 that met the basic requirements. We find when a hospital comes up to basic standards, we do not have to go back oftener than 3, 4, or 5 years. If we hear of any hospital that is not carrying out those requirements, then we go back immediately to that period. We go back naturally to a veterans’ hos- pital if we hear anything about it, and we try to see those as often as possible. It is a critical survey. As I say, they have responded well to it. I remember 2 years ago our representative in his report said, “I do not believe there is good cooperation in the hospital, little teaching, little jealousies, and little cliqueing.” I sent this report to General Hines and his staff; they immediately took it up, in fact I had to step in and state that this is not too serious, do not make any trouble over this; but it shows how responsive they were. I am not here to tell you any more than the facts that we find as a disinterested party. All we are interested in is the care for the veterans. And, while I mentioned the vocational aspect of veterans’ hospital, it is because we have a tremendous need; but, also, it is all in the interest of maintaining the kind of staff required there. I have always believed that a medical corps would be a good and valuable thing in the Vet- erans’ Administration. I am very glad to see the bill that is being dis- cussed, and want it to develop. I feel and my conferees feel that you will have to pay more. I have to find men, and where I used to get them for $5,000 or $6,000, now they want $8,000 or $10,000. Things have taken quite a jump—they have gotten quite an increase in salary. In our study the other day we found the cost of living was up to 27 percent in that vicinity. I imagine that is true all over," So, therefore, we do have to face the problem of higher salaries in our medical services. Now, with the exception of one of our Medical Advisory Committee, all these men are very smart men. That one is myself. But the Vet- erans’ Administration has the advantage of the best thought and we have been sitting down diligently looking at this problem for several months and we believe and others of you, that the time is at hand where we have to analyze ourselves and see how we are going to meet this big load that is coming back on us. I said it would be well to have facilities close to medical centers. I was thinking of communities where scientific medical personnel are available for consultation and the like. It is true when situated near medical schools there is much VETERANS’ ADMINISTRATION 1889 better chance of getting the atmosphere of research and all that. Now, you take where President Truman mentioned Portland, that facility is familiar to me, I was one who helped to locate that hospital. A very distinguished surgeon built it up in the hills. I always told him people would not walk up that hill, but he built that school and he visualized at that time there should be a group of buildings and when the veterans built, they built near that school. Now, the young fellow who is going to learn a specialty or take basic science, if a man is going to be a urologist, he must know the anatomy. And there is pathology. He must learn more about applied pathology. He must learn more about applied plyysiology, because that has advanced greatly since this war. You have heard about shock and hemorrhage and all those things, and you must acquire the latest things which are basic. Therefore, in our thinking and in our education today we are talking about applied basic sciences, and the medical schools of this country, I believe, are going to be very sympathetic to a program like this. You know what happened in Minnesota the other day. Our representative said you should set up your graduate program and affiliate with the medical school and the chief surgeon and the dean of medical school said they would cooperate and take the men for basic science for 6 months or a year, and then they have the rest of the 3 or 4 years in the veterans’ hospital under supervision. At the end of the time, here is a qualified man to go into the service. Now, a hospital that teaches is a better hospital because of its teaching. So, I think they could do more—the head of the nursing division is here— but they sure graduate training and educational aspects at the hospital. Now, we are all activated by trying to get into these industries the best we can for these veterans. We have one common purpose, but I must say, I have always felt they were doing a very good job. But, like our civilian hospitals, since the war started we have had lots of problems. Now it is true that you will get things going wrong in any hospital; you will have things wrong in your own home. Things may go wrong. We do want them right. We must give our attention to trained administrators for all of our hospitals. You asked—I was asked—whether it should be a layman or medical man. Well, you cannot compare them with the civil hospitals. A great problem in civil hospitals is to get the money and spend it and budget it, and there is a tremendous business problem; consequently, laymen often get that position because of their business background; but to be successful, they must have a medical director who takes care of the professional side. Now, it is true the medical director sometimes would not have the business side. In our course at Northwestern one has to take that side, too, to get that side. In our course at Northwestern the layman has to take the fundamentals of medicine before he can get his degree. The largest hospitals and teaching hospitals are run by medical men. In the Veterans’ Administration it is strictly a medical problem, and I think the proper plan is to have a competent chief medical officer who is a good clinician and understands the problem of medi- cine, and give him additional assistants and administrators of the type he needs who have been training. Then you have your pro- fessional and administrative set-up all combined and coordinated in a fine way. 75183—45—pt. 5 4 1890 VETERANS’ ADMINISTRATION The Chairman. Do you say all veterans’ hospitals come up to the standard ? Dr. MacEachern. These 20 will come up to the teaching standard just as soon as things are stabilized with the personnel. Ten of them are ready now to give—there are 34 plans in 10 hospitals that are ready now. The Chairman, You are speaking now with reference to teaching? Dr. MacEachern. But as far as the standards I am talking about ? The Chairman. Yes. Dr. MacEachern. All of the 89 hospitals have been approved. The Chairman. I thought we had 94. Dr. MacEachern. We have not covered 94. The Chairman. All you have covered are up to standard ? Dr. MacEachern. All the 89; yes. The Chairman. Did you read these attacks on the veterans’ hos- pitals ? Dr. MacEachern. Yes. The Chairman. What do you think of them ? Dr. MacEachern. Well, I never get excited at anything I read unless I can go and see for myself or get a survey made. You can take instances in any hospital and get a good story on it. I do not believe that represented widespread conditions. Another thing, I do not believe anybody is competent to make statements on findings from hearsay but should make a survey and take in the whole picture. I want to know who made the survey and study. There are things to my mind, I cannot always take. Now, I do not care for the authority; I want to know what is back of it all; I want to know if 100 patients in that hospital have the same thing as in the report. Now, they may have found complaints. I do not know but that you can find complaints in any hospital. Complaints do spread; they get more—everybody enlarges a little on it. Perhaps they state the facts; I do not know. Of course, if there is mistreatment of patients, that is a bad thing. If there are any shortcomings in veterans’ hospitals they should be corrected? The Chairman. I agree with you. Dr. MacEachern. And when we hear any complaint of any vet- erans’ hospital, we immediately go there to look it over. Mr. Yursell. Do I understand this survey is given these hospitals without cost? Dr. MacEachern. Yes; without cost. Mr. Vurseel. And you have been making this survey for how many years? Dr. MacEachern. Since 1924. Mr. Yursell. Since 1924. Now, you found some 20 of them in the very top bracket? Dr. MacEachern. Yes. There should be more. Mr. Yursell, And you say that some 89 have been approved. Now, what do we understand the approval carries, what endorsement? Dr. MacEachern. It is the whole book here; I will leave this with you [indicating], but it means they are meeting basic standards of building, equipment, personnel, medical services; they have the nurs- ing services, food services, and sanitation as well as you can get these; they have a set-up that is going to assure good care of patients, that VETERANS’ ADMINISTRATION 1891 their death rates are within normal limits, that they are having con- ferences every week or two weeks for the doctors getting together; that the specimens they get from the operating room are discussed by the group, that the staff keep up with current literature through libraries; and everything that tends to the good care of the patients. Mr. Vursell. Now, would you say then that your summation would be that, granting in a large organization like this, there will be some maladministration, due to lack of help, due to war crisis we are in, you would not be able to have just the type of personnel—that on the whole you find the Administration’s administration from your survey has done a commendable job generally? Dr. MacEachern. Under the circumstances, I would say it is gen- erally ; yes. Those specifically mentioned, I am not prepared to dis- cuss, but all our inspections have been by well-trained men, and I would say yes. The Chairman. How do those 89 hospitals compare with other hospitals throughout the country? Dr. MacEachern. I would say there is quite a difference in those hospitals. We talk about other hospitals throughout the country, there are so many of them, there are 1,000 not on our list yet, as meeting basic standards. Of the others we always find a considerable num- ber of deficiencies to correct, except the teaching hospitals, and the large well-known outstanding institutions, so if you want to ask me, very plainly, I will say they compare very, very well. If you would see on my desk the civilian problems compared with the veterans— the fact is, in the veterans’ hospitals everything is under control. There are medical men in the hospital 24 hours a day; in our civilian hospitals we cannot get even interns and residents, and many of them are running day and night without a doctor on the ground. Now, we have not come to the place in civilian hospitals where we can have a resident in every hospital, but in veterans’ institutions there is a group of doctors there all the time; they are on the ward all the time; they see their patients all the time. In our civilian hospitals the doctors come in, make their visits, and go out. And, of course, a number of the civilian hospitals are outstanding because of their research and teaching and the years of experience; but, taking the average of hospitals, I do not see where the veterans take any second seat to them. The Chairman. Doctor, what do you think of the proposition of utilizing private and municipal hospitals in connection with treatment of veterans? Dr. MacEachern. Veterans’ service? The Chairman. Yes. Dr. MacEachern. You mean using so-called private or community hospitals? The Chairman. Yes. Dr. MacEachern. I think it has been done before on the contract plan, has it not? Just how far you can do it now with the civilian hospitals overcrowded and long waiting lists from 60 to 300, I just do not know. You may have some difficulties. I think it is a feasible thing but if you are going to have a large number of patients, 200 to 1892 VETERANS’ ADMINISTRATION 300 patients, yon will have to have a large expansion in our civilian hospitals, and at present they are not taking care of the civilian load in many places. Mrs. Rogers. May I ask a question ? The Chairman. Mrs. Rogers. Mrs. Rogers. Doctor, under civil-service regulations, after 4:80 p. m., the doctors are not usually in the veterans’ hospital, are they? Under civil-service rules and regulations after 4:30, with exception of the O. D. Dr. MacEachern, I do not understand what you mean. • Mrs. Rogers. Under civil service—you know the doctors operate under civil-service rules and regulations? Dr. MacEachern. Yes. Mrs. Rogers. The doctors leave at 4:30 p. m. and after that there is only one doctor on duty except for emergency operation. Dr. MacEachern. The civil service has 8-hour regulation, you mean? I know I have been in many veterans’ hospitals after 5 and 6 at night and found many doctors at work, Mrs. Rogers, That is where they live on the reservation? Dr. MacEachern. Yes. Mrs. Rogers. In some of the hospitals doctors are not on the reser- vation, they cannot get the houses for them, cannot get houses nearby. Doctor, do you inspect the basement and all of that ? Dr. MacEachern. Yes. Mrs. Rogers, Have you investigated the abuses? Dr. MacEachern. Well, we cannot do that except when it is brought to our attention. We have not found anything like that yet. I have seen those reports in the paper. Mrs. Rogers. You have not taken the trouble to investigate them. Dr. MacEachern. I think that would handle them best—you know, you are changing personnel so much that we do not know who you are getting in tomorrow—the best way to handle that is through your administrative set-up. If you have a good administrative set-up it will be done. Mrs. Rogers. But if they have not already handled it, what should be done ? Dr. MacEachern. Well, I think there should be an apprentice stage first. If you have a proper plan of personnel management you are going to know that type of person before you take them on; then when you make your job assignment, you should make sure that person knows the job, and that you should follow- that person to make sure of the type of employee you have. One of the things we must have with this new code is the art and science of personnel management. Our best civilian hospitals today are putting in personnel managers. They know the type of employees they are getting, and the different training, and then you must have your personal relations within your group; that is, that you know all the people you have and that they are out for the best interest of the patient, I think it is an administrative set-up and you will make your investigation through machinery set up in the Veterans’ Admin- istration, and take such action as is necessary. It may do—it may mean dismissal of the people; it may be some other punishment meted out to them. VETERANS’ ADMINISTRATION 1893 That should not occur in any hospital. And if you have good ad- ministrative qualities, a good set-up and everything in what we call the art and science of personnel management, and good relations it will not happen very often. We need that now in these big hospitals. Fundamentally, it is a personnel matter. It should never occur. Mrs. Rogers. Thank you, Doctor. The Chairman. Are you gentlemen finished? Mr. Scrtvner. I have no questions. Mr. Carnahan. I wanted to ask the doctor if he has any compara- tive figures on cases that reach the court from malpractice as they might come from Veterans’ Administration facilities? Dr. MacEachern. For malpractice? Mr. Carnahan. Yes. Dr. MacEachern. Do you mean lawsuits? Mr. Carnahan. Yes. lawsuits. Dr. MacEachern. Well, of course medico-legal cases today are practically settled, all of them, out of court without knowing what happens. Most of the cases are settled because of liability insurance policies. The cases that are not are those cited in the journals from time to time and thev are not so many. Mr. Carnahan. How often do you improve or change your rating scale, by which you rate hospitals? Dr. MacEachern. Every year. Mr. Carnahan. And who arranges such scale? Dr. MacEachern. No hospital is ever changed in rating without an inspection. Mr. Carnahan. I mean, who sets up the items that makes up your rating scale? Dr. MacEachern. You mean this [indicating] ? Mr. Carnahan. Yes. Dr. MacEachern. Our organization, of which I am director. And these have been developed over all these years. These are the re- quirements they must comply with. ,Then our survey takes things that are not up to date in standards and it goes to the institution and a follow-up letter also goes to the Director of the Bureau, and the recommendations are considered and accepted and if necessary, car- ried out. always, if they are reasonably right. Mr. Carnahan. Your scale can be applied to an objective? Dr. MacEachern. Yes. Mr. Carnahan. It is not an opinion of somebodv? Dr. MacEachern. Oh, no. Now. many hospitals like Hines do not have to be inspected every year. We go to them as often as we can. These are going to be set up for educational purposes and are going to be inspected every year because we know—we want to know they are giving the right training. Mr. Carnahan. And in your opinion the very best medical thought that goes into your rating scale? Dr. MacEachern. Yes. When we started this in hospitals in 89 only on the minimum requirements—they lacked laboratories. X-rays, things the patients should have. Now there are 3,132. It cost us one and three-quarter million dollars in our own—our own surgeons paid out of their OAvn pockets. We do not accept even railway fare. 1894 VETERANS’ ADMINISTRATION We have just covered 32 hospitals for the Navy and 10 for the Public Health Service. Mr. Carnahan. Ordinarily, how long does it take for an inspection of an ordinary hospital ? Dr. MacEachern. One or two days after you have made the basic survey. To make those educational surveys it would take about 3 or 4 days. I want to explain to you that when we go to Hines, for instance, for survey, we have all that information on file [indicating]. We have the physical plant and everything right there before us. If we went to the Bronx or Los Angeles, we have all the past infor- mation, and therefore, when you go there you get down to the essentials of the present time, by virtue of the information you have filed. Going for the first time, it takes longer. The Chairman. Any questions ? Mr. Domengeaux ? Mr. Domengeaux. Yes. Doctor, you stated you have just completed a survey of some thirty naval hospitals? Dr. MacEachern. Thirty-two. Mr. Domengeaux. I assume you have also inspected Army hos- pitals ? Dr. MacEachern. Yes. Mr. Domengeaux. How does the veterans hospital compare with the Army and Navy hospitals? Dr. MacEachern. I would not like to answer that question for fear I would be misunderstood too much. I would say that the Army and Navy—I would say that the Army stands up very excellent, too. And they are much the same in their set-up and all that; and the Public Health Service. The Navy is very fortunate in having such outstand- ing men that they get through the Navy, they have not had as much difficulty as we have in civilian or other hospitals because of the per- sonnel they have developed. For educational purposes, they all would come to the same level. Mr. Carnahan. The Army and Navy under the same circumstances have an advantage ? Dr. MacEachern. Yes. Mr. Carnahan. And it is not fair to make that comparison ? Dr. MacEachern. That is the way I would put it. Mr. Carnahan. Doctor, in your survey, is the question of cost per patient per day taken into consideration? Dr. MacEachern. No. We keep away from the financial aspects of it. All we are interested in is care of the patients. Mr. Carnahan. That is all, Doctor. The Chairman. You wanted to ask him some questions, Mr. McQueen ? Mr. McQueen. On this survey, Doctor, of Veterans’ Administra- tion hospitals—it covers 89 hospitals—that some of these surveys are as old as 1936 and some as late as 1944. Now, have you regular time you make a survey? Dr. MacEachern. When we have a hospital we are not sure of we do it every year. Of the hospital we are sure of running along, we do not do it more than every 4 or 5 years, when they are stabilized, we will say. For instance, it would be foolish to make a survey of Johns Hopkins or Massachusetts General every year. We direct our VETERANS’ ADMINISTRATION 1895 efforts toward those that are weaker. We have directed our efforts the past year that—to hospitals that do not keep basic standards. Now, we get statistical and other reports on all these hospitals every year. We get information. Mr. McQueen. Well, that would likewise hold good in Veterans’ Administration hospitals? We will say you have not been in since 1936 and you know that that standard is maintained—or, if you made only three examinations since 1935, that hospital stands out. Dr. MacEachern. I never go to a place where there is a veterans’ hospital without making an informal visit. That does not represent our visits. Mr. McQueen. In other words, there are many visits which are not included in it? Dr. MacEachern. Yes. We have 13,000 outstanding surgeons in this country, or 12,000 about, and they are working in most of these communities and areas. There are meetings of these in every com- munity almost each year, until they stopped the travel, and we gather a good deal of information from other sources. Air. McQueen. Now, you talked about a regional consultant. Is it your idea that the veterans’ hospital system is getting to a point where it should be broken down administratively in regions? Or do you mean that these consultants should be confined to certain areas? Dr. MacEachern. Well, I had in mind the Army. Now, there are nine service commands. Let us take the sixth survey—the Sixth Service Command. Of course, we have our chief medical officer. Then we have a man in general surgery to travel around, see all the cases; a man in neurology, orthopedics. Now, my idea was you would have a general man in medicine, a general man in surgery, and perhaps in neurology and urology and some of the other specialties. That is in that report [indicating]. Now, for instance, we have discussed perhaps physical medicine and rehabilitation. Each man in his specialty would travel from hospital to hospital. He would spend 3 or 4 days or a week in each hospital. While he was there he would see all the cases in that service. Mr. McQueen. Would you recommend that the Veterans’ Admin- istration follow that program, or adopt some similar plan? Dr. MacEachern. Yes. I would recommend they consider it. Mr. McQueen. Consider it. Dr. MacEachern. Unless you can—of course, local consultants are excellent men if they will spend enough time in the hospitals. You cannot expect the doctor and high-grade specialists to spend a whole day in the veterans’ hospital for $25. Mr. McQueen. No. Dr. MacEachern. And if he goes to that hospital—I do not like the idea of a consultant to come just for one patient. I would rather the consultant would come to a hospital from outside and see each case of the men in the hospital. Mr. McQueen. Now, Doctor, you spoke of our having 18,000 trained medical administrative men that would soon be released from the Army. Dr. MacEachern. No; they are in the Administrative Corps. I would not say they are very well trained. Mr. McQueen. They are in the Administrative Corps. Their serv- ices will presumably be available? aVoicTi 1896 VETERANS’ ADMINISTRATION Dr. MacEachern. Yes. Mr. McQueen. How much of a staff for a 500-bed hospital would it take to have the Administrative Corps to assist the doctors? Dr. MacEachern. A couple of clinical assistants and a couple of administrative assistants, I would say, offhand, in that 500-bed hospital. Mr. McQueen. In other words, you would say or recommend Dr, MacEachern. I would not say that is the exact figure. I would want to know the institution and the ramifications of it. Mr. McQueen. Each hospital should have a sufficient number of men assigned to it to bring it up to what it should be at this time? Dr. MacEachern. Yes. I do not believe the chief medical officer should have to spend a lot of time going around looking at linen closets and the sanitation and the supply rooms and all that. I think he should give more time for medicine and have an assistant assigned for the physical plant. And he cannot be expected to visit 500 patients a day, or twice a week. He should have these clinical assistants, administrative as- sistants, that should go around to the wards on those cases. The ward officer is there but he is very busy clinically. Mr. McQueen. Do you think that veterans’ hospital should be managed then by lay people, from a good administration standpoint, or should they be managed by medical men with the lay people work- ing under them ? Dr. MacEachern. I think the chief medical officer should be the officer in command, so to speak, of the hospital. I believe the Army and some of the other services have the best plan, to have necessary clinical and administrative assistants doing all the routine adminis- trative duties. Mr. McQueen. What do you find in the civilian hospitals? Dr. MacEachern. In the civilian hospitals today when you have a lay administrator, unless he is well trained, he is not a success, and a lay administrator, to be successful, has to have a medical director or chief of staff, who will spend a lot of time in the hospital because he cannot handle medical problems well with the professional men; he would not attempt to handle the medical problems; and he should surround himself with a medical head and a medical director, Npw, in the veterans’ hospital, they have been accustomed in their service ward to a medical man around them, and I doubt if they would have confidence in anyone else. They have depended so long in the ward on that that they will expect that. I say, give them a chance to work at that and relieve them of the extra duties. Mr. McQueen. Maybe I did not make myself clear. Take the Hines Hospital at Chicago, it is my understanding that the manager of that hospital is a layman. Dr. MacEachern. Yes; the facility. Mr. McQueen. The facility. But most of the other hospital work has been removed to downtown Chicago. Is that not true ? Dr. MacEachern. Yes. Mr. McQueen. But they still have a manager of that hospital. Do you think that is a proper way to run a hospital, or do j'Ou think it should be a medical man ? VETERANS’ ADMINISTRATION 1897 Dr. MacEachern. I think in the Veterans’ Administration, because their problem is so much medical, that it should be a medical officer. Mr. McQueen. Now, let me ask you, in your report which you sub- mitted here for us of all the hospitals that you inspect, does that include these osteopathic hospitals, too ? Dr. MacEachern. No. Hospitals that are staffed by regular physicians. Mr, McQueen. And does it include any osteopathic hospital ? Dr. MacEachern. No. Mr. McQueen. That is all. Now, Mr. Chairman, I would like to introduce these The Chairman. Thank you very much, Doctor ? Mr. McQueen. I would like to introduce the Surveys of United States Veterans’ Administration Hospitals by the American College of Surgeons, as referred to by Dr. MacEachern. The Chairman. Very well. (The document referred to follows:) American College of Surgeons' Surveys of U. S. Veterans' Administration hospitals Location Years surveyed Bed capacity Present rating Alabama: Montgomery 1941 268 FA 1935,1942 621 FA Tuskegee ... 1930,1935,1942. 1,665 428 Arizona: 1924,1926,1927,1930,1935,1942 FA 1925,1927,1930' 1932,1935,1942 527 FA Arkansas; Fayetteville 1935,1939,1943 . 258 FA North Little Rock 1924,1935,1940 1,625 FA California: 1925,1926,1929,1934,1935,1942 408 FA 1924,1926,1929,1934,1935,1942 1,417 2,416 401 FA 1924,1925,1926,1929,1932,1936,1938 FA San Fernando 1929,1934,1935,1942 FA 1936 - 340 FA 1925,1927,1930,1932,1936 1,026 427 FA 1933,1939 FA District of Columbia: Washington 1925,1934,1937,1943 . 327 FA Florida: 1934,1937,1941 619 FA Lake City 1924,1929,1932,1935,1937,1941 419 FA Gerogia: Atlanta 1924,1934,1937,1941,1942,1944 415 FA Augusta 1924,1930,1634,1937,1941 1,167 203 FA 1924' 1925, l'929j 1931,1932,1936,1943 FA Illinois: 1928,1931,1937,1942 2,300 1,600 196 FA Downey 1926,1931,1937 .• FA Dwight 1936 .. - ... - FA 1924,1931,1944 2,029 214 FA 1943 FA Indiana: 1933,1937,1944 345 FA 1927-1929,1931,1937 1,509 FA Iowa: 1934, 1939 545 FA Knoxville 1925, 1928, 1930, 1934, 1939 1,605 FA Kansas: 1924, 1925, 1934, 1940, 1943 742 FA 1934' 1936, 1939, 1943 248 FA Kentucky: 1932, 1935, 1941 663 FA 1924' 1939' 1932, 1935, 1941 . 375 FA 1924' 1926' 1928, 1932, 1934, 1940 739 FA 1925j 1926, 1930, 1933 1,234 1,633 FA Maryland: Perry Point 1924, 1937, 1043 FA [FA, fully approved; NA, not approved] 1898 VETERANS’ ADMINISTRATION American College of Surgeons’ Surveys of U. S. Veterans’ Administration hospitals—Continued Location Y ears surveyed Bed capacity Present rating Massachusetts: 1935,1939 1,749 FA 1924, 1930, 1935, 1939 1,002 FA 1924! 1930! 1935! 1939 469 FA Michigan; 1942 . .... 463 FA 1924, 1935, 1940 1,723 FA Minnesota: 1931, 1934 786 FA 1925! 1936, 1941 1,197 FA Mississippi; 1934,1941 208 FA 193C, 1934, 1941 785 FA Missouri: 1924, 1931, 1934, 1940 267 FA 1924, 1931,1934, 1940, 1944 203 FA 1925! 1930,1943.. .1 184 FA 1931, 1934, 1936, 1939, 1944. 379 FA 1936, 1942 26 FA 1934, 1938 1, 925 FA New Mexico: 1932, 1935, 1942 313 FA 1925, 1927, 1930, 1935, 1942... 305 FA New York;" 1936,1944 295 FA 1931,1937,1944 428 FA Canandaigua 1933,1937,1944 1,275 FA 1924,1931,1936,1944 625 FA New York City.- . __ 1924,1938,1945 ■ 2,090 FA 1940,1945 2,685 FA Saratoga Springs 1944 47 NA 1924,1931,1933,1936,1944 689 FA North Carolina: Oteen.. 1924,1930,1934,1938,1944 1,269 FA 1930,1933,1936,1941 159 FA Ohio: Brecksville . . ... 1941 285 FA Chillicothe i 1924,1927,1935,1941 1,860 FA Dayton. . ... . 1932,1935,1937,1943,1944 1,077 FA Oklahoma: Muskogee 1924,1931,1934,1936,1939,1943 428 FA Oregon: Portland 1932,1936,1938,1943,1945 623 FA Rosoburg .. ._ 1936,1943 . 566 FA Pennsylvania: Coatesville 1936,1941,1945 1.728 FA Pittsburgh (Aspinwall) 1933,1936,1944 1,134 FA 1934,1937,1942,1944 606 FA South Dakota; Hot Springs 1924,1925,1927,1931,1936,1941 276 FA Tennessee: Memphis. 1924,1930,1932,1935,1941,1942,1944 565 FA Mountain Home 1924,1929,1932,1934,1937,1941. 553 FA Murfreesboro 1941 1 1,007 FA Texas: Dallas 1941 .. 352 FA Legion 1925,1930,1935,1940 . 409 FA Waco 1935,1938,1940 1,394 FA Utah: Salt Lake City... .. _ 1936,1943 204 FA Vermont: White River Junction 1939... .. 188 FA Virginia: Kecoughtan 1924, 1925, 1930, 1932, 1938, 1943, 1944 528 FA Washington: American Lake 1924, 1926, 1930, 1936, 1943 .. 789 FA Walla Walla 1929! 1936! 1043! 1. 421 FA West Virginia: Huntington _ 1937 321 FA Wisconsin: Mendota 1938 ... . 282 FA Wood 1925, 1927, 1932, 1935, 1938, 1942, 1944 1,403 FA Wyoming: Cheyenne.. 1936, 1939, 1943 212 FA Sheridan 1925! 1027! 1930, 1936, 1943 ... 594 FA Total hospitals .1 89 Total beds 68,925 Total surveys 324 Mr. McQueen. I would like to introduce this Manual of Hospital Standardization in the record. The Chairman. Very well. VETERANS’ ADMINISTRATION 1899 (The bound manual referred to was filed with the committee.) Mr. McQueen. I would like to introduce this report on the 20 hos- pitals surveyed for teaching purposes. The Chairman. All right. (The bound report referred to was filed with the committee.) The Chairman. The committee will stand adjourned until 10 o’clock tomorow morning. (Whereupon, at 4:40 p. m. the committee adjourned to 10 a. m. of the following day.) AMERICAN COLLEGE OF SURGEONS—MANUAL OF HOSPITAL STANDARDIZATION (In compiling the subject matter of this Manual of Hospital Standardization, frequent reference has been made to authoritative statements from Hospital Organization and Management in respect to many of the phases presented. Grateful acknowledgment is made to the author, Dr. Malcolm T. MacEachern, and to the publishers, Physicians’ Record Co., Chicago.) History, Development, and Progress of Hospital Standardization The American College of Surgeons, founded in 1913 by surgeons of the United States and Canada, is the originator of hospital standardization. The desire of the college to advance the practice of surgery was directly responsible for the beginning of this movement. In order that surgery might be placed on a higher, more ethical plane, the college established as one of the major requirements for admission to fellowship that each candidate submit 100 medical records of patients upon whom he had operated, as evidence of surgical judgment and technical ability. Few candidates, however, could comply with this requirement inasmuch as hospitals in the United States and Canada seldom kept records which provided accurate data. It was also discovered that the average hospital lacked laboratory, X-ray, and other essential diagnostic and therapeutic facili- ties necessary to the surgeon in making a proper preoperative study of his patient. Furthermore, medical staffs of hospitals were not organized and the professional work generally lacked supervision; most hospitals were deficient from the standpoint of scientific efficiency. The need for improvement was evident. After several years of preliminary study and investigation, which included surveys of many hospitals and consultations with eminent authorities and officers of national organizations, the epoch-making program in hospital and medical history, known as hospital standardization, was inaugurated in 1918. This program, sponsored and financed by the American College of Surgeons, was received with interest beyond all expectation by the hospitals of the United States and Canada. The growth of the movement has been constant and sub- stantial and now its influence extends to foreign countries, where many insti- tutions are applying the principles advocated, which insure efficient and scientific care of the patient. There are now, at the close of the twenty-second annual survey, more than 44,000 reports on file which show definite and encouraging evidence of progress by hospitals in the fulfillment of their obligations to their ill and injured patients. Hospital standardization defined Hospital standardization is a movement to encourage all hospitals to apply certain fundamental principles for the efficient care of the patient which are set forth in the minimum standard for hospitals. Its object is to promote better hospitalization in all its phases in order to give the patient the greatest benefits that medical sicence has to offer. Throughout the history and development of hospital standardization a definite theme has been sounded, namely, the proper care of the sick and injured. Its aim is to create in the hospital an environment which will assure the best possible care of the patient. What this means to hospital progress is apparent when one realizes that the standardization program requires that each hospital which qualifies for approval shall have an organized, competent, and ethical medical staff; that the staff shall hold regular conferences for review of the clinical work; that fee-splitting shall be prohibited; that 1900 VETERANS’ ADMINISTRATION accurate and complete medical records shall be written for all patients treated p and that adequate diagnostic and therapeutic facilities, including a clinical laboratory and X-ray department, shall be provided. This involves facilities, personnel, and procedures predicated upon efficient organization, progressive management, and competent personnel imbued with a scientific and humanitarian spirit. When an institution adopts and successfully applies the above-named principles, which express the high standards of modern medical and hospital practice, it is known as a standardized or approved hospital. These fundamental principles, which are readily adaptable to all institutions caring for the sick, are embodied in the minimum standard for hospitals which is printed below. MINIMUM STANDARD FOB HOSPITALS 1. That physicians and surgeons privileged to practice in the hospital be organized as a definite medical staff. Such organization has nothing to do with the question as to whether the hospital is open or closed, nor need it affect the various existing types of medical staff organization. The word “staff” is here defined as the group of doctors who practice in the hospital inclusive of all groups, such as the active medical staff, the associate medical staff, and the courtesy medical staff. 2. That membership upon the medical staff be restricted to physicians and surgeons who are (a) graduates of medicine of approved medical schools, with the degree of doctor of medicine, in good standing, and legally licensed to practice in their respective States or Provinces; (b) competent in their respective fields; and (c) worthy in character and in matters of professional ethics; that in this latter connection the practice of the division of fees, under any guise whatsoever, be prohibited. 3. That the medical staff initiate and, with the approval of the governing board of the hospital, adopt rules, regulations, and policies governing the professional work of the hospital; that these rules, regulations, and policies specifically provide (a) that medical staff meetings be held at least once each month; (b) that the medical staff review and analyze at regular inter- vals their clinical experience in the various departments of the hospital, such as medicine, surgery, obstethics, and the other specialties ; the medical records of patients, free and pay, to be the basis for such review and anlaysis. 4. That accurate and complete medical records be written for all patients and filed in an accessible manner in the hospital, a complete medical record being one which includes identification data ; complaint; personal and family history; history of present illness; physical examination; special examina- tions, such as consultations, clinical laboratory, X-ray, and other examina- tions ; provisional or working diagnosis; medical or surgical treatment; gross and microscopical pathological findings ; progress notes ; final diagnosis ; condition on discharge; follow-up; and, in case of death, autopsy findings. 5. That diagnostic and therapeutic facilities under competent medical supervision be available for the study, diagnosis, and treatment of patients, these to include at least (a) a clinical laboratory providing chemical, bac- teriological, serological, and pathological services; (&) an X-ray department providing radiographic and fluoroscopic services. The principles of the minimum standard for hospitals are the same today as when the standard was originally formulated in 1918. Therefore, it cannot be said that more hospitals are meeting the requirements at present because of a lowered standard. Hospitals have progressed not only because the public has demanded better service but because hospital standardization has aided in the establishment of a proper environment for the physician, his associates, his assistants, and his coworkers so that they may render to every patient the most scientific service which is possible. Spirit of hospital standardization Hospital standardization contemplates that hospitals by meeting the minimum requirements shall be standardized insofar as the fundamental principles or essentials of efficient hospital care of the patient are concerned. It is not the intention, however, that hospitals by adhering to minimum standards shall be deprived of their individuality. On the contrary, the minimum standard for hospitals has in actual practice promoted independence in adaptation of the standard to varying conditions, and every hospital is encouraged to seek indi- vidual growth and development. The fundamental idea is that the individuality of the hospital must be conserved. VETERANS’ ADMINISTRATION 1901 While the scientific aspect of the present day hospital is most important, it must not completely overshadow the humanitarian spirit of the institution. The patient in a hospital is an individual, and, therefore, he cannot be standardized. Rather, he must be individualized in diagnosis and treatment, and he must never be considered as an inanimate number or merely as one of a group. He must be received, treated, and discharged not according to iron-clad routinism but accord- ing to the requirements of the individual case. Hospitals are learning the impor- tant lesson that in order to achieve their purpose of providing adequate care for the sick and injured they must be prepared to give humanitarian service as well as scientific service. It is entirely possible for a hospital to be both standardized and individualized, both scientific and humanitarian. Hospital standardization makes it possible for an institution to express a distinct personality. The very spirit of the move- ment is intended to encourage each institution in individual growth so that it may render an efficiently standardized and scientific service made even more effective by a genuine attitude of individualized humanitarianism. Important aspects of hospital standardization The sponsors of hospital standardization believed that through improving the organization of hospitals, and with proper utilization of existing facilities and personnel, much could be done to better the quality of service rendered to the patient. Hospital standardization is not dependent on any legal endorsement whatsoever, that is, no institution is compelled by law to adopt the principles advocated or to incorporate them in its constitution. Acceptance and maintenance of the minimum standard for hospitals are entirely optional. The worthiness and value of hospital standardization have been manifested by its wide and voluntary acceptance, by its rapid growth and development, and by the increased esteem which is accorded those institutions which have adopted the standard. Few hos- pitals have been unable to maintain the requirements after they have adopted the principles and applied them with diligence and sincerity. They have found that the adoption of the minimum standard for hospitals has led to more rapid development and higher standards than were previously attempted. Hospital standardization is not limited to any one part of the hospital; it is not restricted to any one group; it is not confined to any one locality, but it is equally applicable to all hospitals which manifest a true desire to focus every phase of their organization and service on the proper care of the patient. Experi- ence has proved that this can best be accomplished through applying the minimum requirements as described in detail in the text to follow. These requirements are fundamental to sound organization and proper coordination within the hospital in rendering scientific and efficient service to the sick and injured. Growth of hospital standardization The first group of hospitals to be surveyed comprised institutions of 100 beds and over. Commencing in 1918, 24 annual surveys have been made. Remarkable progress in the growth of approved hospitals in this class has been shown. Be- tween the years 1918 and 1941 the number of approved hospitals of 100 beds and over increased from 89 to 1,928. In 1918, only 12.9 percent of hospitals in this class met the minimum standard for hospitals. In 1941, 93.0 percent met the requirements and were on the approved list. A summary of the surveys of hos- pitals for each year from 1918 to 1941 inclusive is given in table I. In 1922, the American College of Surgeons began its surveys of the next group of hospitals, those of 50 to 99 beds. Already 20 annual surveys have been made of these hospitals, and while the increase in the number meeting the requirements has not been so rapid as in the group of hospitals of 100 beds and over, it has been most gratifying. At the end of the 1941 survey, 738 hospitals in this group, or 68.2 percent of the 1,082 hospitals which were surveyed, were approved. In 1924, the survey was extended to include all hospitals of 25 to 49 beds. The hospitals of this group have many difficult situations to overcome since they are sometimes deprived of close affiliation with the larger institutions. However, the high standard which many of these institutions maintain despite physical, financial, and personnel handicaps is commendable. The managements deserve encouragement in their efforts. Up to the present 18 annual surveys of this group of hospitals have been made, with the result that 207, or 88.8 percent of the hospitals surveyed, are approved. In 1925, at the request of the United States Veterans’ Administration, a survey was undertaken of all veterans’ hospitals in the United States. In the same 1902 VETERANS’ ADMINISTRATION year similar requests were received from the United States Public Health Service, the Army, and the Navy. Seventeen annual surveys have been completed, with the result that 171, or 93.0 percent of the hospitals surveyed, are approved. The number of hospitals surveyed has increased more than five times, and the percentage of approved institutions of 25 beds and over has increased from 89 or 12.9 percent in 1918 to 2,873 or 77.9 percent in 1941. It is interesting to note that progress in meeting the requirements for approval has been steady and continu- ous. It is believed that the time is not far distant when only hospitals which meet the minimum requirements for approval will attempt to care for the sick and injured. Table I.—Surveys of hospitals, 1918 to 1941 liiiliiiiiliiiliiiiiiiii ; i; i! 111111111! 1111 i 11 i i iiSiSISiSS'ilisissiii Surveyed 100 beds and over liiasiSliiHsiaiSaaasis Approved M « 00 05 50 Percent SiiSiiiiiisEiSiisE 1 Surveyed 50 to 99 beds aSgSSSiilSilSSSSSiil i Approved K)MM00l00TC(K0MOfr0.k5(0OMMMe essential requirements embodied in the minimum standard on the opposite page! Ambulance service Hospital managements are urged to insist that ambulances serving them be properly equipped and operated. The right kind of first aid and transportation is particularly important, since lack of care at this stage may result in so much harm that the best of subsequent medical and surgical service may be unavailing. Each hospital management and a committee of the medical staff should co- operate actively with organizations conducting ambulance service in order to insure that the indicated equipment is provided and that the ambulance person- nel is properly trained. Since doctors and trained ambulance staffs will not al- ways be on hand before injured persons are moved from the site of the accident, it is also of great importance that policemen, firemen, safety crews in industry, and the public generally be informed as to what constitutes safe first-aid prac- tices and safe transportation. The slogan, “Splint ’em where they lie,” should be popularized and applied whenever indicated, and when fractures of the long bones exist, traction splints should be used. Neither medication nor antiseptics should be dispensed by lay ambulance attendants. Plain sterile dressings should be placed over the injuries to avoid further contamination, and cleansing of the wound should be left to the skilled surgeon. Morphine and hypodermic syringes must not be kept in the ambulance unless closely guarded and unless a physician is a regular member of the trained ambulance personnel. Shock may be minimized by careful handling and by keeping the patient warm by the use of blankets and other approved methods. Approved mechanical resuscitators or inhalators, using oxygen and carbon dioxide, are valuable aids when applied by trained operators, especially in cases of gas poisoning. These mechanical aids, however, should not replace prone pressure artificial respiration, the method which is of first choice and which is always aavilable. On account of the nature of the service, the state of cleanliness of an ambu- lance must be acceptably maintained. At frequent intervals the inside of the 1960 VETERANS’ ADMINISTRATION ambulance should be washed thoroughly with soap and water, and vacuum cleaned where indicated. After each trip the used supplies, sheets, bandages, etc., should be replaced immediately with fresh supplies, one of the ambulance personnel being responsible for maintenance of equipment. The ambulance personnel should consist of a driver qualified in first aid, and a physician or trained attendant. Thd equipment should include stretchers, clean sheets, blankets, sterile dressings, bandages, towels, adhesive tape of varying widths and lengths, cravat or fracture bandages, traction straps, cotton sheet wadding, wooden tongue depressors, 16-ply clothesline, wooden splints, a Mur- ray-Jones arm splint, a Thomas ring splint, or a Keller-Blake hinged half-ring splint. Obviously, the mechanical condition of the ambulance—tires, brakes, lights, motor, etc.—must be so maintained as to insure prompt, safe, and un- interrupted service. All calls must be answered promptly and this presupposes that there is a personnel covering the 24-hour period. Minimum Standard for Nursing in Hospitals 1. Organization: There shall be a well organized department of nursing in the hospital, under competent supervision and direction, for the efficient adminis- tration and rendering of the nursing service, and for the education of student nurses when a school of nursing is maintained. 2. Personnel: There shall be an adequate number of competent trained personnel for supervision of the nursing service and for efficient nursing care of the patients. 3. Facilities: There shall be adequate and conveniently arranged modern facilities and readily available standard supplies for furnishing prompt and ef- ficient nursing service. 4. Education: When a nursing school is maintained in connection with the hospital, it shall provide definite educational requirements in accordance with accepted national standards, adequate teaching personnel and facilities, and a comprehensive system of school records. 5. Records: There shall be maintained an extensive system of nurses’ clinical records, including all data pertaining to the nursing care of the patient, observa- tions of signs and symptoms, orders executed for physicians, nursing services rendered, and other pertinent information that will show the condition of the patient and the response to treatment. 6. Conferences: Weekly meetings of the graduate nursing staff shall be'held to review and analyze the nursing service, to determine the quality of the nursing care rendered to patients, and to increase the efficiency of the nursing service when indicated. 7. Relation to patients: Due care shall be exercised at all times to insure the safe and efficient nursing care of the patient through proper assignment of duties, competent supervision over student nurses when used to render nursing care, and an adequate ratio of nurses to patients. Nursing When the hospital accepts the responsibility for treatment of a patient, it enters into an implied contract to furnish him with adequate and complete scientific care. In the fulfillment of this contract one of the most important duties of the hospital is to provide the patient with nursing service from the time he is admitted until he is discharged. The section on nursing of the council on professional practice of the American Hospital Association, in cooperation with a committee of the National League of Nursing Education, has stated the essentials of good nursing service as follows : “The amount and kind of nursing provided by the hospital for its patients should be based on the patient’s needs and not upon his ability to pay for this service. In other words, the responsibility of the hospital is to furnish adequate care to all patients regardless of their ability to pay for it. By adequate nursing care is meant the amount of professional care essential to provide the proper professional treatment for the well-being and recovery of the patient, both mental and physical. If the patients desire more than the essentials of good nursing care, they may well be expected to pay for the additional service.” The importance of efficient nursing service cannot be overemphasized and has a marked bearing on the end results in the treatment of the patient. Unless the physician can have the assistance of good nursing in carrying out the treat- ment ordered for his patients, he is much handicapped in the practice of his profession. VETERANS’ ADMINISTRATION 1961 Organization: The first requirement of the minimum standard for nursing emphasizes the importance of good organization. The department of nursing must be as well organized as other departments of the hospital so that there will be a clear definition of authority, responsibility, and functions in order that efficient nursing care may be assured to the patient. This involves executive and administrative ability on the part of the director of nursing, who should organize the department along acceptable and practical lines. While nursing service is a distinct function performed by specially trained individuals, the work must nevertheless be planned and conducted to support and coordinate other services in a larger and more complete organization. The plan of organiza- tion should be determined by the size and nature of the institution, and though it may vary from time to time, the underlying principles should have a basic character. As in other departments, well-considered rules, regulations, policies, and procedures, with which each employee should become familiar, must be estab- lished for the administrative and technical guidance of the personnel. Personnel: Different types of personnel are required in the hospital to render nursing care, as it varies from the highly specialized technical procedures of the skilled graduate nurse to the nonprofessional services performed by adjunct personnel. An analysis of nursing service as required in the care of patients may be divided into professional and nonprofessional duties which must be assigned to persons who are properly trained to perform them. 1. Director of nursing service: The director of the nursing service is the administrative head in charge of all members of the personnel who render nursing care in the hospital, including the special nurse employed by the patient. When the hospital conducts a school of nursing, the director may also be the principal of the school, thereby coordinating the nursing activities of the hospital with the educational activities of the school. The director of nurses is, however, primarily an administrator and therefore must have admin- istrative and executive qualifications. First, she should cooperate with the accounting department in arriving at a budget. This, when approved by the governing body, becomes her authority for expenditures, in accordance with which she employs all of the necessary nursing personnel. Second, she should select the members of her staff. For the graduate nurse, a certain legal status is established by the requirement of registration in the State and a license to practice her profession. This is, however, only a mini- mum requirement and does not assure suitability for the specific position. The same general qualifications—age, education, health, personality, and profes- sional experience—must be considered by the director in choosing all the members of her staff. Third, having selected the personnel, the dii’ector of nurses is confronted with management problems that require her to be a capable executive. Dis cipline must be maintained, the organization must be made effective, and the care of the patient must be up to the standard that the hospital has contracted to give. The report previously quoted states the qual iflcations of the director of nurses as follows: “It is generally agreed that she should be a woman qualified by preparation and experience to conduct a nursing service, a woman of education and refine- ment, graduated from an accredited school of nurses, possessing qualities of leadership and a personal knowledge of good nursing practice. It is essential that the director of nursing service be a recognized leader in community affairs. Regardless of whether there be a school or not, she should possess teaching ability as in hospitals without schools a staff education program is essential.” In controlling her staff and performing her executive duties the director of nurses should base her judgments on observations and reports. Knowing good nursing practice, she can judge whether or not the patient is receiving good nursing care, even though she may not be present to observe the actual service. Except in the very small hospital her observation must be supple- mented by reports from assistants, supervisors, and others in administrative positions who are directly responsible. Such reports may be informal but they should always be informative. The larger the hospital, the less opportunity the director of nurses has for personal observation. As head of the nursing service, she is responsible for furnishing certain re- ports to other departments such as those concerned with business management. A record of patients admitted, orders for diets, and similar matters should be sent at once to the dietary department. Wherever reports are necessary for 1962 VETERANS’ ADMINISTRATION the smooth functioning of the service, the director of nurses should be meticulous in seeing that they are accurate and promptly submitted. As an administrator, the director of nurses should be provided with an ade- quate number of competent assistants so that her own efficiency may not be impaired. Thus, either personally or through an assistant, she will be able to give that close supervision which is necessary for an efficient organization. 2. Assistants to the director of nures: Nuring-service functions at all hours of the night and day; yet the director of nurses cannot always be actively on duty and she must have assistants to relieve her both during the day and at night. The appointment of assistants to the director for day relief is necessary in all hospitals. Someone should be in authority constantly to exercise super- vision of the nursing service during the absence of the director. She may be on floor duty, the supervisor of the operating room, or any other nurse. What her other duties may be is immaterial so long as she is officially given the temporary authority. As the hospital increases in size, the duties assigned to the assistant necessarily become more numerous and her time becomes more absorbed until in the larger hospitals there are one or more nurses as full-time assistants to the director. In the small hospital where authority is assigned to different persons on duty during the director’s absence, the assistant merely has the power to deal with administrative affairs as they arise, and the specific duties of the director are not designated to her. In the larger hospital many duties are specified a,s the assistant’s responsibility, even in the presence of the director. In the very large institution where there are one or more full- time assistants, the duties are assigned in accordance with the demands and the type of organization. The assistant to the director for night relief is an essential appointment in any hospital. In the small institution the limited experience of the assist- ant who has supervisory as well as inursing duties may require her to call the director in major matters, but the director should not be called at night for the numerous petty details that constantly arise. In the larger hospital the assistant to the director for night relief, or the night supervisor as she is commonly called, relieves not only the director of nurses but also the ad- ministrator. Her authority is not restricted to the nursing staff; it is an administrative authority over the activities occurring at night in the entire institution. Only in the very large institution is there a night superintendent who represents the director of nurses. The duties of the night supervisor should be definitely assigned and promul- gated. Her supervisory responsibilities are the same as those of the director, but limited to the operation of the hospital at night. For coordination between night and day activities, the night supervisor should leave specific reports for the director of nurses, completed immediately before going off duty and containing a concise statement of all important activities for the information of the day staff. While certain formal reports, such as the midnight census, are usually designated, the night supervisor should not confine herself to routine reports. 3. Supervisors and head nurses: Supervisors and head nurses are graduate nurses assigned to manage the administrative detail of nursing care of the floors or divisions. In the very small hospital the director’s assistant may be the only supervisor and she will he expected to render a certain amount of nursing service. On the other hand, in the larger hospital the nursing load must be carefully studied and sufficient supervisors appointed to insure the effective performance of duties. The supervisor is responsible for arranging the duties of the personnel assigned to her, for seeing that these duties are properly performed, for main- taining discipline, and for keeping the supplies and equipment in her division up to accepted standards and readily available for proper use. Service of food to patients is a responsibility of the dietitian, but it is often economically impossible to separate this function entirely from nursing. Custom- arily. the food as ordered is sent to the floor and the floor supervisor assigns members of the nursing personnel to serve the patients. In every instance, it is the responsibility of the floor supervisor to be certain that the patient is receiving the food ordered by the attending physician. The assignment and performance of certain housekeeping duties by maids and employees from the housekeeping department should be under the direction of the floor supervisor in order to minimize disturbance to patients. She. however, should report any incidents of improper service to the housekeeper under whom the employee directly works and leave matters of discipline to her. Head nurses are employed in some large hospitals when it is found advisable to place under one supervisor a larger number of patients than she can possibly VETERANS’ ADMINISTRATION 1963 he responsible for in all detail. The head nurses are subordinate to the supervisor and are responsible to her for the actual care of the patients, but all matters of administration are left to the supervisor. 4. Graduate nurses : Graduate nurses employed in the hospital should be legally licensed to practice their profession and they should have the general qualifications required of all members of the personnel rendering nursing service. The committee on the grading of nursing schools has well stated what should be required of a graduate nurse in An Activity Analysis of Nursing. This may be summarized as follows: Irrespective of the special field in which the graduate nurse has elected to practice, she should: (a) Be prepared to give expert bedside care and she should have such knowledge of the household arts as will enable her to deal effectively with domestic emergencies arising out of illness. (ft) Be competent to observe and to interpret the physical manifestations of the patient’s condition and also the social and environmental factors which may hasten or delay his recovery. (c) Have the special knowledge and skill required in managing situations peculiar to certain common types of illness. id) Be able to apply, in nursing situations, those principles of mental hygiene which make for a better understanding of the psychological factor in illness. (e) Be capable of taking part in the promotion of health and the prevention of disease. if) Possess the essential knowledge and ability to teach measures for the preservation and the restoration of health. ig) Be able to cooperate effectively with the family, hospital personnel, and health and social agencies in the interests of patient and community. ih) Be able, by the practice of her profession, to attain a measure of eco- nomic security and to provide for sickness and old age. Graduate nurses fall into two classes : The graduate staff nurse and the graduate nurse on special duty. In view of the higher standards of nursing education, the employment of student nurses to give professional care has been found impractical and unsound econom- ically. As a result, an increasing number of graduate staff nurses are provided for this purpose. It has been found, however, that their time and training are too valuable to require them to perform all of the nonprofessional duties that were formerly assigned to the nursing staff. Gradually their work is being concen- trated on giving expert nursing care while housekeeping and similar duties are being performed by less highly trained personnel in the nursing organization. More specifically, the duties of the graduate staff nurse on general duty consist of the administration of actual treatment covered by standing orders approved by the medical staff or ordered in writing by the attending physicians. The grad- uate staff nurse should be trained to observe symptoms and to record her observa- tions, but she should not perform duties that are exclusively the function of the physician. Under the present day custom of assigning to less highly trained personnel many of the duties of caring for the patients, it is the responsibility of the graduate staff nurse to see that these duties are suitably performed for the patients. The graduate nurse on special duty must- fit into the general organization of the nursing personnel, even though she is employed by the patient. She should report to the director of nurses when she comes on duty, for she is responsible to her for acting in conformity with the standards of the hospital, and she must satisfy the director that the patient is being properly attended. The graduate nurse on special duty performs all of the duties of graduate staff nurses and also many tasks that are undertaken by less skilled help when the patient is relying on general nursing service. She should have at her disposal help from the subsidiary workers, and in case of necessity she should have the privilege of calling on the general duty nurse for assistance. When she is not on duty or is to be temporarily unavailable, she should notify the supervisor of the floor; the entire care of the patient then devolves on the general duty nurse until her return. 5. Student nurses: Every hospital conducting a school for nurses should have enough graduate supervisors and general staff nurses to give the student nurse proper supervision, to assign to her only those responsibilities for which she has been prepared, and to provide at the same time adequate nursing care for the patient. 1964 VETERANS’ ADA1INISTRATI0N 6. Subsidiary workers: Subsidiary workers are defined as all persons other than graduate registered nurses and student nurses who are employed in the care of the sick. Some call the male subsidiary worker an orderly, others a nurse’s aide; nurse’s assistant or attendant may be the title of the female subsidiary worker. Orderlies are assigned to perform for male patients certain duties that are customarily performed for female patients by nurses. Orderlies are not recog- nized as nurses, but since they are required to perform some nursing services, they should be given special training by the hospital beyond their basic educa- tional requirements. Attendants, both male and female, are employed by the hospital to perform certain duties for the patient that do not require skill and training. Since the attendant is directly in contact with the patient, he should have more education than ordinary maids and porters and special training in the duties to winch he may be assigned. In order to keep the standards of the hospital high and to pro- vide adequate nursing care to patients, the attendant should be strictly limited to the performance of duties that do not require the skill of the graduate nurse. It is generally recognized that the duties of attendants should be specifically stated and that assignment on the floors should be definitely made by the supervisor. The joint board of directors of the three national nursing organizations, namely, the American Nurses’ Association, the National League of Nursing Education, and the National Organization for Public Health Nursing, has compiled and published a bulletin outlining “Principles and Policies in Relation to Subsidiary Workers in the Care of the Sick.” Facilities.—In the administering of various forms of treatment recommended by the attending physician, the nurse will require considerable equipment, furnish- ings, and supplies. These facilities should be so conveniently arranged that they conserve the distance traveled and time consumed in rendering service to the patient. The lack of proper instruments, sterilizing equipment, special apparatus, and the like may greatly handicap the expedition and the efficiency of good nursing service. The growing tendency toward centralization and standardization of supplies has led to the installation of the central supply room which services the various nursing units. If this service is well organized, it is more conducive to efficiency and economy in the use of supplies. Education.—When a hospital decides that it is justified in maintaining a school of nursing, it must consider carefully its obligations to provide the educa- tional facilities as well as the proper living conditions that will attract applicants who can meet the nursing requirements of the present day. Adherence to national standards as promulgated by the National League of Nursing Education is essen- tial. Just as the hospital finds that it is necessary to limit the selection of students to those of higli mental, physical, and moral standards, so it must also provide a course of instruction of such standard that the cost must become a reckoning factor of increasing proportions. No hospital should undertake a school of nursing without adequate teaching facilities—classrooms, demonstra- tion rooms, and laboratory with essential equipment; a teaching personnel of at least 5 graduate nurses; and a daily average of not less than 75 patients in order to provide a sufficient range and variety of clinical material which is most de- sirab’e in the teaching of student nurses. The prevailing educational requirements for admission to schools of nursing include at least graduation from high school or its equivalent. Even in those States where the State board of nurse examiners does not require the registrants to be high-school gradxaates, the majority of hospitals have voluntarily established these educational requirements for admission to the school of nursing. An addi- tional 2 years of college work or a college degree is desirable. The course of training in the hospital should not be less than 3 years, including a minimum of 4 months’ preliminary instruction, and should provide at least the curriculum in theory and practice required by the State board of nurse examiners. Records.—Records are as essential in the nursing department as in all of the other departments of the hospital for keeping a clear account of the duties per- formed by the graduate nurse and the educational record of the student nurse. The school of nursing record of the individual student consists of one of the acceptable systems in use which shows the amount and types of theoretical instruc- tion and clinical experience of the student from the time of her admission, her standing, final grades, and eligibility for examination by the State board. The nurse’s section of the medical record consists of the graphic chart, physician’s orders, orders for treatment, and record of treatment and symptoms. VETERANS’ ADMINISTRATION 1965 The graphic chart is used in many variable forms, although the data recorded are essentially the same. The chart shows primarily the graphic record of tem- perature, pulse, and respiration for the days the patient is hospitalized. Addi- tional entries, such as operation, hemorrhage, delivery, and similar occurrences, should be strictly limited. Physician’s orders should be entered on a prescribed form, either written by the physician or dictated and signed by him. The more common systems of securing these written orders are as follows: 1. A page attached to the chart on which the physician writes his orders. 2. A blank bound book in which orders are written. 3. A standard prescription record. The disadvantage of the first two systems far outweigh the advantages. They do not permit sending the original prescription to the pharmacy as required in most States. Moreover, the pages soon become illegible and it is difficult to differ- entiate the canceled orders from the standing orders. The third system is a record hound in book form with duplicate pages; the original page is perforated to form four order blanks. When the book is filled, the carbon copies should be properly labeled and sent to the medical-records office for permanent filing. The orders written by the physician should be transcribed by the nurse to a form entitled “Orders for Treatment.” The body of the form is divided into two sections, the left for medication and the right for diet and other treatment. In each half, space is allowed for the dates and the detail of the order. Under medication, prescriptions should be copied in full as soon as they are received. Orders for routine diet should be entered according to the standard designation, but the complete order should be transcribed for special diets and other orders. The nurse’s report of what she has done and what she has observed should be contained in the record of treatment and symptoms. The hour at which treat- ment was given, all medicine and diets, and the nurse’s personal observations should be recorded in concise form. Nurses’ notes constitute an important part of the medical record and should be preserved as an integral part thereof. The practice of destroying nurses’ records is not approved. When the American College of Surgeons inspects a hospital, consideration is given to the nurses’ records as well as to those of the physician, radiologist, pathologist, and others. One of the most important duties of the nurse is the accurate recording of data pertaining to the condition of the patient, especially with reference to the symptoms which she observes. By this means she becomes a valuable collaborator with the physician in his efforts to study and combat disease as evidenced by the symptoms. Every nurse should be given special training in the compilation of bedside records and should be taught how to observe accurately and express herself concisely. If nurses’ records are up to the required standard, they offer valuable information and serve to round out the entire medical record. Conferences.—The nursing staff should hold conferences for the appraisal of its activities to determine whether or not the nursing service is adequate and what can be done to keep it on a high plane of efficiency. Such meetings tend to arouse a deeper interest in good nursing service, add to the nurse’s knowledge of her professional work, and generally help the medical service and adminis- tration. These conferences should be held regularly once a week for an hour; a definite program should be followed, and minutes should be kept of the dis- cussion. Relation to patients.—It is quite obvious that due care must be exercised in the assignment of nurses and adjunct personnel to patients. This applies par- ticularly to the student nurse who may not be qual fled to do many of the nursing procedures required in her tour of duty. Therefore, the careful assignment and supervision of her work is imperative. Furthermore, the utmost caution must be exercised in order that adjunct nursing personnel or subsidiary workers limit their activities to nonprofessional duties. Of vast importance is the ratio of nursing personnel to patients. This varies considerably in different institutions because of the numerous factors involved. Many attempts have been made to arrive at a standard ratio of nurses to patients, but variation is so great in the type of patient admitted and in the conditions under which the nursing pei’sonnel care for them that the same figures cannot be made applicable to any two hospitals. If averages are used as a guide, the nursing load of each institution and of each department in it can be studied, and then members of the nursing staff can be given a flexible assign- ment to meet the load as determined. 1966 VETERANS’ ADMINISTRATION The department of studies of the National League of Nursing Education has made studies of the bedside nursing time required for various types of patients and the figures in table I are quoted as a guide. Table I.—Average hours of bedside nursing in each 2Jf hours Adult Obstretical Pediatrics Medical Surgical Mothers Infants Infants 2-5 years 5 years and over 3-3M 3-3H 2M-3 234-3 6 4 H 4 Considering the distribution of nursing on this basis in a hypothetical hospital under ordinary conditions, table II would be a schedule of nursing personnel re- quired for a minimum and maximum number of nursing hours. This table is a modification of two tables prepared by the department of studies of the National League of Nursing Education. Table II.-—'Nursing personnel and other workers required when the minimum and maximum of the recommended number of bedside nursing hours are provided Type of service Type of ward Bed ca- pacity Daily average patients Head nurses Grad- uate bedside nurses Ward helpers1 Order- lies 1 Bedside nursing hours per patient in 24 hours Medical and surgical: Ward ... 26 21 i 9-11 2 3 -3H 3 -3H 5 do 26 21 i 9-11 1 3 Private, semipri- vate and ward. 14 11 i 8-8 1 Mixed 16 18 13 14 1 8-9 \ 6-7 1 o /4 -414 \3 -3H 2H-3 2J4-3 > 1 f 2 3 Maternity: Beds 2 13 12 10 10 i [ 5-6 1 4-4 2 1 ■, 1 25 20 j I 7-9 150 120 5 56-65 9 6 1 It is assumed that there will be the number of workers listed in this column on the ward during each 24 hours. In a 6-day week, 1 relief worker is required for each 6 workers. 2 Includes 1 isolation room. However, it is always advisable in determining the ratio of nurses to patients to make a careful study of the nursing load of the individual hospital. This will vary not only according to type of patient and worker but also according to the variation in the work load throughout the day in the hospital. It is quite obvious that more nurses will be required in the morning in order to cope with the work, and the number will gradually diminish through the afernoon and evening. The distribution of the nursing service should therefore be based on a careful analysis of the work load. Minimum Standard for Dietary Departments in Hospitals 1. Organization: There shall be a properly organized dietary department under the direction of a competent graduate dietitian whose training conforms to standards approved by the American Dietetic Association, this department being x’esponsible for: (a) the efficient administration of the general food service, (ft) the scientific diet of patients, and (c) the education of the student nurse or the student dietitian in hospital dietetics. 2. Facilities: Adequate administrative and teaching facilities shall be provided for the dietary department, including in particular: (a) the necessary accom- modations and equipment for the dietitian’s office, kitchens, storage rooms, re- VETERANS’ ADMINISTRATION 1967 frigeration, and other service requirements, and (ft) a well equipped classroom and laboratory for the education of student nurses or student dietitians when a school of nursing is attached to the hospital or there are student dietitians in raining. 3. Personnel: There shall be an adequate administrative and technical staff competent in their respective activities, and conforming to proper physical, mental, and character standards. 4. Records; A comprehensive system of administrative, financial, clinical, and technical records shall be provided and correlated so far as necessary with medical and other records of the hospital. 5. Policies: The director of dietetics and staff, with the approval and co- operation of the superintendent or director and governing board of the hospital, shall initiate and develop rules and regulations pertaining to the administrative and professional policies of the department. These rules and regulations shall specifically provide for departmental and interdepartmental conferences at regular intervals to review the work of the dietary department for the purpose of improving the service which is rendered and its general efficiency. Dietary department During recent years there has been a remarkable advancement in food service in hospitals and now dietetics is recognized as an important specialty. All pa- tients, whether bedridden or convalescent, and whether or not they are suffering from disorders of metabolism, require special and scientific dieting. All em- ployees, regardless of their positions in the hospital, should have the benefit of proper scientific food service. To meet these needs, hospitals have not only given much thought to the administration of general and special diets, but they have made extensive studies to determine the most economical and efficient methods of handling food. Every approved hospital requires a well organized dietary department; there- fore the American College of Surgeons has formulated certain fundamental and guiding principles with respect to its administration. These principles are expressed in the Minimum Standard for Dietetic Departments, which follows. Organization.—It is imperative that the department be under the direction of a competent graduate dietitian if it is to function to the greatest advantage. Although the science of dietetics is comparatively new, it has proved to be of such therapeutic value that the services of a trained administrator are almost indis- pensable. As a result, the dietitian who is head of the department is recognized as one of the senior administrative officers, and is therefore responsible directly to the superintendent. In order to carry this responsibility, she must possess the qualifications which are specified by the American Dietetic Association. Sum- marized briefly, these qualifications are: 1. Graduate of a recognized school of home economics which provides a theoretical knowledge of food chemistry, physiology, and hygiene. 2. Practical training in a hospital approved for such a course where the dietitian will have learned to prepare and serve diets. 3. Administrative ability and training which enables the dietitian to or- ganize her staff and its work so as to produce the best possible results at the least cost. 4. Business ability developed through training which makes it possible for the dietitian to manage properly and prevent waste. 5. Knowledge and judgment of a purchasing agent, whether she actually buys or not. 6. Mechanical turn of mind to appreciate the machinery in operation in her department and to have it used to the best advantage. It is obvious that the successful dietitian is confronted with numerous prob- lems, such as scientific diets, organization, planning, equipment, food buying, stor- age, and accounting. She must be an economist and an administrator as well as a scientist if her department is to be highly efficient. The duties of a dietitian may be be classified into three groups: administrative, scientific, and educational. The administrative duties occupy a large portion of her time and ordinarily include: 1. Planning menus for patients and personnel. 2. Collaborating in purchasing food supplies and kitchen equipment. 3. Supervising the preparation of food. 4. Directing the task of serving meals promptly and attractively. 1968 VETERANS’ ADMINISTRATION 5. Keeping accurate records. 6. Directing all employees who are connected with the dietary department. 7. Regulating the food budget so as to effect every possible economy and at the same time maintain a high standard of food service. The scientific duties of the dietitian are concerned with diet therapy and in- clude : 1. Planning of general diets. 2. Planning menus for patients on special diets. 3. Supervising the preparation of special diets in respect to food values and appeal to the appetite. 4. Inspecting special trays before they are sent to the floors. 5. Checking and weighing food returned on special trays to determine patient’s reaction to food and to record the intake. 6. Directing and supervising nutrition for out-patients. Since the dietary department is recognized as a definite therapeutic unit of the hospital, the dietitian must work in close cooperation with the medical staff. In general diets, the routine diet lists of (he hospital enable the physician to order the type of food that will supplement his other treatment. In the observation, diagnosis, and treatment of many diseases, the physician will modify the general diet list by special order. With few exceptions, the physician orders the diet in general terms, leaving the detail to the dietitian who has become a most valuable aid to the clinician in the scientific practice of medicine. The dietitian’s scientific duties bring her in close association with the laboratory worker; therefore a good working relationship must exist between the clinical laboratory and the dietary department. The educational duties of the dietitian include: 1. Teaching student dietitians in accordance with the standards formulated by the American Dietetic Association. 2. Instructing student nurses in the principles of dietetics. 3. Instructing medical students in the principles of diet therapy. 4. Teaching patients proper dietary habits. * ■ In addition to her administrative, scientific, and educational functions the dietitian is receiving increasing recognition in the promotion of health and the prevention of disease. Not only does her influence affect the health of the indi- vidual patient, but her contact with the family, the school child, the student, and various other groups whom she educates along the lines of sound dieting, guides their future physical condition. More and more is (he dietitian assuming h status in the out-patient department. Here the nutrition clinic, an innovation of recent years, renders a most valuable service in the care of ambulatory patients. In this clinic, the dietitian has opportunity to assist the clinician in guiding the course of diet for the patient. Patients are referred to the clinic for consultation and advice regarding the diet to be followed in the treatment of their disease. Some hospitals of less than 50 beds may conclude that they cannot afford to em- ploy a dietitian, but inasmuch as food service involves about one-third of the total expenditures of the hospital, few institutions can afford to be withut a well trained dietitian. Facilities.—The physical requirements for modern food service should include not only the necessary space for kitchen, storage, refrigeration, special diet kitchen, dining room, and possibly preparation rooms and bake shop, hut should also take into consideration the important factors of location, lighting, ventilation, heating, steam, water and fuel supply, transportation of food, dishwashing, and garbage disposal. If the hospital is a teaching unit for student nurses or student dietitians, there should be a diet laboratory and a well equipped classroom for didactic teaching. Personnel.—The personnel of the dietary department should consist of the administrative and technical staff. Resides the dietitian, other employees should be skilled in the preparation and service of foods, and the duties of the skilled and unskilled should interlock accurately in order that food of good quality may al- ways he ready for service at stated hours. Recent studies have shown that the average general ratio of dietitians to pa limits is approximately 1 to 100, and that in hospitals of 250 beds and over the ratio is a 0.75 to 100. As there are many hos- pitals of 50 beds or less employing dietitians, it is obvious that their work will in- clude assignments outside the dietary department. In larger hospitals the number of assistant dietitians and other employees, such as chefs and assistant chefs, waitresses, maids, porters, and kitchen help, should be determined by such fac- VETERANS’ ADMINISTRATION 1969 tors as the average number of patients, number of special diets, type of service, extent of instruction, and physical conveniences of the department. Records.—The department which does not keep records of its operations is handicapped. The recorded data should consist of administrative, business, technical, and clinical notations. A proper system of administrative and busi- ness records gives the dietitian basic information on unit costs. Graphs may be compiled from these records to serve as guides in purchasing and to teach stu- dent dietitians. Technical records should contain notations on food values and other data, compiled for reference in the preparation of diet. Clinical records should pertain to metabolic or diet therapy cases and includes a report of the in- take and output in relation to sugar, blood urea, and other elements indicated in different types of diseases in which special diets are used. The dietitian will need her own file of laboratory and other findings to use as a guide in her work. The record, moreover, will be a means of correlating the work of the dietitian, the clinician, and the laboratory worker to the end that more rational treatment will be administered. Policies.—The dietary department of the hospital comes in contact with numer- ous departments in rendering its service and there should be the utmost co- ordination and cooperation in order to assure efficiency. Therefore definite and clearly stated department rules, regulations, and statement of policies, with the setting forth of duties and relationships, are essential, and with these each worker in the department should be familiar in order that the greatest efficiency may be maintained, and that the dietary service may supply the increasing de- mands of hospital service and scientific medicine. Minimum Standard for Medical Social Services in Hospitals 1. Functions : The activities, in which the social-service department may appro- priately engage and which should be developed in close collaboration with the medical staff, shall be the following: (a) the practice of medical social case work; (ft) the development of the medical social program within the medical institution; (e) participation in the development of social and health programs in the community; (d) participation in the educational program for professional personnel; and (e) medical social research. Medical social case work involves the study of the individual patient’s social situation, interests, and needs in relation to his illness, and the medical social treatment of the patient in collaboration with him and his physician when those social needs and interests affect the physical and mental health of the patient. 2. Organization: The medical and social service departments shall be closely integrated in relationship and organization. There shall be one director or executive head of the social-service department who shall be responsible to the executive officer of the institution and through him to the board of management. Funds for financing the social-service department shall come from the hospital treasury. The budget recommended by the director of the social-service depart- ment and allocated by the administrator for that department shall be controlled and administered by the director of the social-service department. 3. Facilities: Provision shall be made for a central office for the social-service department, and for such individual offices as the professional staff, in the per- formance of its social-work activities, may require. The offices shall be accessible to patients and to doctors but shall afford privacy for interviews. 4. Records: It is essential that the social-service department keep records of its work with patients and thus preserve such information as is relevant to medical social study and treatment. Since medical social records are a part of the professional data of the hospital, they shall be available only to professional personnel concerned with the treatment of the patients. Medical social service 1 Medical social service has been developed in the hospital as a service to the patient, the physician, the hospital administration, and the community, in order to help meet the problem of the patient whose medical need may be aggravated by social factors and who, therefore, may require social treatment which is based on his medical condition and care. It has long been recognized by practicing physicians that many social elements play an important part in the incidence and control of disease and that there is need to know the patient as an individual person in relation to the environment 1 Basic material extracted from Statement of Standards for Medical Social Service De- partments, adopted bv the American Association of Medical Social Service Workers, May 1936. 75183—45—pt. 5 9 1970 VETERANS’ ADMINISTRATION in which he lives and works, his capacity to understand and participate in a plan of medical treatment, his obligations, and his material and personal resources. Nevertheless, the physician sees his patient in a hospital or clinic where the patient is isolated from his natural environment, and the physician is hindered from understanding as fully as is desirable the social factors that may be con- tributing to the patient’s illness or retarding his treatment and convalescence. It is important to know how effectively the clinic or hospital patient can use the resources of the medical institution and of the community, and it will often be necessary to assist him to carry out the plan of treatment advised by the physi- cian if he is to have as early and as complete restoration to health as possible. The selection of well qualified personnel who have adequate preparation through professional education and experience in the specialized field of medical social service is essential for the fulfillment of (he activities to he defined in this statement. Therefore, the director of the social service department herself should be a person with these qualifications and she should appoint to positions on her staff (hose who have had such preparation. Since the requirements for membership in the American Association of Medical Social Service Workers are changing from time to time in accordance with the demands of the field, they are suggested as criteria for selecting directors and staff workers. Functions.—The following activities should he developed by the social service department: 1. Practice of medical social case work. 2. Development of the medical social program within the medical institu- tion. 3. Participation in the development of social and health programs in the community. 4. Participation in the educational program for professional personnel. 5. Medical social research. In order to carry on the activities of the social service department, the per- sonnel should be engaged in medical social case work, even though the number of patients receiving comprehensive medical social treatment may be limited at any one time. Certain services that might be considered largely administrative may properly be considered forms of medical social case work when the indi- vidual patient and his problem are studied together, and when the need for more comprehensive medical social case treatment is recognized and secured for the patient; for instance, in the social admission of patients to the hospital or out- patient department; the social review of all patients in a given area, such as a ward, a clinic, or a diagnostic group; and certain types of follow-up. Medical social case work may range from a simple and abbreviated process to a full and comprehensive one. Such considerations as the need in each indi- vidual case, the decision by the doctor and the worker to treat all or a part of the problems presented, the limitations set by the administration, and the avail- ability of community resources determine the degree of service to be given. Social study and treatment may be carried on entirely by the social service de- partment or in cooperation with another case working agency, in continued collaboration with the physician. A department shou1d give evidence of steady growth in quality of work, experimentation with new ideas, and development of new methods. When there is a recognized need for considering the patient as an individual person in his relationship to the many and varied procedures within the hospital, the social service department should consider the patient’s needs with the admin- istration, the medical staff, and the various other professional departments involved, and to help formulate policies affecting those procedures. It is appro- priate for the social service department to initiate social and health programs in the community and to participate in planning and developing such programs. In community planning relationships, representatives of the social service de- partment should constantly test their thinking with that of the administration and the medical and other professional staffs. The social service department may he selected to collaborate with schools of social work in carrying out the educational program for medical social students and to provide held work opportunities for medical social students and other students of social work. The social service department will also he expected to secure further educational opportunities for its own professional staff. For medical, nursing, and other professional groups within the hospital, the social service department may, on the request of the responsible head of the group and VETERANS’ ADMINISTRATION 1971 with the approval of the hospital administrator, participate in courses or con- ferences designed to focus on the social aspects of illness. A free interchange of thought regarding the special method and technique of each professional group is necessary, in order that the patient may derive the most benefit from the integration of the various services offered by the institution. For those patients whose needs require medical social case work, the social service department it- self will be responsible for that case work and for supervising other professional personnel who may be participating in such treatment for educational or other reasons. . x , The members of the staff of the social service department should approach practice with an inquiring mind, alert to the value of studying those problems which recur in their own practice, and ready to collaborate in study projects undertaken by related professions, by community agencies, and by others in the field of medical social work. When funds are available, individual members of the social service staff may be released from their duties for particular research projects. Organization.—It is important that the medical and social service departments be closely integrated in relationship and organization. There should be one director or executive head of the social service department who should be re- sponsible to the executive officer of the institution and through him to the board of management. Funds for financing the social service department should come from the hos- pital treasury. If the department has had to receive money from other sources, the hospital authorities should try to finance the department as soon as possible. The budget recommended by the director of the social service department and allocated by the administrator for that department should be controlled and ad- ministered by the director of the social service department. The department should consider the use of carefully selected and supervised volunteers to whom may be delegated tasks within their individual capacities. The social service department should also consider the value of having a com- mittee made up of lay and professional persons who are interested in studying the work of the department in its relationships within and outside the hospital, and who will act in an advisory capacity in developing new projects and in fur- thering the broad understanding of the department’s work by those responsible for its support. Facilities.—A central office for the social serwice department and individual offices which may be required by the professional staff in the performance of its social work activities should be provided. The offices should be accessible to patients and to doctors but should afford privacy for interviews. For its ef- ficient operation, the social service department needs to have adequate clerical assistance, filing space, office equipment, telephones, and means of transportation. Records.—The purposes of recording are: service to the patient, education, and research. Medical social records serve to facilitate planning with the physician the medichl social treatment to be given, and judging with him the effectiveness of the medical social treatment already given. There should be a full medical social record filed as a part of the unit medical record or separately, according to the practice of the individual hospital. When it is separately written and filed, it should contain medical information pertinent to the social situation. Social service notes may also be included among the medical progress notes or on a consultation sheet in the medical record if there is social information that pertains to the physician’s care of the patient and if the notes are succinct and carefully chosen from the standpoint of the physician’s interest. Since medical social records are a part of the professional data of the hospital, they should be available and easily accessible only to professional personnel con- cerned with the treatment of the patients, with the understanding that there will be consultation with the medical social worker responsible, so that amplifica- tion and interpretation may be given by her after the consultation with the physician. The social service department should keep a statistical count of its recorded cases. For this purpose, there is strongly advised the plan outlined by the com- mittee on statistics of the American Association of Medical Social Workers, and the United States Children’s Bureau. Other statistical material may be added in accordance with the special interests of the individual institution. 1972 VETERANS’ ADMINISTRATION Minimum Standard for the Hospital Medical Library 1. Content: All general hospitals shall maintain an adequate medical library comprised of a basic collection of carefully selected, authoritative medical text- books and inference works of the latest edition, and files of current journals, including those which most effectively reflect recent developments in medicine, surgery, and those specialties, which are represented in the clinical sendees of the hospital. 2. Housing: The collection shall he housed in or adjacent to a convenient read- ing room furnished in such a manner as to encourage study and research. It shall be classified and arranged so that it is easily accessible to the librarian and members of the medical staff. 3. Personnel: The library shall be under the supervision of a qualified librarian. She shall act as custodian of its contents, and also shall arrange for the necessary cataloging and indexing which will enable the resident staff to do reference work quickly and easily. Assistance in the preparation of bibliographies, trans- lations, abstracts, and reviews of the literature shall be made available either by employing a full-time research librarian or by the use of the extension facili- ties offered by larger libraries. 4. Extension facilites: The librarian shall provide information and brochures describing the facilites that are offered to members of the medical profession by the staffs of specific libraries which have been established on a more extensive basis in order to supplement the work of the local librarian and to serve the literary needs of professional men regardless of their location. 5. Committee on the library: Selected members of the medical staff shall func- tion as a permanent committee of the library, and their duties shall be to foster and develop the resources and interests of the library and to encourage the use of its facilities. Hospital medical library Content.—With the rapid growth of medical literature in recent years and the many demands which are being made upon the time of members of the medical staff and interns, every general hospital should maintain at least a small medical library within its own walls. The purpose of the library is to make easily avail- able to members of the staff medical literature presenting standard procedures as well as that which is descriptive of the most recent developments in medicine, surgery, and the specialties represented in the services of the hospital. Text- books and reference works of late edition are essential for ready reference with respect to standard procedures. However, since new developments are presented first in current journals, each hospital medical library should be equipped with a broad selection of journals covering the literature of the last five years and with the indexes which will make the contents of those journals evident. The size of the collection will depend upon the size of the hospital, the availability and use made of other library facilities, and the specific needs of the staff. A hospital having more than one hundred beds and dependent upon its own resources for filling the immediate needs of the staff, should have as its aim a collection of 1,000 volumes. Reference may be made to a list of textbooks, current medical journals, and monographs prepared and published by the department of literary research of the American College of Surgeons which will be revised from time to time. Housing.—The collection of books, reprints, and journals should be housed in or adjacent to a conveniently located reading room. It is frequently found ad- visable to place the reading room near to the medical records room for the convenience of both readers and librarians. The room should be cheerful and attractive and equipped with study tables, proper lighting, and other facilities that will encourage study, research, and the reading of recently received issues. The textbooks should be classified and arranged on the shelves with the bound journals in such a manner as to be easily accessible to the librarian and to mem- bers of the medical staff. Current issues should be arranged upon open shelves or tables where they will attract the interest of the regular or casual visitor. The library should be open to readers at least 8 hours each day; when the librarian is not on duty, the key should be left with the medical records librarian or a responsible office secretary. Personnel.—The library should be under the supervision of a qualified librarian who will devote at least half time to this work. She should arrange for the necessary cataloging ard indexing of the textbooks and monographs and for the binding and shelving of the current journals. As custodian of the collection she VETERANS' ADMINISTRATION 1973 should keep a record of all books and journals loaned and of their return in accordance with the rules adopted by the hospital administrator in conjunction with and through the action of the committee on the library. She should main- tain a record of journal issues currently received in the library and notify the publishers of any discrepancies, either directly or through the hospital purchasing department. Assistance in the preparation of bibliographies, translations, abstracts, and reviews of the literature should be made available either by employing a full time research librarian or by the use of the extension facilities offered by larger libraries prepared to serve a widely distributed clientele. In the larger in- stitutions it may be necessary to supplement the services of the full-time re- search librarian with the extension facilities. In many hospitals, the librarian will be able to supply a limited research service, but if more extensive studies are desired, they should be carried on with the assistance of staffs especially equipped to do this work. A hospital medical librarian may not have an ex- tensive collection of indexes to assist in compiling complete bibliographies or a wide knowledge of foreign languages as a basis for translating. Again many foreign journals will not be available to her locally, nor will she have in her collec- tion the early monographs required for a historical study. These aids she may obtain through the various services of larger libraries. Extension facilities.—The librarian should be familiar with and have on file literature concerning the services offered to members of the medical profes- sion by the library and department of literary research of the American College of Surgeons, the library < f the American Medical Association, the library of the American Hospital Association, the Surgeon General’s library, and through general interlibrary loan. Each library listed offers a different type of serv- ice and, in order that the hospital medical librarian may adequately advise how a specific need can be met, she should familiarize herself with these serv- ice;:, visit medical libraries in her vicinity, and keep abreast of the latest developments in her field by attending the annual meetings of the Medical Library Association. Committee on the library.—This committee may consist of three to five per- sons selected from the members of the medical staff who should function as a permanent committee. An interested member of the governing board might also be included on this committee. The duties of the committee are to foster and encourage contributions in support of the library and to act with the hos- pital administrator and the librarian in the formulation and the enforcement of rules governing the use of the library. The committee should act also in an advisory capacity with respect to the purchase of textbooks, reference works, monographs, and journals, and in the solution of administrative problems of the library. Finally, it should aid in developing the library and in encouraging the use of its facilities by those who are entitled to that privilege. standardization of the small hospital 1. A physical plant, free from hazards, and providing, either within the hospital or by affiliation with a larger institution, all facilities which are practicable and possible for the care of the patient. 2. Clearly stated constitution, bylaws, rules, and regulations providing for a governing board, a medical staff, and such administrative officials as are war- ranted by the size of the hospital. 3. A medical staff which may or may not be divided into specialties or clinical departments, depending on local conditions hut if possible embracing at least medicine, surgery, obstetrics and gynecology, and the specialties of eye, ear, nose and throat. 4 Medical staff conferences, monthly or more frequently, for the thorough review and analysis of the clinical work based on the medical records, and embracing deaths, unimproved cases, infections, complications, errors in diag- noses, results of treatment, and an analysis of clinical reports. 5. Accurate and complete medical records written for all patients admitted to the hospital, and each containing sufficient data to justify the diagnosis and to warrant the treatment. G. A clinical laboratory providing a complete and properly supervised serv'ca, including at least the minimum or emergency service within the institution, and the major or more complicated service through acceptable affiliation when necessary. Fundamental principles in the standardization of the small hospital 1974 VETERANS’ ADMINISTRATION 7. An X-ray department providing a complete and properly supervised X- ray service, including at least the minimum or emergency service within the institution, and the major or more complicated service through acceptable af- filiation when necessary. The minimum standard requirements are readily applicable to the small hos- pital and are of inestimable value in establishing proper organization and ad- ministration to care efficiently for the sick and injured. Governing boards of small hospitals are urged to adopt the principles of the Minimum Standard for Hospitals. The fact that a hospital has only 25 or 30 beds should not prevent it from qualifying for approval. Too frequently the management of the small hospital is of the opinion that approval is based on an elaborate physical plant and expensive equipment; hut this is not the case. In most instances the small hospital, with a modern building and equipment sufficient to satisfy the demands of an enlightened public and to exist in the community, can readily meet the requirements in this respect. The surveys of the American College of Surgeons reveal that the usual deficiencies of the small hospital are especially related to matters of medical staff organization, staff meetings, medical records, and the proper supervision of the various clinical de- partments, all of which may be corrected through the united efforts of the medical staff and hospital management. A prohibitive financial outlay is not involved. It is a problem of organization and performance, not of physical plant and equipment. It is to be expected that certain difficulties may be encountered in meeting the requirements in the small hospital, but in every instance adjustments can be made and a practical and acceptable plan worked out. Frequently some of the services (particularly clinical laboratory and X-ray) may have to be supplemented from outside sources, but in spite of the difficulties encountered, a considerable number of small hospitals are creditably fulfilling the minimum requirements. Medical staff organisation The small hospital can easily have an organized medical staff. Experience has proved beyond a doubt that organized effort in conducting the medical work of a hospital is absolutely essential, regardless of how limited a number of phy- sicians may he privileged to practice in the institution. When there are even as few as three or four physicians, medical staff organization may exist in its simplest form—an undifferentiated group. Provision should be made for the periodic election of officers who function in an executive capacity in matters pertaining to the medical work of the hospital. This type of medical staff or- ganization usually applies to the small privately owned hospital, to the specialized sanitarium, or to the institution owned by an industrial corporation, the medical staff of which is employed on a full-time or part-time basis, and the organization of which is simple yet essential to the proper conduct of the medical work. In the small community or church hospital privileges are usually extended to a group of physicians practicing locally, and sometimes to an additional number from the surrounding communities who refer or occasionally care for patients in the hospital. There are also consultants who are more or less regularly called from nearby cities. It has been found advisable under these circumstances to divide the medical staff into groups; and every physician admitted to the hos- pital should be qualified for membership on the medical staff and assigned annually to one of the groups which the governing board may designate. These groups may include: 1. Honorary or consulting medical staff. 2. Attending or active medical staff. 3. Associate or courtesy medical staff. Here again, officers should be elected annually, and the executive committee should assume supervision of the clinical work and act in an advisory capacity when medical matters are concerned. This type of medical staff organization is acceptable when the majority of its members are in general practice. In the small hospital it is sometimes possible to establish clinical divisions of the medical staff. This tends to fix responsibility more definitely, stimulate scientific interest, and facilitate the administration of the professional services. Usually the clinical departments of medicine, surgery, obstetrics and gynecology, and eye, ear, nose, and throat may be organized. Each section should have a head or chief, or a staff committee responsible for the development and manage- ment of the service and for the supervision of all clinical work of the division. The organization of clinical departments presents a problem for each individual VETERANS’ ADMINISTRATION 1975 hospital, either large or small, and in order that practical application may be made of the principle, care must be exercised to guard against departmentalization which exceeds the degree of local specialization. A properly organized medical staff will not give advantages to any individual or group of physicians, or discriminate against the young physician properly qualified and competent, but will insure desirable supervision of all clinical work done in the institution. There are many ways of promoting cooperation between tbe medical staff and the governing board. The most satisfactory plan, which has been accepted by hospitals generally, is the organization of a joint conference committee com- posed of duly selected members of the medical staff and the governing board which meets periodically to discuss problems of mutual concern. Some hospitals appoint a member of the medical staff to serve on the governing board, but this plan not only tends to create jealousy among the hospital’s own confreres, brit blights the interest of other members of the medical staff who have no connection with the administration of tbe hospital. There is always the possibility that the member of the medical staff who serves on the governing board will pre- sent personal opinions rather than voice the sentiment of the medical staff as a whole. For these reasons, therefore, a joint conference committee is to be preferred. Qualifications and appointment to the medical staff— Tbe qualifications for membership on the medical staff, outlined in detail elsewhere in this text, are equally applicable to the small hospital, and it is needless to elaborate upon the principle which requires that membership on the medical staff of all hospitals be restricted to competent, experienced, ethical physicians and surgeons. The principles of hospital standardization emphasize the responsibility of the hos- pital management in selecting the medical staff and recommend a procedure to be followed in extending hospital privileges to physicians. Each physician should submit his qualifications in a written application, (see addendum V, pp. 104-105) and these should be investigated by a committee of the medical staff which should report to the medical staff as a whole with recommendations. If approved by the medical staff, the applicant is recommended to the govern- ing board for membership in one of the medical staff divisions. It is considered advisable to extend hospital privileges for one year only, with the understand- ing that if the applicant’s work and conduct have been satisfactory, further extension of privileges will be granted. This method saves the hospital embar- rassment when occasionally mistakes occur in granting privileges to unworthy physicians. The American College of Surgeons has laid down definite principles of fi- nancial relations in the professional care of the patient (see page 19) with which the medical staff of every approved hospital should comply. Each phy- sician privileged to work in the approved hospital should subscribe to these principles when he becomes a member of the medical staff and lives up to them consistently. Bylaws, rules, and regulations.—The first step in the organization of a medical staff is to formulate complete bylaws, rules, and regulations which set forth the type of organization and the duties, responsibilities, and procedures. They should be approved by the medical staff, signed by the chairman and secretary, and submitted to the governing board of the hospital for adoption. Since the governing board is responsible for the conduct of the hospital in all its activities, the bylaws, rules, and regulations should be officially adopted and attested by the signatures of the chairman and secretary of this board. Finally, the signatures of all members of the medical staff should be attached as evidence of good faith and of agreement to abide by the provisions adopted. Each hospital is expected to use its initiative in evolving rules which are applicable to its own needs. The American College of Surgeons has formulated and recommends the adoption of certain fundamental principles which should be included in all medical staff bylaws, rules, and regulations. For these suggestions reference is made to addendum I, pages 78 to 97, of this text. Medical staff conferences.—One of the major requirements of the approved hospital is that medical-staff conferences be held at least once each month. This requirement may easily be met by the small hospital, for every institution caring for the sick and injured has a proportionate amount of interesting clinical ma- terial. The properly conducted medical-staff conference not only provides for a thorough review7 and analysis of the clinical work done in the institution, but constitutes more or less a postgraduate course in medicine. Every physician, re- gardless of his medical education, his training as an intern, and even his post- 1976 VETERANS’ ADMINISTRATION graduate study, must continue to supplant and supplement his fund of medical knowledge. In many instances physicians practicing in the small communities have little opportunity for postgraduate study in the large, sometimes distant, medical centers because of time required and expense involved, but the medical staff conference can fulfill to a considerable degree this need for postgraduate education. Attendance at medical staff conferences should never be less than 75 percent of the active medical staff. The attendance record of the individual member gives an excellent index of his interest in fulfilling his professional responsibility to the hospital. Good attendance at medical staff conferences, however, presup- poses that an active committee of the medical staff has given its time and effort in the selection of material and the preparation of a program of interest. Accurate minutes of all medical staff conferences should be prepared by the secretary of the medical staff; these should include not only the attendance rec- ord and reports of the various committees, but complete abstracts of all clinical cases should be presented and discussed. It is important that the minutes he prepared in an orderly fashion and kept on file in the hospital for reference and for review by the representative of the American College of Surgeons when he makes the regular survey of the hospital. His report relative to medical staff organization and proceedings is based primarily on the records of the secretary of the medical staff. (See addendum IV, p. 103.) Medical records.—Every hospital, large or small, requires complete and ac- ceptable medical records. In the small institution without interns or residents, the medical records may have to be written by the physicians themselves with whatever assistance the hospital can provide. The hospital may he too small to warrant a full time records librarian, hut some person in the organization should undertake this work on a part time basis; it is well to assign the responsibility to one individual. The hospital may be able to employ on a part-time basis some- one who can take medical dictation. Such a worker is a great aid to the physician and facilitates the keeping of adequate medical records. However, some hos- pitals in their efforts to provide medical records have resorted to the practice of allowing nurses or other nonmedical personnel to interview patients and write histories, progress notxs, and other component parts, but these medical records are of uniformly poor quality and the practice should be discouraged. The procuring of adequate and complete medical records is wholly the responsibility of the attending physician and should always he under his direct supervision. A medical records department constitutes a major problem in many snxail hospitals. Physicians frequently fail to realize their responsibility in these matters and the lack of a medical record consciousness on their part is regrettable. This lack of interest is generally due to failure to use the medical records properly after they are written, and although a medical record is of value to the patient primarily in that it assm-es him better seiwice and accui’ate diagnosis and treatment, it is also invaluable to the physician in the scientific practice of medicine. The appointment of a member of the medical staff as medical records registrar, or of an active medical records committee, to review the medical records con- scientiously and diligently, and see that they are kept up to a proper standard, is essential. Adequate medical records may be maintained in any hospital in which the proper record consciousness is developed on the part of the entire professional and lay personnel. Medical records should be accessibly filed in a conveniently located record room, and should be regarded as the permanent property of the hospital, to be released only on order of the attending physician with the patient’s consent or by order of a court. Numerical filing, either by admission or discharge number, is the most common method of filing medical records in hospitals at the present time. A complete cross-index system which will include separate indexes for patient, disease, operation, and physician may easily be provided, and to insure a uniform classification an acceptable nomenclature of disease should he adopted. This latter, and all of the required material for a cross-index system are inexpensive, and it has been found that an adequate, simple cross-index and filing system may he maintained by a part time records librarian devoting only a few hours each week to this work. The maintenance of a complete medical records depart1 ment will then enable the medical staff properly to review, analyze, and evaluate collectively the clinical work done in the institution, and to use the medical rec- ords for scientific study. Clinical laboratory.—The management of all hospitals should be responsible for providing an adequate clinical laboratory service. This should include a VETERANS’ ADMINISTRATION 1977 small, practical clinical laboratory where the essential examinations, immediately necessary in assisting the clinician in making or confirming his diagnosis, may be made. These examinations include urinalysis, blood counts or examinations, coagulation time, smears, sputums, and spinal fluid cell counts. It is preferable that some blood chemistry be done, too, if competent technical service is avail- able. The more elaborate examinations, such as tissue pathology, Widal’s and Wassermann’s tests, and other special procedures may be done in the larger laboratory in a nearby hospital or city. However, contact with the larger labora- tory should always be made by the hospital management rather than by the individual physician, for it is only in this way that reports of examinations made will find their way to the files of the hospital. Too much stress cannot be placed upon tbe importance of routine examina- tion of all tissues removed at operation. Every piece of tissue should be sent to a qualified pathologist for gross or microscopic examination and report. For further elucidation or confirmation of the diagnosis a microscopic examina- tion should be made of all tissues at the discretion of the pathologist. Investi- gation has shown that the larger accredited clinical laboratories are usually willing to cooperate with the small hospital in providing this necessary supple- mentary service at a cost that is not prohibitive, and certainly every patient in a modern hospital is entitled to this service. In the small hospital some difficulty may be experienced in providing super- vision and competent technical personnel for the clinical laboratory. Each hospital offers an individual problem which in most instances can readily be solved. It is desirable, if at all possible, for the hospital to have the part-time services of a well-trained clinical pathologist. Oftentimes arrangements can be made for a pathologist to serve two or more hospitals—provided that each has a competent technical staff. He can make rounds at regular intervals to examine tissues, carry out special tests,-and supervise the work of the depart- ment. When feasible, the visiting pathologist should arrange to attend the me tings of the medical staff for by actively entering into the clinical discus- sions, he is able, because of ids scientific Interest, to exert a great influence on the practice of medicine in the community. In some instances it is practical only to have a member of the medical staff who has had fundamental training in clinical laboratory work supervise the activities of the clinical laboratory. Obviously, when a member of the medical staff assumes this supervision, arrangements should be made with a competent pathologist in a nearby city. In the best interests of the institution and the community the selected physician should pursue all possible means of increasing his knowledge of clinical pathology. The consulting pathologist should visit the hospital periodically and be called when unusual problems arise in the de- partment. The laboratory technician must have training and experience sufficient to insure the hospital management and medical staff that she is competent to do the work assigned to her. She should be a registered technician or one who has successfully passed her qualifying board. Frequently one technician can be trained to handle the work in both the clinical laboratory and X-ray department. If this is not feasible, possibly a graduate nurse who has had the necessary training and experience can take charge of this work along with her other duties. A member of the medical staff may volunteer to do the technical work until the hospital can make more suitable arrangements. How- ever, every instance will require individual consideration in planning the laboratory service of the small hospital. There have been no arbitrary regulations adopted relative to details of keeping clinical laboratory records. However, all reports of findings should be filed in tbe department and cross-indexed, including reports of work sent out to the larger hospital laboratories. Duplicate reports should be made of all laboratory procedures, to become a permanent part of the patient’s medical record. X-ray department.—Every hospital should have at least a portable X-ray unit for an emergency service, particularly for the nonambulatory patient. The ambulatory patient may be sent to the X-ray department in the nearest large hospital. It is desirable, however, for each small hospital to maintain sufficient equipment for radiographic and fluoroscopic X-ray work. Competent supervision of technical personnel is also essential in the X-ray department, and a part-time radiologist who will periodically visit the hospital an 1 make the necessary interpretations of X-ray films is to be preferi'ed. If this is not possible, a member of the medical staff with fundamental training 1978 VETERANS’ ADMINISTRATION in radiology and particularly interested in the field may be assigned to supervise this service. In the latter case, a competent consulting radiologist in a nearby city should be engaged and called upon to assist in interpreting obscure findings. In all instances the department should have medical supervision, for the respon- sibility of interpreting the X-ray films constitutes medical roentgenology—a branch of medicine—and is the work of a physician. A satisfactory technical service may usually be arranged by combining the duties of a properly trained technician with other work in the hospital, such as clinical laboratory technician, anesthetist, medical records librarian, or others. A written report of the interpretation of all X-ray films and treatments should be properly signed by the radiologist and retained in the files of the department, reports being cross-indexed according to the pathology described. A duplicate of all X-ray reports should be attached to the patient’s chart to become a per- manent part of the medical record. Adequate provision is essential for the filing and storage of X-ray films in fireproof cabinets or vaults, where it is generally agreed that they should remain as the permanent property of the hospital. Roentgenograms are a part of the patient’s hospital record and should not be removed from the hospital unless subpencd by a court and accom- panied by an authorized representative of the hospital. Summary.—The American College of Surgeons urges that each small hospital organize a medical staff, maintain adequate medical records, and hold regular staff conferences that they may avail themselves of the best possible clinical diagnostic services. The extent of organization and service will, of course, depehd upon the hospital location and environment. It is not intended that hospital standardization shall work a hardship on any hospital; in fact, in most instances improved facilities and properly organized departments enable the small hospital to gain further public confidence and thus to retain in the community an increasing number of patients who otherwise would find their way into the larger city institutions. Hospital standardization has therefore provided for the growth and progress of the small hospital which has adopted the principles of the minimum standard for hospitals and applied them in an acceptable manner. Addendum I. Bylaws, Rules, and Regulations for Medical Staffs as Approved by the American College of Surgeons From the point of view of organization of the medical staff it is found that hospitals may be divided into four types. Hospitals of types I, II, and III are owned by governmental bodies, communities, church organizations, fraternal organizations, or joint stock companies. They are organized not for profit, and may admit free, part pay, and pay patients. Free patients are attended by the active medical staff; pay patients are usually referred by their own physician and are attended by him. Some pay patients who have no attending physician will apply for admission and they must be assigned to physicians by the hospital. Type IV hospital is privately owned, either by a partnership which may be lay or medical, or by an industrial corporation. It is organized for profit and admits only pay patients. TYPE I HOSPITAL, 50 BEDS OR LESS The hospital is owned by a church, fraternal organization, the community, or a joint stock company. It is organized not for profit and admits free, part pay, and pay patients. Free patients are attended by the active medical staff; pay patients are usually referred by their own physician and are attended by him. Some pay patients will apply for admission who have no attending physician and must be assigned by the hospital. The hospital is usually of 50 beds or less. Its medical staff is comprised of local physicians and those from neighboring communities who are permitted to attend pay patients. Only a limited departmentalization is possible. It is desirable to control the work of the medical staff, limiting each member to that which his training and experience have made him capable of carrying on successfully. Provision for adequate control may be made by selecting those parts of the bylaws for a hospital of type II which are applicable, and adapting them to the needs and possibilities of the smaller hospital. Each hospital must use its initiative in formulating bylaws, rules, and regula- tions which are applicable to its own needs. Those portions of the following sample bylaws, rules, and regulations in the suggested form which do not pertain VETERANS’ ADMINISTRATION 1979 to a given hospital or which cannot become operable within the institution should be modified. There are, however, a number of major principles which are fundamental and which should be embodied in all medical staff bylaws, rules, and regulations in order to comply with the minimum requirements of Hospital Standardization. These are outlined under “Clause III of the Minimum Standard for Hospitals” (pp. 21 and 22). Since the governing board is responsible for the conduct of the hospital, the bylaws, rules, and regulations should be officially adopted and attested by the signatures of its chairman and secretary in order to make the document effective. Finally, the signatures of all members of the medical staff should be affixed as evidence of good faith and agreement to abide thereby. In order to prevent the bylaws from becoming antiquated and disregarded, they should be revised every 3 to 5 years by a committee of the medical staff and the director of the hospital, approved by the governing board, and a copy placed in the minute book of the medical staff proceedings for ready reference. Bylaws Preamble Recognizing that the best interests of the patient are protected by concerted effort, the physicians practicing in Hospital hereby organize themselves in conformity with the bylaws, rules, and regulations herein- after stated. For the purpose of these bylaws the word medical staff shall be interpreted to include all physicians who are privileged to attend patients in Hospital. Whenever the term governing board appears, it shall be interpreted to refer to the board of directors, the board of trustees, the board of managers, or other controlling group. The name of this organization shall be the “Medical Staff of Hospital.” Article I. Name Article II. Purpose The purpose of the organization shall be : 1. To insure that all patients admitted to the hospital or treated in the out- patient department receive the best possible care. 2. To provide a means whereby problems of a medico-administrative nature may be discussed by the medical staff with the governing board and the administration. 3. To initiate and maintain self-government. 4. To provide education and to maintain educational standards. Article III. Membership The applicant for membership on the medical staff shall be a graduate of an approved medical school, legally licensed to practice in the State (or province) of qualified for membership in the local medical society, and practicing in the community or within reasonable distance of the hospital. Section 1. Qualifications Section 2. Ethics and Ethical Relationships The code of ethics as adopted by the American Medical Association and the “Principle of Financial Relations in the Professional Care of the Patient” of the American College of Surgeons shall govern the professional conduct of the mem- bers of the medical staff. Specifically, all members of the medical staff shall pledge themselves that they will not receive from or pay to another physician, either directly or indirectly, any part of a fee received for professional services. On the contrary it shall be agreed that all fees shall be collected and retained by the individual physician in accordance with the value of services rendered. Application for membership on the medical staff shall be presented in writing, on the prescribed form, which shall state the qualifications and references of the applicant, and shall also signify his agreement to abide by the bylaws, rules, and regulations of the medical staff. Section 3. Application for Membership 1980 VETERANS’ ADMINISTRATION Section 4. Terms of Appointment (a) Appointments to the medical staff shall be made by the governing board of the hospital and shall be for the period of 1 year or until the end of the fiscal year of the hospital. At the end of the fiscal year the governing board of the hospital may reappoint all members of the medical staff for a further period of 1 year, provided the medical staff has not recommended that any specific appoint- ment shall not be renewed. In such case all other reappointments may be made. (ft) Should the governing board wish to take the initiative in refusing to make reappointment of any member, it shall so advise the medical staff, stating reasons and asking for recommendations as to further action. (o) In no case shall the governing board take action on an application, refuse to renew an appointment, or cancel an appointment previously made without conference with the medical staff. id) Appointment to the medical staff shall confer on the appointee only such privileges as may be hereinafter provided. (a) The application for membership on the medical staff shall be presented to the director of the hospital and by him referred to the secretary of the medical staff. (b) At the first regular meeting thereafter, the secretary shall present the application to the medical staff, at which time it shall be either rejected or referred to the credentials committee. (c) The credentials committee shall investigate the character, qualifications, and standing of the applicant and shall submit a report of findings at the next regular meeting of the medical staff, or as soon thereafter as possible, recommend- ing that the application be accepted, deferred, or rejected. In no case shall this report be delayed for more than 3 months. (d) On receipt of the report of the credentials committee, the medical staff shall recommend to the governing board that the application be accepted deferred, or rejected. (e) The recommendation of the medical staff shall be transmitted to the gov- erning board through the director of the hospital. if) The governing board shall either accept the recommendation of the medical staff or shall refer it back for further consideration. In the latter case the gov- erning board shall instruct its secretary to state to the medical staff the reasons for such action. {(/) When final action has been taken by the governing board, the director of the hospital shall be authorized to transmit this decision to the candidate for membership, and if he is accepted, to secure his signature to the bylaws, rules, and regulations. Such signature shall constitute his agreement to be governed by the said bylaws, rules, and regulations. Section 5. Procedure for Appointment Section 6. Emergency and Temporary Privileges (a) In case of emergency, the physician attending the patient shall be expected to do all in his power to save the life of the patient, including the calling of such consultation as may be available. For the purpose of this section, an emergency is defined as a condition in which the life of the patient is in immediate danger and in which any delay in administering treatment would add to that danger. (b) The director of the hospital shall have the authority to grant temporary privileges to a physician who is a member of the local medical society and desires to attend an occasional patient in the hospital but who is not a member of the medical staff. Such temporary privileges shall be granted after conference with the chief of staff to determine an authoritative opinion as to the competence and ethical standing of the physician who desires such temporary privilegs, and in the exercise of such privileges he shall be under direct supervision of the chief of staff. Temporary privileges may not be granted to attend more than four pa- tients in any 1 year, after which the physician to whom temporary privileges have been granted shall be required to become a member of the medical staff before being allowed to attend additional patients. Article IV. Divisions of the Medical Staff Section I. The Medical Staff The medical staff shall be divided into honorary, consulting, active, associate, and courtesy groups. VETERANS’ ADMINISTRATION 1981 Section 2. The Honorary Medical Staff The honorary medical staff shall consist of physicians who are not active in the hospital and who are honored by emeritus positions. These may be physicians who have retired from active hospital service or physicians of outstanding repu- tation. The honorary medical staff shall he appointed by the governing hoard on rec- ommendation of the active medical staff and shall have no assigned duties or responsibilities. Section 3. The Consulting Medical Staff (a) The consulting medical staff shall consist of recognized specialists who are active in the hospital or who have signified willingness to accept such ap- pointment. These may be fellows of the American College of Surgeons or the American College of Physicians, diplomates of one of the national boards of medical specialties, members of the national society representing the specialty, or others whom the credentials committee may consider to be worthy of being appointed as members of the consulting staff. Membership on the consulting staff shall not render the member ineligible for membership on the active staff. (h) Appointment shall be made by the governing board on recommendation of the active medical staff. Credentials shall not be required for such appoint- ments and the proposed member may be invited to accept appointment. (c) The duties of the members of the consulting medical staff shall be to give their services, without charge, in the care of free patients on request of any member of the active medical staff, and also in any case in which consultation is required by the rules of the hospital. Section 4. The Active Medical Staff (a) The active medical staff shall shall consist of physicians who are resident in the community and are both willing and able to devote their time to the inter- ests of the hospital. Members of the active medical staff shall not be required to be exclusive specialists, but it is to be expected that they will be well skilled in the particular branch of medicine to which they are assigned, and that a large portion of their private practice will fall within that specialty. (h) Appointments shall be made annually by the governing board on recom- mendation of the active medical staff. Former members of the active medical staff may he reappointed and, in so fjpr as it is possible, new appointees shall have been members of the courtesy medical staff. (c) The duties of the active medical staff shall be to attend free patients when such patients are admitted and to transact all business of the medical staff. Only members of the active medical staff shall be eligible to vute or hold office. Section 5. The Courtesy Medical Staff The courtesy medical staff shall consist of those members of the medical pro- fession, eligible as herein provided for medical-staff membership, who wish to attend private patients in the hospital, hut who do not wish to become members of the active medical staff or who, by reason of residence, are not eligible for such appointment. They shall be appointed in the same manner as other mem- bers of the medical staff and they shall have the privilege of attending private patients, but they shall not be eligible to vote or hold office. They shall have no assigned duties. Article V. Clinical Departments Section I. Services The active medical staff shall be divided into medical, surgical, and such other services as the size and degree of specialization of the active medical staff may warrant. Section 2. Assignment to Services Assignment to the different services shall be made by the active medical staff at its first meeting after its membership has been appointed by the governing board and members shall remain on service for 1 year or until a successor has been appointed. 1982 VETERANS’ ADMINISTRATION Section 3. Organization of Services Immediately after assignment has been made the members of each service shall meet and shall organize in such a manner as to insure proper care of free patients. Article VI. Officers and Committees Section I. Officers The officers of the medical staff shall be the president, the vice president, and the secretary. These shall be elected at the annual meeting of the medical staff, and shall hold office until the next annual meeting or until a successor is elected. The President, who shall also be the chief of the medical staff, shall call and preside at all meetings, shall be a member ex officio of all committees, and shall have general supervision over all of the professional work of the hospital. The vice president in the absence of the president shall assume all his duties and have all his authority. He shall also be expected to perform such duties of supervision as may be assigned to him by the president. The secretary shall keep accurate and complete minutes of all meetings, call meetngs on order of the president, attend to all correspondence, and perform such other duties as ordinarily pertain to his office. If there are funds to be ac- counted for, he shall also act as treasurer. Section 2. Committees Committees of the medical staff shall be standing and special. All committees other than the executive shall be appointed by the president. (In the very small hospital having only a few members on its medical staff it may be advisable to have the entire staff act as a committee of the whole for the transaction of busi- ness, delegating specific duties such as supervision of medical records to individ- ual members.) The executive committee shall consist of the president and secretary of the medical staff and of three other members of the active medical staff to be elected at the time of the annual meeting. The duties of the executive committee shall be to consider carefully and act on all matters which are not of a clinical nature and it is to be expected that all such business of the medical staff shall be trans- acted by the executive committee in order that the time of the regular meetings of the medical staff may be devoted to matters pertaining to the professional care of patients. The executive committee shall present, at each meeting of the medical staff, a report of any action that it may have taken since the last meet- ing. The’executive committee shall act as a liaison group between the medical staff and the administration of the hospital. The medical records committee shall consist of three members of the medical staff and shall meet weekly for the purpose of reviewing the medical records of all patients discharged during the week. The committee shall report to the medical staff the names of any members who are persistently delinquent in the completion of their records. It shall also act as a program committee and be responsible for the preparation and presentation of all programs. The credentials committee shall consist of three members of the active medical staff. Its duties shall be to investigate the credentials of all applicants for mem- bership and to make recommendations in conformity with article III, section 5 (c) of these bylaws. The intern committee shall consist of three members of the medical staff. Its duties shall be to act as an advisory committee in the selection of interns, to outline courses of instruction for the resident medical staff and to see that they are carried out, and to assist the administration in matters of government and discipline of the resident medical staff. Special committees shall be appointed from time to time as may be required to carry out properly the duties of the medical staff. Such committees shall con- fine their work to the purposes for which they were appointed and shall report to the full medical staff. They shall not have power of action unless such is specifically granted by the motion which created the committee. VETERANS’ ADMINISTRATION 1983 Article VII. Meetings Section I. The Annual Meeting The annual meeting of the medical staff shall be the last meeting before the end of the fiscal year of the hospital. At this meeting the retiring officers and committees shall make such reports as may be desirable, officers for the ensuing year shall be elected, and recommendations for appointment to the active medical staff shall be made. Section 2. Regular Meetings Regular meetings of the medical staff shall be held at least monthly at a time and place to be provided in the rules and regulations for the government of the medical staff. Section 8. Special Meetings Special meetings of the medical staff may be called at any time by the presi- dent and shall be called at the request of any five members of the active medical staff. Section 4. Attendance at Meetings (a.) Members of the active medical staff shall be required to attend all meet- ings. Absence from three consecutive meetings or from one-third of the regular meetings for the year, without acceptable excuse, shall be considered as resigna- tion from the active medical staff, and shall automatically place the absentee on the courtesy medical staff of the hospital. (ft.) Reinstatement of members of the active medical staff to positions rendered vacant because of absence from meetings may be made on application, the procedure being the same as in the case of original appointment. (c.) Members of the honorary, consulting, and courtesy divisions of-the medi- cal staff shall not be required to attend meetings, but it is expected that they will attend and participate in these meetings unless they are unavoidably pre- vented from doing so. {d.) A member of any division of the medical staff who has attended a case that is to be presented for discussion at any meeting shall be notified and re- quired to be present. Failure to attend on receipt of such notice shall involve the penalty, in the case of a member of the consulting or active medical staff, of reverting to the courtesy medical staff and, in the case of a member of the courtesy medical staff, of forfeiting his medical staff membership. (e) Should a member of the medical staff be absent from any meeting at which a case that he has attended is to be presented, it shall be discussed nevertheless unless the member is unavoidably absent and has requested postponement of the discussion. In no case shall such postponement be granted for a period longer than that which will elapse until the next regular medical staff meeting. Fifty percent of the total membership of the active medical staff shall constitute a quorum. Section 5. Quorum Section 6. Agenda The agenda at any regular meeting shall be: A. Business: 1. Call to order. 2. Reading of the minutes of the last regular and of all special meetings. 3. Unfinished business. 4. Communications. 5. Reports of standing and of special business committees. 6. New business. B. Medical: 7. Review of patients in the hospital with special reference to diagnoses, treatment, and delayed recovery; selected cases discharged since the last conference with special consideration of selected deaths, unimproved cases, infections, complications, errors in diagnoses, and results of treatment; and analysis of clinical reports from the various departments. 1984 VETERANS’ ADMINISTRATION 8. Reports of standing and of special medical staff committees. 9. Discussion and recommendations for improvement of the professional work of the hospital. 10. Adjournment. The agenda at special meetings shall be; 1. Reading of the notice calling the meeting. 2. Discussion of the business for which the meeting was called. 8. Adjournment. The medical staff shall adopt such rules and regulations as may be necessary for the proper conduct of its work. Such rules and regulations shall be a part of these bylaws, except that they may be amended at any regular meeting without previous notice by a two-thirds vote of the total membership of the active im d- ical staff. Such amendments shall become effective when approved by the gov- erning board. Article VIII. Rules and Regulations Article IX. Amendments These bylaws may be amended after notice given at any regular meeting of the active medical staff. Such notice shall be laid on the table until the next regular meeting and a two-thirds majority of those present shall be required for adoption. Amendments so made shall be effective when approved by the gov- erning board. Article X. Adoption These bylaws shall be adopted at any regular meeting of the active medical staff and shall become effective when approved by the governing board of the hospital. They shall, when adopted and approved, be equally binding on the governing board and the medical staff. Adopted by the active medical staff of Hospital. President of medical staff Date Secretary of medical staff Approved by the governing board of Hospital. Date _ Rules and Regulations Secretary of the governing board 1. The monthly meeting of the medical staff shall be held 2. Except in emergency, no patient shall be admitted to the hospital until after a provisional diagnosis has been stated and the consent of the director secured. In case of emergency the provisional diagnosis shall be stated as soon after admis- sion as possible. 3. Physicians admitting private patients shall be held responsible for giving such information as may be necessary to assure the protection of other patients from those who are a source of danger from any cause whatever. 4. All fi'ee patients shall be attended by members of the active medical staff, and shall be assigned to the service concerned in the treatment of the disease which necessitated admission or in rotation if there is no service division. No physician shall receive any compensation for attendance in the case of any patient who is admitted free by the hospital. Pay patients shall be attended by their own private physicians. In the case of a pay patient applying for admission who has no attending physician, he shall be assigned in rotation to the members of the active medical staff on duty in the service to which the illness of the patient indicates assignment. 5. Laboratories shall be provided in the hospital to insure as complete a serv- ice as possible. Examinations which cannot be made in the hospital shall be referred to an outside approved laboratory and in the case of pay patients will be charged to the patient at cost. Standing orders shall be formulated by conference between the medical staff and the director of the hospital. They may be changed only by the director after conference with the medical staff. These orders shall be followed insofar as VETERANS’ ADMINISTRATION 1985 proper treatment of tlie patient will allow, and when specific orders are not writ- ten by the attending physician they shall constitute the orders for treatment. 7. All orders for treatment shall be in writing. Verbal orders shall not be accepted or carried out. An order shall be considered to be in writing if dictated to a senior nurse or other authorized person and signed by at- tending physician. Orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his or her own name. At his ne.:t visit the attending physician shall sign such orders. 8. As far as possible the use of propietary remedies shall be avoided When such are ordered for private patients by the attending physician, they will be secured and a special charge made to the patient. 0. The attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include identi- fication data; complaint; personal history; family history; history of present illness; physical examination; special reports such as consultation, clinical laboratory, X-ray, and others; provisional diagnosis, medical or surgical treat- ment, pathological findings, progress notes, final diagnosis, condition on discharge, follow-up, and autopsy report when available. N > medical record shall be filed until it is complete except on order of the medical records committee. 10. A complete history and physical examination in all cases shall be written within 24 hours after admission. 11. When such history and physical examination are not recorded before the time stated for operation, the operation shall he canceled, unless the attend- ing surgeon states in writing that such delay would be detrimental to the patient. 12. All records are the property of the hospital and shall not be taken away without permission. In case of readmission of a patient all previous records shall be available for the use of the attending physician. This shall apply whether the patient be free or pay; and whether he be attended by the same* physician or by another. 13. Except in cases of emergency, patients for operation shall be admitted not later than 4 o’clock the day previous to- operation. 14. All operations performed shall be fully described by the attending sur- geon. All tissues removed at operation shall be sent to the hospital pathologist who shall make such examination as he may consider necessary to arrive at a pathological diagnosis. 15. In all cases where a patient is admitted in a condition of abortion, she or her representative shall sign a statement certifying that neither any em- ployee of the hospital nor the attending physician was directly or indirectly responsible for its production. 16. Except in emergency, consultation with a member of the consulting or of the active medical staff shall be required in all major cases in which the pa- tient is not a good risk and in all curettages or other operations which may interrupt a known, suspected, or possible pregnancy. The consultant shall make and sign a record of his findings and recommendations in every such case. In all cases where a rule of the hospital requires consultation and in the case of free patients, the consultant shall give his services without charge. 17. Each member of the courtesy medical staff, not resident in the city, or immediate vicinity, shall name a member of the medical staff who is resident in the city, who may be called to attend his patients in emergency. In case of failure to name such associate, the director of the hospital shall have au- thority to call any member cf the staff should he consider it necessary. IS. Patients shall be discharged only on written order of the attending phy- sician. At the time of discharge the attending physician shall see that the record is complete, state his final diagnosis, and sign the record. 19. At the monthly meeting of the medical staff the medical records librarian shall submit a report of the professional work of the hospital for the previous month. This shall show patients discharged and the results, deaths (the cause being stated as given by the attending physician), autopsies, consultations, and infections of all kinds.' The discussion at the meeting shall be based on this report and at no meeting shall abstract discussion of scientific medical subjects be permitted. After each meeting the secretary of the medical staff shall trans- mit to the director of the hospital such reports and recommendations as the medical staff may wish to make to him or through him to the governing board. 20. Every member of the medical staff shall be actively interested in securing autopsies whenever possible. No autopsy shall be performed without written 75183—45—pt. 5 10 1986 VETERANS’ ADMINISTRATION consent of a responsible relative or friend. All autopsies shall be per- formed by the hospital pathologist or by a physician to whom he may delegate the duty. 21. The hospital shall admit patients suffering from all types of disease except the following: (Specify diseases not treated). Patients *may be treated only by physicians who have submitted proper credentials and have been duly appointed to membership on the medical staff. Adopted at a regular meeting of the active medical staff. President of the medical staff Date Secretary of medical staff Approved by the governing board. Date . Secretary of the governing board TYPE II HOSPITAL (50 TO 100 BEDS) The hospital is owned by a church, fraternal organization, the community, or a joint stock company. It is organized not for profit and admits free, part pay, and pay patients. Free patients are attended by the active medical staff; pay patients are usually referred by their own physician and are attended by him. Some pay patients will apply for admission who have no attending physician and must be assigned by the hospital. The hospital is usually one of from 50 to 150 beds. Its medical staff is com- prised of local physicians and those from neighboring communities who are permitted to attend pay patients, but there is some specialization and as a result there is a certain amount of departmentalization. Each hospital must use its initiative in formulating bylaws, rules, and regula- tions which are applicable to its own needs. Those portions of the following sample bylaws, rules, and regulations in the suggested form which do not pertain to a given hospital or which cannot become operable within the institution should be modified. There are, however, a number of major principles which are fun- damental and which should be embodied in all medical staff bylaws, rules, and regulations in order to comply with the minimum requirements of hospital stand- ardization. These are outlined under clause III of the Minimum Standard for Hospitals (pp. 21 and 22). Since the governing board is responsible for the conduct of the hospital, the bylaws, rules, and regulations should be officially adopted and attested by the signatures of its chairman and secretary in order to make the document effective. Finally, the signatures of all members of the medical staff should be affixed as evidence of good faith and agreement to abide thereby. In order to prevent the bylaws from becoming antiquated and disregarded, they should be revised every 3 to 5 years by a committee of the medical staff and the director of the hospital, approved by the governing board, and a copy placed in the minute book of the medical staff proceedings for ready reference. Bylaws Preamble Recognizing that the best interests of the patient are protected by concerted effort, the physicians practicing in Hospital hereby organ- ize themselves in conformity with the bylaws, rules, and regulations hereinafter stated. For the purpose of these bylaws the words “medical staff” shall be interpreted to include all physicians who are privileged to attend patients in Hospital. Whenever the term “governing board” appears, it shall be interpreted to refer to the board of directors, the board of trustees, the board of managers, or other controlling group. 4 Hide I. Name The name of this organization shall be the medical staff of Hospital. VETERANS’ ADMINISTRATION 1987 Article II. Purpose The purpose of the organization shall be— 1. To insure that all patients admitted to the hospitals or treated in the out- patient department receive the best possible care. 2. To provide a means whereby problems of a medico-administrative nature may be discussed by the medical staff with the governing board and the admin- istration. 3. To initiate and maintain self-government. 4. To provide education and to maintain educational standards. Article III. Membership Section 1. Qualifications The applicant for membership on the medical staff shall be a graduate of an approved medical school, legally licensed to practice in the State (or Province) of qualified for membership in the local medical society, and practicing in the community or within reasonable distance of the hospital. Section 2. Ethics and Ethical Relationships The code of ethics as adopted by the American Medical Association and the Principles of Financial Relations in the Professional Care of the Patient of the American College of Surgeons shall govern the professional conduct of the members of the medical staff. Specifically, all members of the medical staff shall pledge themseves that they will not receive from or pay to another physician, either directly or indirectly, any part of a fee received for professional services. On the contrary it shall be agreed that all fees shall be collected and retained by the individual physician in accordance with the value of services rendered. Section 3. Application for Membership Application for membership on the medical staff shall be presented in writing, on the prescribed form, which shall state the qualifications and references of the applicant, and shall also signify his agreement to abide by the bylaws, rules, and regulations of the medical staff. Section 4. Terms of Appointment (а) Appointments to the medical staff shall be made by the governing board of the hospital and shall be for the period of 1 year or until the end of the fiscal year of the hospital. At the end of the fiscal year the governing hoard of the hospital may reappoint all members of the medical staff for a further period of 1 year, provided the medical staff has not recommended that any specific appoint- ment shall not be renewed. In such case all other reappointments may he made. (б) Should the governing board wish to take the initiative in refusing to make reappointment of any member, it shall so advise the medical staff, stating reasons and asking for recommendations as to further action. (c) In no case shall the governing board take action on an application, refuse to renew an appointment, or cancel an appointment previously made without conference with the medical staff. (d) Appointment to the medical staff shall confer on the appointee only such privileges as may be hereinafter provided. Section 5. Procedure for Appointment (а) The application for membership on the medical staff shall be presented to the director of the hospital and by him referred to the secretary of the medical staff. (б) At the first regular meeting thereafter, the secretary shall present the application to the medical staff, at which time it shall be either rejected or re- ferred to the credentials committee. (c) The credentials committee shall investigate the character, qualifications, and standing of the applicant and shall submit a report of findings at the regular 1988 VETERANS’ ADMINISTRATION meeting of the medical staff, or as soon thereafter as possible, recommending that the application be accepted, deferred, or rejected. In no case shall this report be delayed for more than 3 months. (d) When determining qualifications, the credentials committee shall also assign privileges as provided in article VI, sections 1 and 2 of these bylaws. (e) On receipt of the report of the credentials committee, the medical staff shall recommend to the governing board that the application be accepted, de- ferred, or rejected. if) The recommendation of the medical staff shall be transmitted to the gov- erning board through the director of the hospital. iff) The governing board shall either accept the recommendation of the medical staff or shall refer it back for further consideration. In the latter case the governing hoard shall instruct its secretary to state to the medical staff the reasons for such action. (h) When the final action has been taken by the governing board, the director of the hospital shall be authorized to transmit this decision to the candidate for membership, and if he is accepted, to seeure his signature to these bylaws, rules, and regulations. Such signature shall constitute his agreement to be governed by the said bylaws, rules, and regulations. Section 6. Emergency and Temporary Privileges (a) In case of emergency, the physician attending the patients shall be ex- pected to do all in his power to save the life of the patient, including the calling of such consultation as may be quickly available. For the purpose of this sec- tion, an emergency is defined as a condition in which the life of the patient is in immediate danger and in which any delay in administering treatment would add to that danger. (ft) The directors of the hospital shall have the authority to grant temporary privileges to a physician who is a member of the local medical society and de- sires to attend an occasional patient in the hospital but who is not a member of the medical staff. Such temporary privileges shall he granted after conference with the chief of staff to determine an authoritative opinion as to the compe- tence and ethical standing of the physician who desires such temporary privileges, and in the exercise of such privileges he shall be under direct supervision of the chief of staff. Temporary privileges may not be granted to attend more than four patients in any one year, after which the physician to whom temporary privileges have been granted shall be required to become a member of the medical staff before being allowed to attend additional patients. Article IV. Divisions of the medical staff Section 1. The Medical Staff The medical staff shall be divided into honorary, consulting, active, associate, and courtesy groups. Section. 2. The Honorary Medical Staff The honorary medical staff shall consist of physicians who are not active in the hospital and who are honored by emeritus positions. These may be phy- sicians who have retired from active hospital service or physicians of outstand- ing reputation. The honorary medical staff shall be appointed by the governing board on recommendation of the active medical staff and shall have no assigned duties or responsibilities. Their privileges shall be determined by the credentials com- mittee as provided in article VI of these bylaws. Section 3. The Consulting Medical Staff (a) The consulting medical staff shall consist of recognized specialists who are active in the hospital or who have signified willingness to accept such ap- pointment. These may be Fellows of the American College of Surgeons or the American College of Physicians, diplomates of one of the national boards of medical specialties, members of the national society representing the specialty, or others whom the credentials committee may consider to be worthy of being appointed as members of the consulting staff. Membership on the consulting staff shall not render the member ineligible for membership on the active staff. VETERANS’ ADMINISTRATION 1989 (&) Appointment shall be made by the governing board on recommenda- tion of the active medical staff. Credentials shall not be required' for such appointments and the proposed member may be invited to accept appointment. (c) The duties of the members of the consulting medical staff shall be to give their services without charge in the care of free patients on request of any member of the active medical staff, and also in any case in which consultation is required by the rules of the hospital. (d) Insofar as their specialty is concerned, members of the consulting medical staff shall have unrestricted privileges, but in cases not falling within their specialty they shall have such privileges as may be determined by the cre- dentials committee as provided in article VI of these bylaws.. Section 4. The Active Medical Staff (a) The active medical staff shall consist of physicians, resident in the com- munity, who have been selected to attend free patients in the hospital and to whom all such patients shall be assigned. Members of the active medical staff shall not be required to be exclusive specialists, but it is to be expected that they will be well skilled in the particular branch of medicine to which they are assigned, and that a large proportion of their private practice will fall within that specialty. (&) Appointments shall be made annually by the governing board on recom- mendation of the active medical staff from the former members of the active medical staff and, insofar as it is possible, vacancies shall be filled by promo- tion of members of the associate medical staff. (c) The duties of the active medical staff shall be to attend free patients and, insofar as free work is concerned, they shall attend only such patients as are admitted to the service to which they are assigned. All business of the medi- cal staff shall be transacted by the active medical staff and only members of the active medical staff shall be eligible to vote or hold office. id) Insofar as free cases are concerned, the members of the active medical staff shall have unrestricted privileges and shall treat patients assigned to their services to a conclusion regardless of whether- this treatment is carried on in the in- or out-patient department. Insofar as private cases are concerned, they shall have unrestricted privileges in the treatment of patients falling within the specialty to which they are appointed, but in others they shall have only such privileges as may be determined by the credentials committee in conformity with article VI of these bylaws. (a) The associate medical staff shall consist of junior members of the medical staff or of physicians who have not been actively interested in the work of the hospital but have expressed a wish to become active as vacancies occur. (&) They shall be appointed and assigned to services in the same manner as members of the active medical staff and each shall be associated with a member of the active medical staff. (e) The duties of the members of the associate medical staff shall be to attend free patients in accordance with assignment by the senior with whom they are associated. They may be required also to act on all committees except the executive committee and the credentials committee. id) Insofar as free cases are concerned, they shall be limited to the treat- ment of cases falling within their service in accordance with assignment by their senior. Insofar as private patients are concerned, they shall have such privi- leges as may be determined by the credentials committee in conformity with article VI of these bylaws. Section 5. The Associate Medical Staff Section 6. The Courtesy Medical Staff The courtesy medical staff shall consist of those members of the medical pro- fession, eligible as herein provided for medical staff membership, who wish to attend private patients in the hospital, but who do not wish to become members of the active medical staff or who, by reason of residence, are not eligible for such appointment. They shall be appointed in the same manner as other members of the medical staff and they shall have such privileges as may be determined by the credentials committee in conformity with article VI of these bylaws but they shall not be eligible to vote or hold office. 1990 VETERANS’ ADMINISTRATION Article V. Clinical Departments Section 1. Services The active medical staff shall be divided into medical, surgical, and such other services as the size and degree of specialization of the active medical staff may warrant. Section 2. Assignment to Services Ass’gnraent to the different services shall be made by the active medical staff at its first meeting after its membership has been appointed by the governing board and members shall remain on service for 1 year or until a successor has been appointed. Section 3. Organization of Services Immediately after assignment has been made the members of each service shall meet and shall organize in such a manner as to insure proper care of free patients. Article VI. Determination of Qualifications and Privileges Section 1. Classification of Privileges Privileges extended to physicians who have been appointed to the medical staff shall be divided into major, intermediate, and minor, and shall be determined by the credentials committee. The following shall serve as a guide in differenti- ating the three types of privileges : (a) Major privileges in any service will allow the physician to treat patients when, for any cause, such treatment involves a serious hazard to the life of the patient. (&) Intermediate privileges in any service will allow the physician to treat patients when, for any cause, such treatment does not involve a serious hazard to the life of the patient but does involve a danger of disability. (c) Minor privileges in any service will allow the physician to treat patients when, for any cause, the treatment does not involve either a serious hazard to the life of the patient or a danger of disability. Section 2. Newly Appointed Medical Staff Members All members of the medical staff when newly appointed shall be granted only minor privileges until such time as the credentials committee shall determine what further privileges may be granted with safety to the patient, such exten- sion of privileges being based, as far as possible, on records of performance as provided in sections 3 and 4 of this article. A system of professional service accounting shall be maintained under which records of performance of each member of the medical staff shall be available. (a) On or immediately after admission of the patient the attending physician shall classify the treatment proposed, in conformity with the pathology found, under one of the following prognostic categories: Section 3. Professional Service Accounting Elective 1. Good 2. Fair 3. Bad Emergency 4. Good 5. Fair 6. Bad Palliative 7. Good 8. Fair 9. Bad Should the attending physician consider the risk to be fair or bad in any of the categories or should he subsequently desire to change his prognosis, he shall he required to state his reasons. At the time of discharge, the immediate result shall be stated as recovered or died. (h) The professional service accounting shall be administered by a professional service accountant, appointed by the administration with the advice of the medi- cal staff, whose duty it shall be to check the prognosis and statement of result to determine whether they are correctly stated; to determine whether the result is such as may be reasonably expected from the prognosis and, if not, whether the result is justified or inevitable; and to determine any errors that may be apparent as evidenced by the medical record. VETERANS’ ADMINISTRATION 1991 (c) In cases in which the professional service accountant does not feel com- petent to pas* judgment or in which there may be reason for discussion, the record shall be referred to the credentials committee who may exercise judgment or refer the case to the active medical staff for discussion and decision. (d) The decision of the professional service accountant, of the credentials committee, or of the active medical staff, as the case may be, shall be attached as a memorandum to the medical record. This memorandum shall not be pre- served as a part of the medical record. (e) The medical records librarian shall keep a record of the performance of each physician, and she shall enter the decisions and remarks as above provided, except that no record of errors shall be kept after the medical staff has taken appropriate action. This record shall be kept confidential and shall be accessible only to the credentials committee when determining the recommendations which it will make for promotion and appointment to the various services, except that any member of the medical staff desiring information as to his own performance may have access to his own section of the record at any time. After all entries for the year have been made, the various columns shall be totaled. Section 4. Dix*ect Observation Every member of the consulting or active medical staff, at the conclusion of any case in which he has been associated with a member of the associate or courtesy medical staff, shall transmit to the medical records librarian a memoran- dum stating whether, from his observation of competence insofar as the par- ticular case is concerned, the member of the associate or courtesy medical staff may be granted further privilegs as specified in section 1 of this article. Such expression of opinion shall be kept as absolutely confidential by the medical rec- ords librarian and shall be accessible only to the credentials committee when making recommendations for promotion, appointment to service, or granting of increased privileges. Section 5. Recommendations for Promotion or Appointment to Services When making recommendations for promotion, appointment to services, or the granting of privileges, the credentials committee shall base its judgment on the consensus as determined under section 4 of this article, together with the record of performance as provided in section 3 of this article, and on the further qualifications of the member of the staff as shown in his filed credentials. Article VII. Officers and Committees The officers of the medical staff shall be the president, the vice president, and the secretary. These shall be elected at the annual meeting of the medical staff, and shall hold office until the next annual meeting or until a successor is elected. The president, who shall also be the chief of the medical staff, shall call and preside at all meetings, shall be a member ex officio of all committees, and shall have general supervision over all of the professional work of the hospital. The vice president in the absence of the president shall assume all his duties and have all his authority. He shall also be expected to perform such duties of supervision as may be assigned to him by the president. The secretary shall keep accurate and complete minutes of all call meetings on order of the president, attend to all correspondence, and perform such other duties as ordinarily pertain to his office. If there are funds to be accounted for, he shall also act as treasurer. Section 1. Officers Section 2. Committees Committees of the medical staff shall be standing and special. All committees other than the executive shall be appointed by the president. The executive committee shall consist of the president and secretary of the medical staff and of three other members of the active medical staff to be elected at the time of the annual meeting. The duties of the executive committee shall be to consider carefully and act on all matters which are not of a clinical nature and it is to be expected that all such business of the medical staff shall be trans- acted by the executive committee in order that the time of the regular meetings 1992 VETERANS’ ADMINISTRATION of the medical staff may be devoted to matters pertaining to the professional care of patients. The executive committee shall present, at each meeting of the medical staff, a report of any action that it may have taken since the last meeting. The executive committee shall act as a liaison group between the medical staff and the administration of the hospital. The medical records committee shall consist of three members of the medical staff and shall meet weekly for the purpose of reviewing the records of all patients discharged during the week. The committee shall report to the medical staff the names of any members who are persistently delinquent in the completion of their records. It shall also act as a program committee and shall be responsible for the preparation and presentation of all programs. The credentials committee shall consist of not loss than three nor more than seven members, the number and selection being determined in such a manner as to insure representation of the different services which are represented on the medical staff. Its duties shall be to investigate the credentials of all appli- cants for membership and to make recommendations in conformity with article III, section 5c, of these bylaws; to investigate any breach of ethics that may be reported; to review any records that may be referred by the medical director and to arrive at a decision regarding the performance of the medical staff member, or to refer the case to the full medical staff if this is considered desirable; to review all information available regarding the competence of medical staff mem- bers and as a result of such reviews to make recommendations for granting of privileges and the appointment of members to the various services and depart- ments as provided in article VI of these bylaws. The intern committee shall consist of three members of the medical staff. Its duties shall be to act as an advisory committee in the selection of interns, to out- line courses of instruction for the resident medical staff and to see that they are carried out, and to assist the administration in matters of government and discipline of the resident medical staff. Special committees shall be appointed from time to time as may be required to carry out properly the duties of the medical staff. Such committees shall confine their work to the purposes for which they were appointed and shall report to the full medical staff. They shall not have power of action unless such is specifically granted by the motion which created the committee. Article VIII. Meetings Section 1. The Annual Meeting The annual meeting of the medical staff shall be the last meeting before the end of the fiscal year of the hospital. At this meeting the retiring officers and committees shall make such reports as may be desirable, officers for the ensuing year shall be elected, and recommendations for appointment to the active medical staff shall be made. Regular meetings of the medical staff shall be held at least monthly at a time and place to be provided in the rules and regulations for the government of the medical staff. Section 2. Regular Meetings Section 3. Special Meetings Special meetings of the medical staff may be called at any time by the president and shall be called at the request of any five members of the active medical staff. Section 4. Attendance at Meetings (а) All members of the active medical staff shall be required to attend nil meetings. Absence from three consecutive meetings or from one-third of the regular meetings for the year, without acceptable excuse, shall be considered as resignation from the active medical staff, and shall automatically place the absentee on the associate medical staff of the hospital. (б) All members of the associate medical staff shall be expected to attend meetings with the same regularity as members of the active medical staff. Absence from three consecutive meetings or from one-third of the meetings of the year, without acceptable excuse, shall be considered as resignation from the associate medical staff and shall automatically place the absentee on the courtesy medical staff. VETERANS’ ADMINISTRATION 1993 (c) Reinstatement of members of the active and associate medical staffs to positions rendered vacant because of absence from meetings may be made on application, the procedure being the same as in the case of original appoint- ment. (d) Members of the honorary, consulting, and courtesy divisions of the medical staff shall not be required to attend meetings, but it is expected that they will attend and participate in these meetings unless they are unavoidably prevented from doing so. (e) A member of any division of the medical staff who has attended a case that is to be presented for discussion at any meeting shall be notified and shall be required to be present. Failure to attend on receipt of such notice shall involve the penalty, in the case of a member of the consulting or active staff, of reverting to the courtesy staff, and, in the case of a member of the courtesy staff, of forfeiting his staff membership. (/) Should a member of the medical staff be absent from any meeting at which a case that he has attended is to be present, it shall nevertheless be discussed unless the member is unavoidably absent and has requested postponement of the discussion. In no case shall such postponement be granted for a period longer than that which will elapse until the next regular staff meeting. Section 5. Quorum Fifty percent of the total membership of the active medical staff shall constitute a quorum. Section G. Agenda The agenda at any regular meeting shall be A. Business: 1. Call to order. 2. Reading of the minutes of the last regular and of all special meetings. 3. Unfinished business. 4. Communications. 5. Reports of standing and of special business committees. 6. New business. B. Medical: 7. Review of patients in the hospital with special reference to diagnoses, treatment, and delayed recovery; selected cases discharged since the last conference with special consideration of selected deaths, unimproved cases, infections, complications, errors in diagnoses, and results of treatment; and analysis of clinical reports from the various departments. 8. Reports of standing and of special medical staff committees. 9. Discussion and recommendations for improvement of the professional work of the hospital. 10. Adjournment. The agenda at special meetings shall be: 1. Reading of the notice calling the meeting. 2. Discussion of the business for which the meeting was called 3. Adjournment. The medical staff shall adopt such rules and regulations as may be necessary for the proper conduct of its work. Such rules and regulations shall be a part of these bylaws, except that they may be amended at any regular meeting without previous notice by a two-thirds vote of the total membeship of the active medical staff. Such amendments shall become effective when approved by the governing board. Article IX. Rules and Regulations Article X. Amendments These bylaws may be amended after notice given at any regular meeting of the active medical staff. Such notice shall be laid on the table until the next regular meeting and a two-thirds majority of those present shall be required for adoption. Amendments so made shall be effective when approved by the govern- ing board. 1994 VETERANS’ ADMINISTRATION Article XI. Adoption These bylaws shall be adopted at any regular meeting of the active medical staff and shall become effective wThen approved by the governing board of the hospital. They shall, w'hen adopted and approved, be equally binding on the governing board and the medical staff. Adopted by the medical staff of Hospital President of medical staff _ . Secretary of medical staff Date Approved by the governing board of Hospital _ , Secretary of the governing board Date Rules and Regulations 1. The monthly meeting of the medical staff shall be held 2. Except in emergency, no patient shall be admitted to the hospital until after a provisional diagnosis has been stated and the consent of the director secured. In case of emergency the provisional diagnosis shall he stated as soon after admission as possible. 3. Physicians admitting private patients shall be held responsible for giving such information as may be necessary to assure the protection of other patients from those who are a source of danger from any cause whatever. 4. All free patients shall be attended by members of the active medical staff, and shall be assigned (o the service concerned in the treatment of the disease which necessitated admission or in rotation if there is no service division. No physician shall receive any compensation for attendance in the case of any patient who is admitted free by the hospital. Pay patients shall be attended by their own private physicians. In the case of a pay patient applying for ad- mission who has no attending physician, he shall be assigned to the members of the active medical staff on duty in the service to which the illness of the patient indicates assignment. 5. Laboratories shall be provided in the hospital to insure as complete a service as possible. Examinations which cannot be made in the hospital shall be referred to an outside approved laboratory and in the case of pay patients will be charged to the patient at cost. 6. Standing orders shall be formulated by conference between the medical staff and the director. They may be changed only by the director after conference with the medical staff. These orders shall be followed insofar as proper treat- ment of the patient will allow’, and when specific orders are not written by the attending physician they shall constitute the orders for treatment. 7. All orders for treatment shall be in writing. Verbal orders shall not be accepted or carried out. An order shall be considered to be in writing if dictated to a senior nurse or other authorized person and signed by the attending phy- sician. Orders dictated over the telephone shall be signed by the person to w hom dictated with the name of the physician per his or her own name. At his next visit the attending physician shall sign such orders. 8. As far as possible the use of proprietary remedies shall be avoided. When such are ordered for private patients by the attending physician, they wrill be secured and a special charge made to the patient. 9. The attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include identifi- cation data; complaint; personal history; family history; history of present illness; physical examination; special reports such as consultation, clinical lab- oratory, X-ray, and others ; provisional diagnosis; medical or surgical treatment; pathological findings; progress notes; final diagnosis; condition on discharge; follow-up; and autopsy report wdien available. No medical record shall be filed until it is complete, except on order of the medical records committee. 10. A complete history and physical examination shall in all cases be written within 24 hours after admission of the patient. VETERANS’ ADMINISTRATION 1995 11. When such history and physical examination are not recorded before the time stated for operation, the operation shall be canceled, unless tlie attending surgeon states in writing that such delay would be detrimental to the patient 12. All records are the property of the hospital and shall not be taken away without permission. In case of readmission of a patient all previous records shall be available for the use of the attending physician. This shall apply whether the patient be free or pay, and whether he be attended by the same phy- sician or by another. 13. Except in cases of emergency, patients for operation shall be admitted not later than four o’clock the day previous to operation. 14. All operations performed shall be fully described by the attending surgeon. All tissues removed at operation shall be sent to the hospital pathologist who shall make such examination as he may consider necessary to arrive at a patho- logical diagnosis. 15. In all cases where a patient is admitted in a condition of abortion, she or her representative shall sign a statement certifying that neither any employee of the hospital nor the attending physician was directly or indirectly responsible for its production. Id. Except in emergency, consultation with a member of the consulting or of the active medical staff shall be required in all major cases in which the patient is not a good risk and in all curettages or other operations which may interrupt a known, suspected, or possible pregnancy. The consultant shall make and sign a record of his findings and recommendations in every such case. In all cases where a rule of the hospital requires consultation and in the case of free patients, the consultant shall give his services without charge. 17. Each member of the courtesy medical staff, not resident in the city, or immediate vicinity, shall name a member of the medical staff who is resident in the city, who may be called to attend his patients in emergency. In case of failure to name such associate, the director of the hospital shall have authority to call any member of the staff should he consider it necessary. 18. Patients shall be discharged only on written order of the attending phys- ician. At the time of discharge the attending physician shall see that the record is complete, state his final diagnosis, and sign the record. 10, At the monthly meeting of the medical staff the medical records librarian shall submit a report of the professional work of the hospital for the previous month. This shall show patients discharged and the results, deaths (the cause being stated as given by the attending physician), autopsies, consultations, ami infections of all kinds. The discussion at the meeting shall be based on this report and at no meeting shall abstract discussion of scientific medical subjects be permitted. After each meeting the secretary cf the medical staff shall transmit to the director of the hospital such reports and recommendations as the medical staff may wish to make to him or through him to the governing board. 20. Every member of the medical staff shall be actively interested in securing autopsies whenever possible. No autopsy shall be performed without written consent of a responsible relative or friend. All autopsies shall be performed by the hospital pathologist or by a physician to whom he may delegate the duty. 21. The hospital shall admit patients suffering from all types of disease except the following: (Specify diseases not treated). Patients may be treated only by physicians who have submitted proper credentials and have been duly appointed to membership on the medical staff. Adopted at a regular meeting of the active medical staff. President of medical staff Date Secretary of medical staff Approved by the governing board. Date - TYPE nx HOSPITAL (OVER 150 BEDS) The hospital is owned by a church, fraternal organization, the community, or a joint stock company. It is organized not for profit and admits free, part pay, and pay patients. Free patients are attended by the active medical staff; 1996 VETERANS’ ADMINISTRATION pay patients are usually referred by their own physician and are attended by him. Some pay patients will apply for admission who have no attending phys- ician and must be assigned by the hospital. The hospital is one of over 150 beds. Its medical staff is comprised almost entirely of physicians who are definitely specialized and the hospital is strictly departmentalized. Each hospital must use its initiative in formulating bylaws, rules, and regula- tions which are applicable to its own needs. Those portions of the following sample bylaws, rules, and regulations in the suggested form which do not per- tain to a given hospital or which cannot become operable within the instruc- tion should be modified. There are, however, a number of major principles which are fundamental and which should be embodied in all medical staff bylaws, rules, and regulations in order to comply with the minimum requirements of Hospital Standardization. These are outlined under “clause III of the Mini- mum Standard for Hospitals” (pp. 21 and 22). Since the governing board is responsible for the conduct of the hospital, the bylaws, rules, and regulations should be officially adopted and attested by the signatures of its chairman and secretary in order to make the document effec- tive. Finally, the signatures of all members of the medical staff should be affixed as evidence of good faith and agreement to abide thereby. In order to prevent the bylaws from becoming antiquated and disregarded, they should he revised every 3 to 5 years by a committee of the medical staff and the director of the hospital, approved by the governing board, and a copy placed in the minute book of the medical staff proceedings for ready reference. Recognizing that the best interests of the patient are protected by concerted effort, the physicians practicing in Hospital hereby or- ganize themselves in conformity with the bylaws, rules, and regulations herein- after stated. For the purpose of these bylaws the word medical staff shall be interpreted to include all physicians who are privileged to attend patients in Hospital. Whenever the term “governing board” appears, it shall be interpreted to refer to the board of directors, the board of trustees, the board of managers, or other controlling group. Bylaws Preamble Article 1. Name The name of this organization shall be the “Medical Staff of Hospital.’ The purpose of the organization shall be: 1. To insure that all patients admitted to the hospital or treated in the out- patient department receive the best, possible care. 2. To provide a means whereby problems of a medico-administrative nature may be discussed by the medical staff with the governing board and the admin- istration. Article II. Purpose 3. To initiate and maintain self-government. 4. To provide education and to maintain educational standards. Article III. Membership Section I. Qualifications The applicant for membership on the medical staff shall be a graduate cf an approved medical school, legally licensed to practice in the state (or province) of : . qualified for membership in the local medical society, and practicing in the community or within reasonable distance of the hospital. Section 2. Ethics and Ethical Relations!! The code of ethics as adopted by the American Medical Association and the “Principles of Financial Relations in the Professional Care of the Patient” of the American College of Surgeons shall govern the professional conduct of the mem- bers of the medical staff. Specifically, all members of the medical staff shall pledge themselves that they will not receive from or pay to another physician. VETERANS’ ADMINISTRATION 1997 either directly or indirectly, any part of a fee received for professional services. On the contrary it shall he agreed that all fees shall be collected and retained by the individual physician in accordance with the value of services rendered. Section 3. Application for Membership Application for membership on the medical staff shall be presented in writing, on the prescribed form, which shall state the qualifications and references of the applicant, and shall also signify his agreement to abide by the bylaws, rules, and regulations of the medical staff. Section 4. Terms of Appointment («) Appointments to the medical staff shall be made by the governing board of the hospital and shall be for the period of 1 year or until the end of the fiscal year of the hospital. At the end of the fiscal year the governing board of the hospital may reappoint all members of the medical staff for a further period of 1 year, provided the medical staff has not recommended that any specific ap- pointment shall not be renewed. In such case all other reappointments may be made. (b) Should the governing board wish to take the initiative in refusing to make reappointment of any member, it shall so advise the medical staff, stating reasons and asking for recommendations as to further action. (c) In no case shall the governing board take action oh an application, refuse to renew an appointment, or cancel an appointment previously made without con- ference with the medical staff, but regardless of the recommendations of the medical staff, final responsibility for appointment or cancellation of an appoint- ment must rest with the governing board. (d) Appointment to the medical staff shall confer on the appointee only such privileges as may be hereinafter provided. Section 5. Procedure for Appointment (a) The application for membership on the medical staff shall he presented to the director of the hospital and by him referred to the secretary of the medical staff. (b) At the first regular meeting thereafter, the secretary shall present the application to the medical staff, at which time it shall be either recommended for rejection or referred to the credentials committee. (c) The credentials committee shall investigate the character, qualifications, and standing of the applicant and shall submit a report of findings at the next regular meeting of the medical staff, or as soon thereafter as possible, recom- mending that the application be accepted, deferred, or rejected. In no case shall this report be delayed for more than 3 months. (d) When determining qualifications, the credentials committee shall also assign privileges as provided in article VI, sections 1 and 2 of these bylaws. (e) On receipt of the report of the credentials committee, the medical staff shall immediately recommend to the governing board that the application be ac- cepted, deferred, or rejected. if) The recommendation of the medical staff shall be transmitted to the gov- erning board through the director of the hospital. ig) The governing board shall either accept the recommendation of the medical staff or shall refer it back for further consideration. In the latter case the gov- erning board shall instruct its secretary to state to the medical staff the reasons for such action. (h) When final action has been taken by the governing board, the director of the hospital shall be authorized to transmit this decision to the candidate for membership, and if he is accepted, to secure his signature to these bylaws, rules, and regulations. Such signature shall constitute his agreement to be governed by the said bylaws, rules, and regulations. (a) In case of emergency the physician attending the patient shall be expected to do all in his power to save the life of the patient, including the calling of such consultation as may be quickly available. For the purpose of this section, an emergency is defined as a condition in which the life of the patient is in im Section 6. Emergency and Temporary Privileges 1998 VETERANS’ ADMINISTRATION mediate danger and in which any delay in administering treatment would add to that danger. (ft) The director of the hospital shall have the authority to grant temporary privileges to a physician who is a member of the local medical society and desires to attend an occasional patient in the hospital but who is not a member of the medical staff. Su *h temporary privileges shall he granted after conference with the chief of staff or the medical director to determine an authoritative opinion as to the competence and ethical standing of the physician who desires such tem- porary privileges, and in the exercise of such privileges he shall be under direct supervision of the chief of staff. Temporary privileges may not be granted to attend more than four patients in any one year, after which the physician to whom temporary privileges have been granted shall be required to become a member of the medical staff before being allowed to attend additional patients. Article IV. Divisions of the Medical Staff The medical staff shall be divided into honorary, consulting, active, associate, and courtesy groups. Section 1. The Medical Staff Section 2. The Honorary Medical Staff The honorary medical staff shall consist of physicians who are not active in the hospital and who are honored by emeritus positions. These may be physi- cians who have retired from active hospital service or physicians of outstanding reputation not necessarily resident in the community. The honorary medical staff shall be appointed by the governing board on recommendation of the active medical staff and shall have no assigned duties or responsibilities. Their privileges shall be determined by the credentials com- mittee as provided in Article VI of these bylaws. (a) The consulting medical staff shall consist of recognized specialists who are active in the hospital or who have signified willingness to accept such ap- pointment. These may be fellows of the American College of Surgeons or the American College of Physicians, diplomates of one of the national boards of medical specialties, members of the national society representing the speciality, or others whom the credentials committee may consider to be worthy of being appointed as members of the consulting medical staff. Membership on the con- sulting medical staff shall not render the member ineligible for membership on the active medical staff. (ft) Appointment shall be made by the governing board on recommendation of the active medical staff. Credentials shall not be required for such appoint- ments and the proposed member may be invited to accept appointment. (c) The duties of the members of the consulting medical staff shall be to give their services without charge in the care of free patients on request of any mem- ber of the active medical staff, and also in any case in which consultation is re- quired by the rules of the hosiptal. (d) Insofar as their specialty is concerned, members of the consulting medi- cal staff shall have unrestricted privileges, but in cases not falling within their specialty they shall have such privileges as may be determined by the credentials committee as provided in article VI of these bylaws. Section 3. The Consulting Medical Staff Section 4. The Active Medical Staff (a) The active medical staff shall consist of physicians who have been selected to attend free patients in the hospital and to whom all such patients shall be assigned. Members of the active medical staff shall not be 'required to be ex- clusive specialists, but it is to be expected that they will be well-skilled in the particular branch of medicine to which they are assigned, and that the major part of their private practice will fall within that specialty. (ft) Appointments shall be made annually by the governing board on recom- mendation of the active medical staff from the former members of the active medical staff, and insofar as it is possible, vacancies shall be filled by promo- VETERANS' ADMINISTRATION 1999 tion of members of the associate medical staff who have signified a desire to become more active in the work of the hospital. (c) The duties of the active medical staff shall be to attend all free patients and, insofar as free work is concerned, they shall attend only such patients as are admitted to their services. All business of the medical staff shall be trans- acted b ythe active medical staff and only members of the active medical staff shall be eligible to vote and hold office. (d) Insofar as free cases are concerned, members of the active medical staff shall treat patients in both the in- and out-patient departments as assigned to the service and in the treatment of these they shall have unrestricted privileges and shall treat the patient to a conclusion, whether such treatment is given in the in- or out-patient department or both. Insofar as private patients are concerned, they shall have unrestricted privileges in the treatment of patients falling within the specialty to which they are appointed, but in others they shall have only such privileges as may be determined by the credentials committee in conformity with article VI of these bylaws. Section 5. The Associate Medical Staff (cr) The associate medical staff shall consist of junior and less experienced members or of j)hysicians who have not been actively interested in the work of the hospital but have expressed a wish to become active as vanacies occur. (It) They shall be appointed and assigned to services in the same manner as provided for the active medical staff and each shall be associated as junior with a member of the active medical staff. (c) The duties of the members of the associate medical staff shall be to attend free patients in accordance with assignment by the senior with whom they are associated. They may be required also to act on all committees except the executive committee and the credentials committee. (d) Insofar as free cases are concerned, the members of the associate medical staff shall be limited to the treatment of cases falling within the service to which they are appointed and in accordance with assignment by the mem- ber of the active medical staff with whom they are associated. Insofar as private patients tire concerned, they shall have such privileges as provided by the credentials committee in article VI of these bylaws. Section 6. The Courtesy Medical Staff The courtesy medical staff shall consist of those members of the medical pro- fession, eligible as herein provided for medical staff membership, who wish to attend private patients in the hospital, but who do not wish to become members of the active medical staff or who, by reason of residence, are not eligible for such appointment. They shall be appointed in the same manner as other mem- bers of the medical staff and they shall have such privileges as may be deter- mined by the credentials committee in conformity with article VI of these by- laws, but they shall not be eligible to vote or hold office. Article V. Clinical Departments Section I. Services Divisions or services of the medical staff shall be as follows: Medicine to in- clude cardiology, communicable diseases, dermatology and syphilology, diseases of the lungs, diseases of metabolism, endocrinology, gastrointestinal diseases, neuropsychiatry, pediatrics: surgery to include maligant tumor surgery, neuro- logical surgery, obstetrics and gynecology, ophthalmology, otorhinolaryngology, oral surgery, orthopedics, plastic surgery, proctology, thracic surgery, traumatic surgery, urology ; and other services related to the specialties of radiology ; pathol- ogy ; anesthesia. Section 2. Specialization While the members of the active and associate services shall not be required to be exclusive specialists, it is to be expected that they will be well-skilled in the specialty to which they are assigned and that not less than 50 percent of their private work in the hospital shall be in that specialty. The chief of each service shall be a recognized specialist. 2000 VETERANS’ ADMINISTRATION Section 3. Assignment to Services Assignment to the service shall be made at the first meeting of the active medical staff after its members have been appointed by the governing hoard and members so assigned shall remain on service for one year or until a suc- cessor has been appointed. Appointments shall be made after a careful analysis of the efficiency of the candidate as shown by a record of his work in the hospital. Section 4. Organization of Services (а) At the annual meeting there shall be elected a chief of the medical staff who shall be a member of the active medical staff. He shall be responsible for the functioning of the clinical organization of the hospital and shall keep or cause to be kept a careful supervision over the clinical work in all divisions and services. He may, if desired, also be elected as president of the medical staff. (б) Each service shall be organized as a division of the medical staff and shall have as its head a chief of service, who shall be responsible to the chief of the medical staff for the functioning of his service and shall have general supervision over the clinical work falling within his service whether it be free or private. (c) Immediately after appointment, the members of the active medical staff in each service shall meet and each shall designate the member or members of the associate medical staff whom they wish to have as their assistants. (d) The members of each service division shall meet during the first two weeks after they are appointed for the purposes of electing a chief of service and a secretary, and of perfecting such organization and arranging such a schedule of duties for their terra of office as may seem advisable to promote the best interests of the patients. (e) In the medical and surgical services there shall be elected also an assist- ant chief for each service who shall perform such duties as may be assigned by the chief of service. The members of the services shall be responsible to the chiefs of services and through them to the chief of the medical staff. (f) Each service may meet separately, but such meetings shall not release the members from their obligation to attend the general meetings of the medical staff. (g) Insofar as free cases are concerned, members of the active medical staff shall treat patients in both the in- and out-patient departments as assigned to the service and in the treatment of these, they shall have unrestricted privi- leges and shall treat the patient to a conclusion, whether such treatment is given in the in- or out-patient department or both. Insofar as private patients are concerned they shall have unrestricted privileges in the treatment of patients falling within the specialty to which they are appointed, but in others they shall have only such privileges as may be provided by the credentials committee in article VI. Article VI. Determination of Qualifications and Privileges Section 1. Classification of Privileges Privileges extended to physicians who have been appointed to the medical staff shall be divided into major, intermediate, and minor, and shall be deter- mined by the credentials committee. The following shall serve as a guide in differentiating the three types of privileges: (a) Major privileges in any service will allow the physician to treat patients when, for any cause, such treatment involves a serious hazard to the life of the patient. (ft) Intermediate privileges in any service will allow the physician to treat patients when, for any cause, such treatment does not involve a serious hazard to the life of the patient but does involve a danger of disability. (c) Minor privileges in any service will allow the physician to treat patients when, for any cause, the treatment does not involve either a serious hazard to the life of the patient or a danger of disability. Section 2. Newly Appointed Medical Staff Members All members of the staff when newly appointed shall be granted only minor privileges until such time as the credentials committee may determine what VETERANS’ ADMINISTRATION 2001 further privileges may be granted with safety to the patient, such extension of privileges being based, as far as possible, on records of performance as pro- vided in sections 3 and 4 of this article. Section 3. Professional Service Accounting A system of professional service accounting shall be maintained under which records of performance of each member of the staff shall be available. (a) On or immediately after admission of the patient the attending physician shall classify the treatment proposed, in conformity with the pathology found, under one of the following prognostic categories: Elective 1. Good 2. Fair 3. Bad Emergency 4. Good 5. Fair G. Bad Palliative 7. Good 8. Fair 9. Bad Should the attending physician consider the risk to he fair or bad in any of the categories or should he subsequently desire to change his prognosis, he shall he required to state his reasons. At the time of discharge, the immediate result shall he stated as recovered or died. (&) The professional service accounting shall be administered by a profes- sional service accountant, appointed by the administration with the advice of the medical staff, whose duty it shall be to check the prognosis and statement of results to determine whether they are correctly stated; to determine whether the result is such as may be reasonably expected from the prognosis and, if not, whether the result is justified or inevitable; and to determine any errors that may be apparent as evidenced by the medical record. (c) In cases in which the professional service accountant does not feel com- petent to pass judgment or in which there may be reason for discussion tin1 record shall be referred to the credentials committee who may exercise judgment or refer the case to the active medical staff for discussion and decision. (d) The decision of the professional service accountant, of the credentials committee, or of the active medical staff, as the case may be, together with any comment that should be recorded, shall be attached as a memorandum to the medical record. This memorandum shall not be preserved as a part of the medical record. (e) The medical records librarian shall keep a record of the performance of each physician, and she shall enter the decisions and remarks as above provided except that no record of errors shall be kept after the medical staff has tak n appropriate action. This record shall be kept confidential and shall b' acces- sible only to the credentials committee when determining the recommendations which it will make for promotion and appointment to the various serv'ces < x- cept that any member of the staff desiring information as to his own perf< nu- ance may have access to his own section of the record at any time. After all entries for the year have been made, the various columns shall be totaled. Section 4. Direct Observation Every member of the consulting or active medical staff, at the conclusion of any case in which he has been associated with a member of the associate or courtesy medical staff, shall transmit to the medical records librarian a memo- randum stating whether, from his observation of competence insofar as the particular case is concerned, the member of the associate or courtesy medical staff may be granted further privileges as specified in section 1 of this article. Such expression of opinion shall be kept as absolutely confidential by the medi- cal records librarian and shall be accessible only to the credentials committee when making recommendations for promotion, appointment to service, or grant- ing of increased privileges. Section 5. Recommendations for Promotion or Appointment to Services When making recommendations for promotion, appointment to services, or the granting of privileges, the credentials committee shall base its judgment on the consensus as determined under section 4 of this article, together with the opinion of the chief of service concerned, on the record of performance as provided in section 3 of this article, and on the further qualifications of the member of the staff as shown in his filed credentials. 75183—45—pt. 5 11 2002 VETERANS’ ADMINISTRATION Article VII. Officers and Committees Section 1. Officers The officers of the medical staff shall be the president, the vice president, and the secretary. These shall be elected at the annual meeting of the medical staff, and shall hold office until the next annual meeting or until a successor is elected. The president shall call and preside at all meetings and he shall be a member ex officio of all committees. He may, if it is so desired, also be elected as chief of the medical staff. The vice president in the absence of the president shall assume all his duties and have all his authority. He shall also be expected to perform such duties of supervision as may be assigned to him by the president. The secretary shall keep accurate and complete minutes of all meetings, call meetings on order of the president, attend to all correspondence, and perform such other duties as ordinarily pertain to his office. If there are funds to be accounted for, he shall also act as treasurer. Committees shall be standing and special. All committees other than the executive shall be appointed by tbe president. The executive committee shall consist of the president and secretary of the medical staff and of three other members of the active medical staff to be elected at the time of the annual meeting. The duties of the executive com- mittee shall be to consider carefully and act on all matters which are not of a clinical nature, and it is to be expected that all such business of the medical staff shall be transacted by the executive committee in order that the time of the regular meetings of the medical staff may be devoted to matters pertaining to the professional care of patients. The executive committee shall present, at each meeting of the medical staff, a report of any action that it may have taken since the last meeting. The executive committee shall act as a liaison group between the medical staff and the administration of the hospital. The medical records committee shall consist of three members of the medical staff and shall meet weekly for the purpose of reviewing the medical records of all patients discharged during the week. The committee shall report to the medical staff the names of any members who are persistently delinquent in the completion of their recoi’ds. This committee shall be held responsible for notifying the program committee of any cases that should be presented before the medical staff. The program committee shall consist of three members of the medical staff and shall be responsible for the preparation and presentation of the programs of all meetings. The credentials committee shall consist of seven members of the consulting or active staff, so selected as to insure representation of the major specialties. Its duties shall be to investigate the credentials of all applicants for member- ship and to make recommendations in conformity with article III, section 5c, of these bylaws, to investigate any breach of ethics that may be reported; to review any records that may be referred by the medical director and to arrive at a decision regarding the performance of the staff member, or to refer the case to the full active medical staff if this is considered desirable; to review all information available regarding the competence of staff members and as a re- sult of such reviews to make recommendations for the granting of privileges and the appointment of members to the various services and departments as provided in article VI of these bylaws. The intern committee shall consist of three members of the medical staff. Its duties shall be to act as an advisory committee in the selection of interns, to outline courses of instruction for the resident medical staff and to see that they are carried out. and to assist the administration in matters of government and discipline of the resident medical staff. Special committees shall be appointed from time to time as may be required to carry out properly the duties of the medical staff. Such committees shall confine their work to the purposes for which they were appointed and shall Section 2. Committees VETERANS’ ADMINISTRATION 2003 report to the full medical staff. They shall not have power of action unless such is specifically granted by the motion which created the committee. Article VIII. Meetings The annual meeting of the medical staff shall be the last meeting before the end of the fiscal year of the hospital. At this meeting the retiring officers and committees shall make such reports as may he desirable, officers for the ensuing year shall be elected, and recommendations for appointment to the active medi- cal staff shall be made. Section 1. The Annual Meeting Section 2. Regular Meetings Regular meetings of the medical staff shall be held at least monthly at a time and place to be provided in the rules and regulations for the government of the medical staff. Section 3. Special Meetings Special meetings of the medical staff may be called at any time by the presi- dent and shall he called at the request of the governing board, the executive committee, or any five members of the active medical staff. At any special meeting no business shall be transacted except that stated in the notice calling the meeting. Sufficient notice of any meeting shall be posted on the bulletin board in the staff room at least 48 hours before the time set for the meeting. Section 4. Attendance at Meetings (a) All members of the active medical staff shall be required to attend all meetings. Absence from three consecutive meetings or from one-third of the regular meetings for the year, without acceptable excuse, shall be considered as resignation from the active medical staff, and shall automatically place the absentee on the associate or courtesy medical staff of the hospital. (ft) All members of the associate medical staff shall be expected to attend meetings with the same regularity as members of the active medical staff. Absence from three consecutive meetings or from one-third of the meetings for the year, without acceptable excuse, shall be considered as resignation from the associate medical staff and shall automatically place the absentee on the courtesy medical staff. (c) Reinstatement of members of the active and associate medical staffs to positions rendered vacant because of absence from meetings may be made on application, the procedure being the same as in the case of original appointment. (rf) Members of the honorary, consulting, and courtesy divisions of the medi- cal staff shall not be required to attend meetings, but it is expected that they will attend and participate in these meetings unless they are unavoidably pre- vented from doing so. (e) A member of any division of the staff who has attended a case that is to be presented for discussion at any meeting shall be notified and shall be required to be present. Failure to attend on receipt of such notice shall involve the penalty, in the case of a member of the consulting or active medical staff, of reverting to the associate medical staff and, in the case of a member of the courtesy medical staff, of forfeiting his medical staff membership. {f ) Should a member of the staff be absent from any meeting at which a case that he has attended is to be discussed, it shall nevertheless be discussed unless the member is unavoidably absent and has requested that discussion be post- poned. In no case shall postponement be granted for a period longer than that which will elapse until the next regular staff meeting. Section 5. Quorum Fifty percent of the total membership of the active medical staff shall constitute a quorum. 2004 VETERANS’ ADMINISTRATION Section 6. Agenda The agenda at any regular meeting shall be: A. Business: 1. Call to order. 2. Reading of the minutes of the last regular and of all special meetings. 3. Unfinished business. 4. Communications. 5. Reports of standing and of special business committees. 6. New business. B. Medical; 7. Review of patients in the hospital with special reference to diag- nosis, treatment, and delayed recovery; selected cases discharged since the last conference with special consideration of selected deaths, unimproved cases, infections, complications, errors in di- agnosis, and results of treatment; and analysis of Clinical reports from the various departments. 8. Reports of standing and special medical committees. 9. Discussion and recommendations for improvement of the profes- sional work of the hospital. 10. Adjournment. The agenda at special meetings shall be: 1. Reading of the notice calling the meeting. 2. Discussion of the business for which the meeting was called. 3. Adjournment. The medical staff shall adopt such rules and regulations as may be necessary for the proper conduct of its work. Such rules and regulations shall be a part of these bylaws, except that they may be amended at any regular meeting with- out previous notice by a two-thirds vote of the total membership of the active medical staff. Such amendments shall become effective when approved by the governing board. Article IX. Rules and Regulations Article X. Amendments These bylaws may be amended after notice given at any regular meeting of the medical staff. Such notice shall be referred to a special committee which shall report at the next regular meeting and shall require a two-thirds ma- jority of those present for adoption. Amendments so made shall be effective ■when approved by the governing board. These by-laws together with the appended rules and regulations shall be adopted at any regular meeting of the active medical staff, shall replace any previous bylaws, rules, and regulations, and shall become effective when ap- proved by the governing board of the hospital. They shall, when adopted and approved, be equally binding on the governing board and the medical staff. Adopted by the active medical staff of Hospital. Article XL Adoption President of medical staff Secretary of medical staff Date Approved by the governing board of Hospital. Date Secretary of the governing board Rules and Regulations 1. The monthly meeting of the medical staff shall be held 2. Except in emergency, no patient shall be admitted to the hospital until after a provisional diagnosis has been stated and the consent of the director secured. In case of emergency the provisional diagnosis shall be stated as soon after admission as possible. VETERANS’ ADMINISTRATION 2005 3. Physicians admitting private patients shall be held responsible for giving such information as may be necessary to assure the protection of other patients from those who are a source of danger from any cause whatever. 4. All free patients shall be attended by members of the active medical staff, and shall be assigned to the service concerned in the treatment of the disease which necessitated admission. The members of the active medical staff must assign a reasonable number of cases to the juniors who are associated with them and the member of the associate medical staff to whom the case is assigned shall carry on the treatment under supervision of the senior. No physician shall re- ceive compensation for attendance in the case of any patient who is admitted free by the hospital, but in the case of patients from whom the hospital is receiving partial compensation the attending physician may charge a fee proportionate to that received by the hospital. Pay patients shall be attended by their own private physicians. In the case of a pay patient applying for admission who has no attending physician, he shall be assiged to the members of the active medical staff on duty in the service to which the illness of the patient indicates assignment. 5. Laboratories shall be provided in the hospital so that all types of labora- tory examinations may be done. 6. Standing orders shall be formulated by conference between the medical staff and the director. They may be changed only by the director after con- ference with the medical staff. These orders shall be followed insofar as proper treatment of the patient will allow, and when specific orders are not written by the attending physician they shall constitute the orders for treat- ment. Standing orders shall not, however, replace or cancel those written for the specific patient. 7. All orders for treatment shall be in writing. Verbal orders shall not be accepted or carried out. An order shall be considered to be in writing if dictated to a senior nurse or other authorized person and signed by the attending physician. Orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his or her own name. At his next visit the attending physician shall sign such orders, and neglect to do so shall be con- sidered as acknowledgment of their correctness. 8. As far as possible the use of proprietary remedies shall be avoided. When such are ordered for private patients by the attending physician, they will be secured and a special charge made to the patient. 9. The attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include identifi- cation data; complaint; personal history; family history; history of present illness; physical examination; special reports such as consultations, clinical labo- ratory, X-ray, and others; provisional diagnosis; medical or surgical treatment; pathological findings; progress notes; final diagnosis; condition on discharge; follow-up; and autopsy report when available. No medical record shall be filed until it is complete, except on order of the medical records committee. 10. A complete history and physical examination shall in all cases be written within 24 hours after admission of the patient. 11. When such history and physical examination are not recorded before the time stated for operation, the operation shall be canceled, unless the attending surgeon states in writing that such delay would be detrimental to the patient. 12. All records are the property of the hospital and shall not be taken away without permission. In case of readmission of a patient all previous records shall be available for the use of the attending physician. This shall apply whether the patient be free or pay, and whether he be attended by the same physician or by another. IB. Except in cases of emergency, patients for operation shall be admitted not later than 4 o’clock the day previous to operation. 14. All operations performed shall be fully described by the attending surgeon. All tissues removed at operation shall be sent to the hospital pathologist who shall make such examination as he may consider necessary to arrive at a pathological diagnosis. 15. In all cases where a patient is admitted in a condition of abortion, she or her representative shall sign a statement certifying that neither any employee of the hospital nor the attending physician was directly or indirectly responsible for its production. 16. Except in emergency, consultation with a member of the consulting or of the active medical staff shall be required in all major cases in which the 2006 VETERANS’ ADMINISTRATION patient is not a good risk and in all curettages or other operations which may interrupt a known, suspected, or possible pregnancy. The consultant shall make and sign a record of his findings and recommendations in every such case. In all cases where a rule of the hospital requires consultation and in the case of free patients, the consultant shall give his services without charge. 17. Each member of the courtesy medical staff, not resident in the city, or im- mediate vicinity, shall name a member of the medical staff who is resident in the city, who may be called to attend his patients in emergency. In case of failure to name such associate, the director of the hospital shall have authority to call any member of the staff should he consider it necessary. 18. Patients shall be discharged only on written order of the attending phy- sician. At the time of discharge the attending physician shall see that the record is complete, state his final diagnosis, and sign the record. 19. At the monthly meeting of the medical staff the medical records librarian shall submit a report of the professional work of the hospital for the previous month. This shall show patients discharged and the results, deaths (the cause being stated as given by the attending physician), autopsies, consultations, and infections of all kinds. The discussion at the meeting shall be based on this report and at no meeting shall abstract discussion of scientific medical subjects be permitted. After each meeting the secretary of the medical staff shall transmit to the director of the hospital such reports and recommendations as the medical staff may wish to make to him or through him to the governing board. 20. Every member of the medical staff shall be actively interested in securing autopsies whenever possible. No autopsy shall be performed without written consent of a responsible relative or friend. All autopsies shall be performed by the hospital pathologist or by a physician to whom he may delegate the duty. 21. The hospital shall admit patients suffering from all types of disease except the following: (Specify diseases not treated). Patients may be treated only by physicians who have submitted proper credentials and have been duly appointed to membership on the medical staff. 22. Surgeons must be in the operating room and ready to commence operation at the time scheduled, and in no case will the operating room be held longer than 15 minutes after the time scheduled. Adopted at a regular meeting of the active medical staff President of medical staff Secretary of medical staff Date Approved by the governing board: Secretary of the governing board Date TYPE IV HOSPITAL (A HOSPITAL OF ANY SIZE, BUT USUALLY OF LESS THAN 50 BEDS) The hospital is privately owned, either by a partnership which may be lay or medical, or by an industrial corporation. It is organized for profit and admits only pay patients. The hospital may be of any size but is usually less than 50 beds. The medical staff is comprised of those physicians who own the hospital, or if it is owned by a lay corporation, the physicians are employed or controlled by the corporation. Each hospital must use its initiative in formulating bylaws, rules, and regula- tions which are applicable to its own needs. Those portions of the following sample bylaws, rules, and regulations in the suggested form which do not pertain to a given hospital or which cannot become operable within the institution should be modified. There are, however, a number of major principles which are funda- mental and which should be embodied in all medical staff bylaws, rules, and regulations in order to comply with the minimum requirements of hospital standardization. These are outlined under “clause III of the Minimum Standard for Hospitals” (pp. 21 and 22). It is desirable to control the work of the medical staff, limiting each member to that which his training and experience have made him capable of carrying on successfully. Provision for adequate control may lie made by selecting those parts of the bylaws for a hospital of type II which are applicable, and adapting them to the needs and possibilities of this particular type of hospital. Since the governing board is responsible for the conduct of the hospital, the bylaws, rules, and regulations should be officially adopted and attested by the sig- VETERANS’ ADMINISTRATION 2007 natures of its chairman and secretary in order to make the document effective. Finally, the signatures of all members of the medical staff should be affixed as evidence of good faith and agreement to abide thereby. In order to prevent the bylaws from becoming antiquated and disregarded, they should be revised every 3 to 5 years by a committee of the medical staff and the director of the hospital, approved by the governing board, and a copy placed in the minute book of the medical staff proceedings for ready reference. Bylaws, Preamble Recognizing that the best interests of the patient are protected by concerted effort, the physicians practicing in Hospital hereby organize themselves in conformity with the bylaws, rules, and regulations hereinafter stated. For the purpose of these bylaws the words “medical staff” shall be inter- preted to include all physicians who are privileged to attend patients in Hospital. Article I. Name The name of this organization shall be the “Medical Staff of the Hospital.” Article II. Membership Section 1. Qualification Membership shall be limited to: (State name of partnership or otherwise define limitations of medical staff), all of whom are ethical physicians, graduates of approved medical schools, eligible for membership in the local medical society, and licensed to practice in the State (or Province) of Section 2. Assistant and Resident Physicians Assistant and resident physicians may be employed as the demands of practice may warrant. These shall be paid definite salaries and shall work under the direction of one or moi’e of the group as may be determined. These assistant and resident physicians shall not be considered as members of the medical staff, and may or may not be licensed practitioners in the State (or Province) of but shall conform to the same code of ethics as is required for members of the medical staff. Section 3. Ethics and Ethical Relationships The code of ethics as adopted by the American Medical Association and the Principles of Financial Relations in the Professional Care of the Patient of the American College of Surgeons shall govern the conduct of the staff and its individual members. (If a partnership, insert these paragraphs :) Inasmuch as the group is organized as a legal partnership, it is recognized that all fees for professional services shall accrue to the partnership. Each member shall draw his compensation in accordance with the terms of the partner- ship and each employed assistant or resident physician in accordance with the terras of his employment. Receipt of compensation in such a manner is recognized as an ethical business arrangement. The members of the group as individuals and as a whole and on behalf of all assistant and resident physicians shall pledge themselves that in no case in which a patient is referred by an outside physician will they receive from or pay to the referring physician, directly or indirectly, any part of the fee for service to the patient. On the contrary it is agreed that all fees from patients shall be collected from the patient by the referring physician and the group, each separately in accordance with the value of services rendered, and that such fees will be retained as collected. Article III. Staff Divisions and Services There shall be no divisions of the medical staff, but all shall be of the same standing and of equal authority in the professional conduct of the hospital. The following services shall be maintained: Medicine, under a qualified Internist. Surgery, under a qualified surgeon. (Define other service according to the qualifications of the physicians in the group.) 2008 VETERANS’ ADMINISTRATION Article IV. Officers and Committees . Section 1. Officers Officers of the medical staff shall consist of a chief of staff and a secretary. Both shall be elected at the annual meeting and shall hold office until the end of the fiscal year following the election or until a successor has been elected. The chief of the medical staff shall also act as president of the medical staff, and in his absence shall name a substitute who shall perform his duties. He shall call and preside at all meetings, and shall have general supervision over all work in the hospital. The secretary shall keep complete minutes of all meetings, and shall conduct the correspondence of the staff. He shall also be responsible for seeing that cases are selected for presentation at the meetings of the medical staff. Section 2. Committees There shall be no standing committees, but the medical staff as a whole shall act in the place of the usual standing committees. Special committees shall be appointed by the chief of the medical staff from time to time as occasion may arise. Article V. Meetings Section 1. The Annual Meeting The annual meeting shall take place during the second week preceding the end of the fiscal year of the hospital and at this meeting the officers for the following year shall be elected. Section 2. Regular Meetings Regular meetings shall be held weekly. (Designate a day and hour.) At the second meeting of the month the medical records librarian shall present an analy- sis of the work of the hospital for the previous month, and the meeting shall be devoted to a study of this analysis and a general review of the medical records. All other meetings shall be clinical in character and it is expected that insofar as the occurrence of cases of interest will allow, the members of the medical staff will rotate regularly in presenting cases for discussion. Members of the medical staff shall be expected to be present at all meetings. Fifty percent of the membership shall constitute a quorum. Section 3. Agenda Agenda shall be as follows : A. Business: 1. Call to order. 2. Reading of the minutes of the last regular and of all special meetings. 3. Unfinished business. 4. Communications. 5. Reports of standing and of special business committees. 6. New business. B. Medical: 7. Review of patients in the hospital with special reference to diag- noses, treatment, and delayed recovery ; selected cases discharged since the last conference with special consideration of selected deaths, unimproved cases, infections, complications, errors in diagnoses, and results of treatment; and analysis of clinical reports from the various departments. 8. Reports of committees. 9. Discussion and recommendations for improvement of the profes- sional work of the hospital. 10. Adjournment. Article VI. Rules and Regulations The staff shall adopt such rules and regulations as may be necessary for the proper conduct of the work of the hospital. Such rules and regulations shall VETERANS' ADMINISTRATION 2009 be a part of these bylaws except that they may be amended at any regular meet- ing without previous notice by a two-thirds vote of the members of the medical staff. Article VII. Amendments These bylaws may be amended upon notice by any member of the medical staff at any regular meeting. Such notice shall be laid on the table for 1 month, after which time it may be adopted by a two-thirds majority of those members present at any regular meeting. Amendments shall be effective when adopted by the medical staff. 1. The hospital shall receive and treat patients suffering from the following types of disease: (State diseases in accordance with the qualifications of the constituent members of the group). 2. Patients shall In? attended by members of the medical staff in accordance with the selection of the patient, hut in every case it shall he the endeavor to have the patient placed in the service of the member who is best qualified to render service, and in all instances members of the medical staff shall col- laborate as required in the best interests of the patient. 3. Laboratories shall be maintained in the hospital under a competent di- rector to conduct the following laboratory examinations: (Name them). Ar- rangements shall be made to have any other laboratory examinations required by the attending physician done in an approved, ethical laboratory. 4. Routine orders shall be formulated insofar as possible and shall be in- corporated in writing in “Standing Orders.” Such routine orders may be changed only on order of the director of the hospital after approval at a regular meeting of the medical staff. 5. All orders for treatment shall be in writing. Verbal orders shall not be accepted or carried out. An order shall be considered to be in writing if dictated to a senior nurse of other authorized person and signed by the at- tending physician. Orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his or her own name. At his next visit the physician shall sign such orders. 6. The attending physician shall be held responsible for seeing that a com- plete medical record is written for each patient. This record shall include identification data; complaint; personal history; family history; history of the present illness; physical examination; special reports such as consultations, clinical laboratory reports, X-ray reports, and others; provisional diagnosis; medical or surgical treatment; pathological findings; progress notes; final diag- nosis; condition on discharge; follow-up; and autopsy report when available. No medical record shall be filed until it is complete. 7. A complete history and physical examination shall be written not later than 24 hours after admission and, except in emergency, shall be required before the patient goes to operation. When such history and physical examinations are not recorded before the time stated for operation, the operation shall he canceled unless the attending surgeon states in writing that such delay would be detrimental to the patient. 8. All records are the property of the hospital and shall not be taken away without permission. Should the patient be readmitted, all previous records shall be available for the use of the physician attending on the readmission. 9. Patients for operation shall be admitted not later than 4 o’clock of the day previous to operation. Exception may be made when the patient has been examined in the offices of the physician or group using the facilities of the hospital and a complete report of such examination is sent to the hospital at the time of admission, but in no case shall a patient be admitted less than 2 hours before the time set for operation. 10. All operations performed shall be fully described by the attending surgeon, and all tissues removed at operation shall be sent to the hospital pathologist who shall make such examination as he may consider necessary to arrive at a pathological diagnosis. 11. When a patient is admitted in a condition of abortion, she or her rep- resentative shall sign a statement certifying that neither any employee of the hospital nor the attending physician was directly or indirectly responsible for its production. 12. Except in emergency, consultation with a second member of the medical staff shall be required in all major cases in which the patient is not a good Rules and Regulation 2010 VETERANS’ ADMINISTRATION risk, and in all curettages or other operations which may interrupt a known, suspected, or possible pregnancy. The consultant shall make and sign a record of his findings and recommendations in every such case. Adopted at a regular meeting of the medical staff held 19 __ Chief of medical staff Secretary of medical staff Addendum II—Use of Professional Service Accounting to Control Effciency 1 The governing body of the hosiptal is responsible for its operation in every department, but because it is manifest that the members cannot personally attend to all of the details, an administrator is appointed who is the direct representative of the governing body. Directly or through the administrator the governing body provides a physical plant with its equipment, and selects and organizes the necessary personnel. Usually the administrator needs no assistance in this phase of his work. Collateral to the internal organization is the organized medical staff for whose efficiency the governing body is also responsible. In its selection and organization medical judgment is required, and since neither the governing body nor the admin- istrator is qualified to exercise such judgment completely, they must have advice which carries the weight of medical authority. The best means by which this consultation with medical authority can be secured is through the joint advisory committee which, insofar as it is required to advise on the competence of the medical staff, bases its opinions on information secured by the medical records committee, the professional service acountant, or the qualifications committee, sometimes called the auditing committee. In the original selection of the medical staff the governing body is handicapped by lack of information about the applicant. All that is available is found in the credentials submitted and in the knowledge that the applicant has been accepted as a reputable physician by the local medical society. Data concerning his actual skill are only inferential. This handicap can be overcome if proper records of the work of each member of the medical staffs are systematically kept. A constantly increasing amount of specific information accumulates which subsequently enables the governing body to grant privileges and make promotions, and appointments to the various divisions and services depend almost entirely on records of efficiency.. Such a system involves systematized accounting of the professional work of the hospital, and, to be successful, it requires certain basic data and an organization qualified to make proper use of the data. 1. The medical record of the patient is the record of original entry which contains the basic data necessary for professional service accounting. It must, therefore, contain a true and accurate story of the illness as it has affected the patient. It must show the means used to establish a diagnosis, the treatment administered, the progress of the case, and the result insofar as this can be ascer- tained. If end results cannot be secured, those that are apparent at the time of discharge must be used. It is the duty of the medical records committee to see that the attending physician places such a record on file. 2. At the time of admission or as soon thereafter as possible, the attending physician is required to state in the record his estimate of the risk in one of nine prognostic categories (Form I). If the risk is not good in any category, the attending physician should be required to state his reason for considering it fair or bad. FORM I. ESTIMATE OF THE RISK Elective Emergency Palliative 1. Good 4. Good 7. Good 2. Fair 5. Fair 8. Fair 3. Bad 6. Bad 9. Bad Statement of result Recovered Died 3. At the time of discharge it is stated that the patient recovered or died (Form I). If end results can be secured, they may be given consideration at a later date and may modify the original estimate of efficiency. 1 Submitted through the courtesy of Thomas R. Ponton, M. D., Chicago. VETERANS’ ADMINISTRATION 2011 4. As soon as the medical records committee has certified that the record is as complete as can be obtained, it is reviewed by the professional accountant IForm II). This accountant may be an outside authority, the administrator if he be a physician, or a member of the medical staff recommended by the staff and appointed by the governing body. It is his duty to determine : (a) If the prognosis and result are correctly stated. (ft) If the result is such as can be reasonably expected from the prognosis. Review of Medical Record Doctor Hosp. No Stateraent_of Prognosis and Result confirmed □ Yes □ No Case is □ Major □ Intermediate □ Minor Result □ Expected □ Inevitable □ Justifiable Approved for indexing □ Yes □ No Refer to physician for more information □ Yes □ No Refer to Auditing Committee □ Call to attention of Program Committee Q Date Professional service accountant FORM II. REVIEW OF THE RECORD Error in □ Diagnosis □ Judgment □ Treatment □ Technique Comment Date For Auditing Committee (c) If the result is justifiable or inevitable. (d) If any errors have been committed in the management of the case. 5. Records approved by the professional accountant are transmitted to the medical records librarian for indexing (Form III) ; those that show anything of a debatable nature are referred to the qualifications committee; any that have an educational value are referred to the program committee. Service Code PHYSICIANS’INDEX A Medicine F Dermatology K Urology B Surgery G Communicable L Orthopedics Doctor Nema C Gynecology H Pediatrics M Neoplasms D Obstetrics I Miscellaneous N Traumatic Division Actlva Service—S.uxofii7 c cyc>C.ur.rt>JS>c u.m i-imm . c Resul,S \ 1 23456789£ T- Hospital o . I " ® « 3 Number tj „ ■§. o o H SfS'S RDRDRDRDRORORDRDRD | o = 2 1 2 W S_ S. t. 83 8 L L 346 I _B L L 370 N L L 546 _i N 1 L L 469 _i B L L 288 _L B L I I 78 _1 B L . L 5 I 9 i B L 1 485 | B [ _ _ - 1 772 L C L L 921 I M I L Totols 87 96 89 e24I 4 _6 J[_9 3 7 _8 6_I04 12 258 2 10 Notes Goltre.no B M recorded Frocture femur.oqe 76 Troumatic shock [Secondary hemorrhage General peritonitis.cause unknown Ac.oppendlcitis.in hosp24 hours ! before operotion.no blood count [Ruptured peptic ulcer,operotton I refused ot former admission Cholecystitis .posterior coronary Carcinoma pylorus .obstruction (Others not shown) 2012 VETERANS’ ADMINISTRATION 6. The qualifications committee is composed of representatives of the various specialities found in the hospital. It should be nominated by the medical staff and appointed by the governing body. It is the duty of the qualifications com- mittee to review the information contained in all medical records referred by the professional accountant and to pass judgment as outlined above. For each record so referred the qualifications committee should make a note expressing its opinion (Form II). This opinion is based solely on the data con- tained in the medical record, but the attending physician may have further in- formation which would modify the judgment of the committee; hence this should be subject to review at the request of the attending physician. Any case which has an educational value or on which the qualifications com- mittee does not wish to pass final judgment should be referred to the full staff. When errors are found, the medical staff and the governing body should take any action that may be indicated, in order that repetition may be prevented. It is inadvisable, however, to make any permanent record concerning such errors. After appropriate action has been taken, any memoranda regarding the error should be destroyed. 7. After the medical record has been reviewed by the professional accountant, the qualifications committee, or the full staff, it is the duty of the medical records librarian to make the proper entries in the physicians’ index (Form III) which shows a record of the work of each member of the medical staff. Any comment that has been made by the qualifications committee or the full staff should be transferred to the physicians’ index after which the memorandum may be de- stroyed. 8. The physicians’ index (Form III) is kept as a confidential record and should be made available by the medical records librarian only as follows : (a) Any physician may have access to his own record at any time but not to that of any other physician. (ft) The qualifications committee should have access to (he entire index when making recommendations for granting privileges, for promotion, or for appoint- ment to divisions or services. 9. At the end of the year, when all entries have been completed, the medical records librarian, with the assistance of the professional accountant, should total the pages showing the work of the individual members of the medical staff. She also makes a service analysis (Form V) which shows the number of major and minor cases which each member of the medical staff has treated in the various specialties, thereby indicating the service to which each should be assigned. Both of these records are then used by the qualifications committee as the basis for its recommendations for granting privileges, for promotion, or for appointment to the various divisions or services. 10. The committee should recommend a greater number than are required to fill positions available. 11. Up to this point the work of accounting should be in code (Form IV) each physician being assigned a code number, the key to which is kept by the medical records librarian. When the specific recommendations have been decided on, the code is translated and the names of the various physicians substituted for the code number. FORM IV. RECOMMENDATIONS FOR STAFF APPOINTMENT Active: Surgical service—1, 6, 18, 31. 37, 39, 44, 51, 66. Medical service—5, 8, 20, 34, 38, 41, 45, 68. (Similar for other services.) Associate: Surgical service—4, 9, 12. 19, 24, 29, 33, 46. Medical service—10, 16. 17, 23, 27, 30, 36, 43. (Similar for other services.) Courtesy staff—2, 13, 15, 40, 52, 56, 59, 60, 63, 64, 67. Should he required to become member of courtesy staff or denied hospital privi- leges—3, 47, 48, 50. 12, The recommendations of the qualifications committee are transmitted to the joint advisory committee or to the full staff, as may be decided, and from VETERANS' ADMINISTRATION 2013 SERVICE ANALYSIS Doctor Medicine Surgery Gyn. Obs. E.E.N.T. Derm. Comm. Red. Urology Ortho Tumor Troumo Misc. o 2 q ? o o 5 o 2 2 i J c 2 o o 2 c 2 2 o 2 o c 2 5* 2 c 2 o o* 2 o c 2 o 2 o 2 2 j Minor o 2 2 o 2 • o 2 1 6 3 15 1 2 9 1 2 8 1 1 i 1 1 4 1 8 2 3 5 1 3 8 1 3 8 1 2 1 2 1 4 7 12 20 3 i 12 5 i 16 1 II 1 2 5 1 8 21 5 5 I i 1 2 15 , 15 1 1 z 2 22 8 7 8 2 42 3 4 37 2 1 2 1 33 2 2 1 I 2 27 2 5 26 2 50 4 5 15 3 1 18 3 5 1 18 2 2 4 7 63 3 9 1 4 4 1 5 2 2 1 5 i 2 64 1 10 1 . 15 1 6 13 i i Z 66 4 10 40 4 3 , 27 2 i 38 i i 1 27 4 1 5 73 6 7 32 1 1 5 14 4 7 3 1 2 i 4 75 2 4 1 1 5 3 20 2 8 20 1 1 1 i 79 9 1 1 20 4 3 5 36 1 i 18 i 1 1 2 33 i 4 2 2 9 109 13 13 36 7 2 1 1 9 8 18 2 1 5 2 2 9 1 1 1 6 8 6 3 2 4 6 1 fi 1 1 2 1 3 — (Others not shon n) Tofols 118 199 424 83 44 43 507 47 4 240 i 5 5 13 1 481 15 22 5 6 35 29 107 138 i 4 among those recommended the number required to fill the available positions are selected, giving consideration to the spirit of cooperation, ability to devote suffi- cient time to the work, and other personal considerations which make for a harmonious and efficient staff. 13. The nominations which are thus made are transmitted to the governing body for final appointment. 14. The summaries of the work of individuals are combined to give a summary analysis of the whole hospital (Form VI). This may lead to discovery of: (a) Deficiency or completeness of equipment in the various departments. (&) Efficiency or inefficiency of the personnel and its organization. (c) Procedures that are effective and those that are ineffective. (d) Points of weakness and strength in the individuals of the medical staff, in the organization, or in its functioning. From the exact knowledge secured by means of these records, desirable features in the hospital and its internal organization may be perpetuated while those that are undesirable will be eliminated ; but most important is the fact that the granting of privileges, promotions, and appointments to the various divisions and services are made from exact knowledge of the efficiency of the members of the medical staff in their use of the facilities provided for the care of the patients. Addendum IV. Medical Staff Minute Book The medical staff has many medico-administrative and clinical duties to perform requiring the holding of certain meetings from time to time, the pro- ceedings of which should be properly recorded in brief and comprehensive minutes. Too frequently the records of staff proceedings, medico-administra- tive and clinical, are badly neglected and thus are of little or no value. All hospitals should provide a minute book in which may be assembled in a systematic manner the minutes of the staff meetings as well as the reports of committees. A loose-leaf book is most suitable for this purpose inasmuch as it allows for expansion as well as ready removal of pages for typing. 2014 VETERANS’ ADMINISTRATION ■H O 6 '2 CD •fk ro Oi <7> fO -0 4k ro Doctor I i o> |o a & H r> Active Obstetric* to > |f c > O U; 3® o c *< Present Service is o CD 01 o* ro CD o ro CD * cn cn CD O O* 3 a» Number of records reviewed ro O GO ro ll o 4k or O "4 o os o S Major X 04 o O O •o ro to CP CT> o - o Intermediate m 00 (in CD -P hi ro 04 4k o a> Minor (0 fO O § ro Oi 3 04 -vj -J o 00 4k X - o _ _ w 04 o O'. _ _ 04 03 s r 3) ro IO cr> 04 ro - ro O ro ro - 5 cn _ X 04 Of U» 4k 4k D § _ ro _ 4^ _ 4* X 4k ro o ro 00 .. cn __ -4 - X cr> o ro o ro ro X cn 8 & ro _ o 04 M _ — 04 ■>4 X -u OJ o A CT> ... _ 04 4k X O _ o (£> X irth)_ Dermatology . Communicable Traumatic Surgery Tumor Other Total Discharges Number Deaths Autopsies Consultations | Patients NOj % Ho. % Mo. % Ho. ~ % 8 — Cases For Special Consideration infections- JW" 1" ' - *o>o A-ACS (Mtviaao *uou*r. mi) mtsiciab** ricoib Co.. Chicmo m •■*■* 2020 VETERANS’ ADMINISTRATION analysis of hospital service Month of page REPORT OF ADJUNCT DEPARTMENTS CLINICAL LABORATORY URINALYSIS Routine Functional Quantitative Culture BLOOD EXAMINATIONS ~ R. B. C. W. B. C. Schilling Differential Hemog lob in Coagulation Time Sedimentation Time Blood Plasma Typing Wassermann Kahn Mantoux Widal Culture . BLOOD CHEMISTRY Blood Sugar Blood Urea Non-Protein Nitrogen Creatinin Uric Acid Van den Bergh Icterus Index Sulfa Determination BLOOD—Miscellaneous RADIOLOGY Radiographic Examinations Fluoroscopic Examinations X-Ray Treatments Radium Treatments ELECTROCARDIOGRAPHY jj Electrocardiograms TISSUE J Gross Microscopic SPINAL FLUID Cell Count Colloidal Gold Culture Globulin Wassermann MISCELLANEOUS Gastric Analysis Stool -Examination Smear Animal Inoculation Sputum Examination Vaccine Exudate Transudate Throat Culture H Basal Metabolism R Autopsies PHYSICAL THERAPY Total Patients I Total Treatments OCCUPATIONAL THERAPY Total Patients || Total Treatments VETERANS' ADMINISTRATION 2021 aM> no FRACTURE RECORD Data Hoar P.M_ Wante Address vuJa Mo. Bed Dr. Age Sex M. F. M. fl. W. D. White or Colored Time: Occurrence of Accident y ii Occupation Referred by Hospital Entered Cause ofFractuxa First Treatment Final Reduction _ Uood ~ Moderate" ~Bsd ** RESULT 00—100 7&—90 Under 50 Anatomical Functional Description of End Result, including Union. Deformity, Shortening, Function, Patu. Swelling, Nerve, X-Ray (t.) At dlschtrge from Hospital: Date (b) At discharge from O.P.D.: Pete (c) At aobaequent date: Date Disability Absent. Partl.l, Complete Mortality Date Mein cause of death Absence from work: Duration * Ability to resume job ___ ♦Present wage earning capacity Compensation obtained: Yes No » ♦Black Ink: Snrgeon'e Opinion Bed Ink: Patient’a Opinion TREATMENT Closed Reduction Method and Position of Jolnta Anesthetic Used Yes No Remit Obtained (X-Ray No.) Open Reduction Method and Position of Jolnta Remit Obtained (X-Ray Wo.) Was non-operative treatment tried flrat? Hew long after Injury was operation performed? Waa Internal fixation material mbsequently removed? Period of Complete Immobilization Period of Protection Total Period of Immobilization and Protective Treatment ADDENDUM VII FIRST AID AND TRANSPORTATION Was patient splinted where lying? If a long bone la fractured were traction apllnta applied? □ Thomaa-Mnrray □ Keller- Blake . EXAMINATION AND DIAGNOSIS Nature and extent of Injury to soft parts eapeclaliy nerve a and veeaels _ Bones fractured Simple Compound X-RAY — Nos. Locate and deauribe the X-ray findings before reduction in each fractured bone beginning with the most Important fracture and using as Indicated the following terms: gicenstick. subperiosteal. Impacted, transverse, obllrjue, spiral, comminuted, (with descilptioa). Into Joint (with description), shortening, over-riding angulation, etc. " J Complications WaasermannJTest _ | 2022 VETERANS’ ADMINISTRATION Posterior Anterior (Details of Treatment, Operation, etc.) rvaa ACO (■«»!••«» »»r»> Family ’History t a t, £ Present Injury VETERANS’ ADMINISTRATION 2023 SAMPLE* SYNOPTIC CANCER RECORD FORMS ADDENDUM VIII MALIGNANT TUMOR OF RECTUM u .4 , . Hospital or • _ Classification: (see reverse) Service Hosp. or Clinic No— ... , ■■ — Name, Address.———— - Aga M. or F. S. or M. Family Physician.. Address, . „ Date of Pntfawra Family History of Oanrar PAST HISTORY; Change of Bowel Habit Loose .. — Constipated Hemorrhoids PRESENT HISTORY SYMPTOMS OF ONSET: Dates NaSura Date 1st Medical Consultation_., , . — , .. Advice fiiwaa Treatment Before Entranca SYMPTOMS AT ENTRANCE Chief fVimplainf Pain: tof-atian, Tenesmuv, Bleed?ng Frequent SfaaU Abdominal P*'" Vamifiwg Loss of Waight ASSOCIATED DIAGNOSES ENTRANCE EXAMINATION PRIMARY TUMOR: Location ( - . em abova «"u») C.\\»r*r**r Extant: Annular R. Lat_ L. Lat ,,, Ant Pott Fixation: Pott R. Lat L. La» Involvement; Pm«tata P.V Septum Obstruction: Complete Partial METASTASES: Inguinal Nodat Pararactal Nr>dat I Mamorfh^irk PROCTOSCOPY X-RAY EXAM.: Contrast Enama Chest . Bona*-. —... .. —. ■■ SYPHILIS: Sarologic Tests TYPE OF TREATMENT WITH DATES SURGERY: Opwtftr I. Combined Abdominal-Perineal {I or 2 xtaga) — ? Posterior . 3. Abdominal a Exploratory I 5. Colostomy; Alone . .. With Ratartirta k u:t<-alUaao..t RADIATION THERAPY: (enter dates only in spaces below) TKarapixt . - ■ Radium - X-ray: To Primary .. Ta Metasteses OPERATIVE FINDINGS: Location: I. Above Paritnn*iim _ ? Below Paritanaum Extent: I. Mobile 2. Fixed 3. Adjacent Invalvamant Metestoses: I. None - 2. I "jmr - 1 Regional N'wt** a General Abdominal PATHOLOGICAL EXAMINATION Biopsy: D«ta Pa+KftUgict niagftAtit Surgical Specimen: Date. PathoIngUt GrotS Microscopic Pxamiaatifta - nil 23 ACS (NCV. OCT. ttM» ♦buch lorms are available for malignant tumors of breast, uterus (cervix, fundus), ovary, larynx, thvroid, lung—bronchus, esophagus, stomach, colon, bone, eye, skin, kidney, bladder, prostate, testicle, penis, and oral cancer, neurogenic sarcoma, lymphosarcoma, leukemia, and there is a master form which may be used for tumors of other organs. 2024 VETERANS’ ADMINISTRATION CANCER RECORD FORMS—Continued RADIUM □ Pre-Operative □ Post-Operative □ For Recurrence Q With X-ray Data Form Filter Location MCH* Other Units of Dosage 1st Treatment 2nd Treatment — - ■ -—— 3rd Treatment — X-RAY Q Pre-Operative D Post-Operative Q With Radium O For Palliation Q For Metastases Data Begun Date Endad KV Filter Ports Treatment! §j^ 1st Series 2nd Series 3rd Series YEARLY FOLLOW-UP Year Date Status f t Status Symbols: . A Operative Fatality B. Alivo end Well ~ C. Untraced-lnconclusive £ D. Alive with Disease E. Died with Disease F. Died without Disease 4 G. Recurrence Local (Original Site) $ Regional ... - -. ——— H. Metastases Remote 6 7 8 9 in ANNUAL FOLLOW-UP NOTES FINAL RESULT Time Sine® - — Time Sine® Rrtt Treatment - Autopsy: Yes Q No O CLINICAL CLASSIFICATION (Enter accurate classification on front page, as I-A, 2-B. 3-C, etc.) 1. PRIMARY CASE A. Limited to Bowel Well _ _ B. Local Extension — Mobile Turner C. Local Extension — Fixed Tiinvw _ . D. Regional Mftfnsfntas _ E. Hepatic Mfttn,481 Patients were given 11,380 examinations and treatments, of a ttital 39 932 patient \isits toi both out-patient and rating purposes Autopsies during 1944 were 43 to 224, or 19 percent. Complete protocols are on hie in the surgical pathological laboratory for all autopsies performed Obstetrics. The hospital does not maintain an obstetrical service Out-patient depart merit.—A member of the full-time medical staff is in charge o out'patie1r!t ,and reception service, and 20 other members of the medical staff are on full-time assignment to the department. The fact that more than half of the full-time medical staff is on duty in the department is due to the huge backlog of patients for examination that has accumulated during the partial closing of the hospital and since that time. Patients are admitted in the usual out-patient sense for diagnosis and treatment and for rating purposes, from 8:30 a. in. until 4: 30 p. m. daily, except Sunday. Com- plete records of patient visits, physical findings, and treatments administered as well as the physical findings for rating purposes, are made and filed in the hospital. The appointment system is used as a means of follow-up on patients. Pharmacy. The hospital pharmacy is under the supervision of a full-time, registered pharmacist. Only pharmaceutical preparations of standard quality are used. Complete records of drug stock and prescriptions are maintained and narcotic records and supplies are checked regularly. Nursinff. The nursing staff is supervised by a full-time directress of nursing. There was a staff of 43 graduate nurses on duty at the time of survey, 16 of whom were in supervisory capacity, and 27 general duty nurses, allowing a nurse-patient ratio of about 1 to 5. Conferences of the entire nursing staff are held regularly, twice monthly, for the consideration of administrative and other matters. The nurses are housed in a home that is of the same construc- tion as the hospital building. There are, in addition to the graduate nurses, 49 subsidiary workers who are active in the care of patients in the hospital. As noted elsewhere, 160 beds in the hospital were unoccupied at the time of survey due to a shortage of nurses and subsidiary workers. It was expected at that time that an additional 5 graduate nurses and 56 Army enlisted men, the latter to act as orderlies, would report within a few days, which would allow some of the unoccupied beds to be put into active use. Dietary department.—There is an organized dietary department in the hos- pital. Three dietitians are employed, all of whom are graduates of approved schools of dietetics and the chief of the department and one assistant are mem- bers of the American Dietetic Association. Members of the department are active in consultation with staff physicians in the planning and preparation of special diets for patients whose medical records are always available for examination in connection with that purpose. The hospital kitchens, refrig- erators, and supply rooms were visited and found to be in sanitary condition. Medical social-service department.—A full-time, trained directress has charge of the medical social-service department, and two additional trained workers are employed. Social and financial investigations are made of patients when indi- cated, chiefly through interviews with patients and visiting relatives, and full reports of these investigations are on file in the patients’ medical records and in the department. Follow-up work on patients is not undertaken, due to the widely scattered sources from which patients are drawn and the small size of the departmental staff. Library.—The hospital has a medical library of 321 current, standard texts and receives 30 medical periodicals monthly. A full-time librarian is in charge of the library. Residencies.—Plans have not been drawn up for graduate-training programs in genera] surgery or the surgical specialties. An affiliation with a medical school for any educational purpose or for the granting of higher medical degrees has not been established. Conclusions.—This hospital may be said to present limited possibilities as a center for graduate training fn general surgery at present. However, the fore- going report does not give a true picture of the possibilities when it is considered that the hospital was all but closed for about 2 years prior to December 1943, and that the clinical work has been building up gradually since the latter date. At the time of survey, there were 160 beds not in use in the hospital, and 315 beds are under contract for veteran patients in Army, Navy, and marine hospitals in the nearby vicinity. When circumstances will permit all of the beds in the 2032 VETERA NS’ AD MINISTR ATIO N hospital to be actively occupied, the hospital will, without a doubt, have suffi- cient clinical material to justify the establishment of a program of graduate training in surgery, if not one or more of the surgical specialties. There may be, by the same token, a moderate increase in the out-patient patronage, which will add to the available clinical material. As pointed out above, more than half of the full-time medical staff is occupied with examination in the out-patient reception department. It is probable that, as the large number of patients for examination is reduced, this division of the medical staff will equalize itself in order that an increased number of patients in the hospital may be properly cared for. Other considerations with regard to the medical staff which should receive attention in connection with the establishment of graduate-training programs are; a qualified pathologist who would devote more time to the department than at present; a full-time, qualified roentgenologist; additional general staff meet- ings, and/or clinicopathological conferences, as well as departmental meetings at frequent intervals when the size of the staff warrants it. There should be a substantial increase in the autopsy percentage. Paul g. Ferguson, M. D., Director of Surveys Veterans’ Administration Hospital, Los Angeles, Calif. (Col. Charles F. Bayer, Medical Corps, chief medical officer; Col. K. A. Bringham, manager) January 29, 1945. General.—This is a general hospital with an official bed capacity of 1,080. The physical plant consists of a six-storied and partial basement, modern, fireproof building. At the time of survey 104 beds were not in use due to a shortage of graduate nurses and subsidiary workers. It was anticipated, however, that these beds would be utilized as additional nursing and subsidiary personnel became available. The hospital furnishes care for acute surgical and medical condi- tions, as well as out-patient service, to residents of the nearby soldiers’ home (for both male and female patients), which has a bed capacity of about 3.000 and an average daily census of about the same figure. The equipment in all departments of the hospital appears to be adequate for efficient diagnosis and treatment, and is of good quality. The hospital is administered by a manager who is a layman, assisted by the chief medical officer and a clinical director. Members of the medical staff are on either United States Army Medical Corps or United States civil-service status and are assigned to this hospital by the medical director of the Veterans’ Administration; consultants are appointed by the medical director on recom- mendation of the manager and the chief medical officer. The medical staff func- tions under Federal regulations. Medical staff,.—The full-time medical staff consisting of 69 active, 6 dental corps, and 16 supernumerary officers transferred to this facility for assignment, is organized on the closed plan, the clinical director acting as chief of staff under supervision of the chief medical officer. The staff is extensively departmental- ized with heads of departments who are active in control of the clinical work. The consulting staff of eight members is made up of outstanding specialists, chiefly in general surgery and the surgical specialties, practicing in Los Angeles and vicinity; some members of the group are on part-time salary basis arid visit the hospital regularly, while others are on fee basis and are called as the need arises. The medical staff meets each week throughout the year for a review of the clinical work of the hospital. The program consists of consideration of clinical cases, deaths, autopsy material, and sometimes staff or outside speakers on medical subjects. In addition, over-alfidepartmental meetings in medicine and surgery, and journal club meetings for review of current literature, are held weekly throughout the year. These meetings appear to afford a fairly adequate review of the clinical work and are regularly attended by the pathologists and radiologists; only about 50 percent attendance on the part of the active medical staff was recorded for the year 1944, however. Minutes of the general staff meet- ings and attendance records are kept. Clinicopathological conferences are not held. The hospital has no interns or residents at this time. VETERANS’ ADMINISTRATION 2033 Medical records.—A full-time, trained librarian has charge of the completed medical records, assisted by a large corps of trained clerks. The records are prepared by the staff officers and appear to be complete in essential details. Filing is by serial number, recognized nomenclatures are used, and cross-in- dexing according to disease is up to date. The cross-indexes, as far as developed are said to be but little used by the staff physicians for making group studies or other research purposes. Diagnostic and adjunct facilities.—The hospital has well organized and fully equipped clinical and surgical pathological laboratories in which all of the usual types of laboratory procedures are carried out. The full-time pathologist, Maj. H. C. Fortner, is qualified by training and experience, and holds member- ship in a national pathological society. His full-time assistant, Capt. L. M. Hunter, has had training and experience. Eight full-time, trained technicians, of whom two are registered, are employed. All tissues removed at operation are examined and full reports rendered. The radiological department is well equipped, with radiographic, fluoroscopic, superficial and deep therapeutic, and mobile units, and 120 milligrams of radium are available for use. It was stated that a new 400-kilovolt Keleket therapy unit had been shipped and would be installed in the hospital when received, which was expected to be soon. Previously the highest voltage apparatus available for treatment had been 220 kilovolts. The full-time radiologist, Maj. O. G. Lyons, is a diplomate in roentgenology, while his full-time assistant, Maj. W. A. Gore, is qualified by training and experience. Eight full-time technicians, of whom one is registered, are employed. The facilities for physical therapy in the hospital are complete and are super- vised by Lt. Col. Norman E. Titus, the full-time chief of phyiscal medicine. Ten full-time, trained technicians are employed, two of them registered. Com- plete records of treatments are maintained in the department. Other adjunct facilities are basal metabolic and electrocardiographic appara- tus, and occupational therapy, all of which are competently supervised. Surgical department.—The facilities for surgery consist of two major and one minor operating rooms, a fracture room, one cystoscopic room, one major room for ophthalmology-otolaryngology, sterilizing and work rooms. The various rooms are conveniently situated and are said by the surgical staff to be ade- quate for their needs. The supply of surgical instruments is extensive in num- ber and variety and appears to be sufficient for any type of operation ordinarily performed in the hospital. Four graduate nurses, of whom one is supervisor, and five orderlies are assigned to the department. The full-time staff in general surgery and the allied specialties consists of eight members, supervised by the chief of department. The chief and three assistants do all major general surgery; major orthopedic operations are per- formed by a member of the general surgical group and an orthopedist, while a sixth member of the surgical group does the minor orthopedic operations. A full-time urologist and a tumor surgeon, who perform operations in those specialties, complete the surgical group. Of the four members of the separate division of opthalmology-otolaryngology, the chief and one assistant share oper- ations in the specialty between them. It would appear that the surgeons of the consulting group are seldom, if ever, employed as far as the actual performance of operations is concerned. The chiefs of surgery and ophthalmology-otolaryngology are responsible, through the manager, chief medical officer, and clinical director, to the Medical Director of the Veterans’ Administration for all surgery done in the hospital; other members of the general surgical and specialty divisions necessarily share in their responsibility, however. Additional means for the control of surgery are limitation of privileges, routine examination of tissues removed, the closed staff organization, and complete preoperative recording. Anesthetics in the department are administered entirely by physicians, super- vised by Maj. Harold D. Spickerman, the tumor surgeon. The usual types of anesthesia are used with the exception of nitrous oxide, including cyclopropane, ethylene, pentothal sodium, and avertin. Special record forms are used for recording the details of anesthetics but follow-up notations were not noted during examination of the medical records. Full recording of the physical examination, diagnostic laboratory procedures, and the provisional diagnosis is required be- fore the administration of an anesthetic may begin. Infections occurring postoperatively in clean surgical cases are said to be recorded in a book on each of the surgical wards, but a central record in the 75183—45—pt. 5——13 2034 VETERANS’ ADMINISTRATION office of the medical director or chief of surgery, or elsewhere in the hospital, showing the total number of infections occurring in the hospital, is not kept. It is probable that maintenance of a central record would act as a stimulus to reducing the number of infections to a minimum. During the year 1944 there were 740 major and 1,580 minor operations per- formed in the hospital. It was stated that only emergency surgery was done during 1944 and thus far in 1945, due to the shortage of graduate nurses and that a huge backlog of elective surgery is piling up. In normal times the num- ber of elective and emergency operations will average from 3,000 to 3,500. Records as to the nature of the operations performed, collectively, or their divi- sion into general and specialized surgery, were not available for review due to the fact that an operative cross-index is not maintained in the medical records department. Since there are no residents in the hospital, a statement as to how many operations will be performed by a resident in any year cannot be made. In the past, however, younger surgeons on a status comparable to residents have done a limited volume of major and minor surgery under supervision. This arrangement will continue until such time as residencies may be established in the hospital, although the younger surgeons will be advanced in responsibility in surgery as ability is demonstrated. Clinical material.—Male veteran patients are admitted in all general branches of medicine and surgery, while the treatment of female patients is limited to emergency conditions at present. Facilities are not provided for the care of patients with communicable diseases but ample means for segregation and isola- tion make their treatment possible when the need arises. There are 44 beds allotted to clean general surgery, 62 to aseptic general surgery, 30 to women, including gynecology, 35 to urology, 28 to ophthalmology-otolaryngology, 62 to orthopedic surgery, 123 to tumor surgery, and 35 to neurosurgery. Patients are not classified as either free or paying, but all are available and may be utilized for teaching purposes. During 1944 the average daily census in the hospital was 1,064 and 8,397 patients were admitted. An exact division of patients admitted into clinical services is not available, due to the fact that admissions are through the reception service and cases are thoroughly worked up before the diagnosis is announced. An approximation indicates that the following were surgical patients: 1,168 in general surgery; 22 in plastic surgery; 261 in proctology; 120 in neurological surgery; 544 in orthopedic surgery; 515 in urological surgery; 30 in gynecology; 172 in ophthalmology; and 344 in otolaryngology. In addition, 294 acute frac- tures were admitted, with 11 open reductions and 1 postoperative, infection among them. In the out-patient department during 1944 a total of 90,000 treatments were administered to 18,000 patients, and 7,200 patients submitted to 15,000 examina- tions, the latter including examinations for rating purposes. Autopsies during 1944 were 352/897 or 39 percent. Complete protocols are on file in the surgical pathological laboratories for all autopsies performed. Obstetrics.—An obstetrical department is not maintained in the hospital. Out-patient department.—The out-patient department functions separately from the reception service and is staffed by a chief and 17 assistants. Patients are admitted in the usual out-patient sense for diagnosis and treatment, and for rating purposes, from 8 a. m. until 5 p. m., daily except Sunday. Complete records of patient visits, physical findings and treatments administered, as well as the physical findings for rating purposes, are filed in the department. The appoint- ment system is employed as a means of follow-up on patients. Pharmacy.—A full-time, registered pharmacist has charge of the hospital phar- macy. All pharmaceutical preparations used are of standard quality. Complete records are maintained of drug stock and prescriptions, and narcotic records and supplies are checked regularly. Nursing.—The nursing service is supervised by a full-time directress of nursing. There was a staff of 122 graduate nurses on duty at the time of survey, 12 of whom were in supervisory capacity and 110 on general duty, allowing a nurse- patient ratio of about 1 to 8l/o Conferences of the nursing staff are held on Call, averaging monthly, for the consideration of administrative and other busi- ness. A training school for cadet nurses in their last 6 months of training is conducted in the hospital, with faculty and facilities for instruction, and 4 pupils were in training at the time of survey. The nurses occupy homes, of which one is fireproof and the other nonfireproof. In addition to the graduate and cadet nurses, 255 subsidiary workers are employed who are hctive in the care of patients in the hospital. VETERANS’ ADMINISTRATION 2035 As noted elsewhere in this resume, 104 beds in the hospital were unoccupied at the time of survey due to a shortage of nurses and subsidiary workers. It was expected that the beds would be put into use as the necessary graduate nurses and subsidiary workers became available. Dietary departmentEleven dietitians are employed in the organized dietary department of the hospital. All are graduates of approved schools and the chief and three assistants are members of the American Dietetic Association. Members of the staff are active in consultation with medical officers in the planning land preparation of special diets for patients, whose medical records are always available for examination in connection with that purpose. The hospital kitchen, refrigerators, preparation, and supply rooms were visited and found to be in sanitary condition. Medical social service department.—A qualified directress and five full-time, trained assistants are employed in the department of medical social service. Social and financial investigations are made when indicated and full reports are on lile in the patients’ medical records and in the department. Discharged patients are followed up through the media of home visits, mail, and telephone. Library.—The medical library consists of 465 current, standard texts and 38 medical periodicals are received monthly. A full-time librarian is in charge of the library. Residencies.—Programs have not been drawn up for graduate training in gen- eral surgery or the surgical specialties. An affiliation with a medical school for any educational purpose or for the granting of higher medical degrees has not been established. Conclusions.—This institution appears to present excellent possibilities as a center for graduate training in surgery, inasmuch as the quantity of clinical material available and the volume of surgery done are adequate for that purpose. It will be noted that only emergency surgery was done during 1944 and that the volume of surgery in normal times would be at least 400 percent of the volume reported for that year. A classified list of operations performed could not be secured, but it is probable that a good variety of operations and resulting surgical tissues would be available in normal times for resident training due to the fact that the age span of male patients, at least, is being constantly widened by the admission of veterans of World War II. It is probable that basic science instruc- tion in pathology could be given in the hospital and that an affiliation with a medical school would provide for the other basic sciences for which facilities are not available in the hospital. The medical and surgical staffs are well organized- for control of the clinical work, conducting a program of graduate training in general surgery and the instruction of residents. The chiefs of surgery and opthalmology-otolaryngology and the consultants in general surgery, urological surgery, ophthalmology-otolaryngology and tumor surgery are Fellows of the American College of Surgeons. The following points are of importance if the establishment of graduate training programs in this hospital are considered: The percentage of attendance at the weekly meetings of the general medical staff; the fact that clinico- pathological conferences are not held, especially so since a large number of autopsies is performed; cross-indexing of the medical records according to opera- tion has not been developed for use by the medical staff and the possible future residents: the qualifications of the pathologists and radiologists should have further consideration ; a centralized record of infections occurring postoperatively in clean surgical cases is not maintained. It is the recommendation of the American College of Surgeons that, in institutions where programs of graduate training in surgery are functioning or are contemplated, the incidence of autopsies be at least 50 percent and as much more as possible. In addition to the fore- going, the comparatively high nurse-patient ratio is of importance in the field of hospital standardization. Path. S. Ferguson, M. D., Director of Surveys. Veterans’ Administration Hospital, Washington, D. C. (Col. Lewis G. Beardsley, manager; Dr. Grady O. Haynes, chief medical officer) February 6, 1945. Genera].—This is a general hospital with an official bed capacity of 327 and there were 295 patients in the hospital at the time of survey. The physical plant consists of a central four-storied, fireproof, modern building with four adjoining two-storied buildings, all connected by a corridor. Two of the adjacent buildings. 2036 VETERANS’ ADMINISTRATION formerly used as dormitories for a girls’ school, have been converted into wards for patients. One of the buildings is designated as a clinic building which con- tains the laboratory, X-ray department, eye, ear, nose, and throat examining and operating rooms, and the physiotherapy service. There are eight designated ward divisions in the hospital: Building A, respiratory diseases and diagnosis; building B, reception center and eye, ear, nose, and throat examining and treat- ment rooms; building C, general medical and surgical service for Negro patients; building D, medical patients; building G is assigned to the tumor service. The first floor in the main building is assigned to neurological surgery, the second floor to general surgery and the surgical specialties while the third floor is occupied by female and general medical cases. The hospital is well equipped in all departments for diagnosis and the treat- ment of patients, but the physical plant is in need of repair and better mainte- nance, particularly the three ward buildings which should either be extensively rehabilitated or replaced. Medical staff.—The hospital is administered by a manager who is a lieutenant colonel of the Medical Corps of the United States Army, assisted by a chief medical officer who is responsible for direction of the clinical services. There are 29 medical officers assigned to this hospital. Four members of the staff were se- lected by the Veterans' Administration through United States Civil Service and the remainder are commissioned officers in the Medical Corps of the United States Army and assigned to duty at the hospital. The medical staff is organized under the closed plan and all the officers are on full-time basis. The following clinical divisions have been established: The reception out- patient center with 8 medical officers; surgical service, including the surgical specialties, with 8 medical officers; general medical service with 7 medical officers; the urological service with 2 officers; the clinical laboratory with a pathologist in charge, and the X-ray department with 1 radiologist in charge. In addition to this group there are 2 full-time dental officers, and a roster of 24 consultants on part-time basis. A large number of the consultants are not active at this time; some have gone into the armed forces, others have declined to come to the hospital regularly, and 2 or 8 have practically retired. However, about 15 of the consulting specialists will come to the hospital as often as needed. The number of medical officers assigned to this hospital is considered adequate to carry on the professional work. The medical staff meets regularly each week throughout the year for a review of the clinical work of the hospital. The programs consist of consideration of at least two selected cases treated in the hospital, sometimes a medical topic is discussed by one of the staff, and the various departments provide the program in rotation. The meetings are held from 1 to 2 p. m. on Saturdays and the average attendance has been about 22, while there are 29 members on the staff. Records of the meetings consist only of an announcement of the programs to he carried out and there are no regular minutes or abstracted case reports for review. There are no departmental meetings or clinicopathological conferences, although reports of deaths and autopsies may be taken up at the regular weekly meeting. As there are no departmental meetings or elinicopatholdgical conferences of the medical staff, it would seem that the one weekly general meeting has reduced the conferences for clinical review to a minimum. Medical records—The medical officers write the clinical records, which are generally acceptable in the component parts. The medical record department is well organized under the direction of a trained librarian who is assisted by two full-time, and one part-time, clerks. Patients’ charts are filed by serial number and the final diagnosis is recorded in compliance with the nomenclature used by the Veterans’ Administration. Cross-indexing according to disease and opera- tion has not been developed and there is no indication of the medical records being used for group studies. Diagnostic and adjunct facilities.-—The hospital has fully equipped clinical and surgical pathological laboratories in which all types of laboratory procedures are carried out. The full-time pathologist, Maj. Carmelo De Angelis, is said to he well qualified in clinical and tissue pathology. He is assisted by a staff of 5 trained technicians. This department is said to be doing a large number of examinations, but the annual report for 1944 was not available for review. There were 8,417 tissues examined last year, and 65 autopsies were reported, which represents 22 percent of deaths in the hospital. The radiological department is supplied with modern radiocrrehi'-, fl ’or"SCopic, and therapeutic apparatus. The therapy department has a 200-kilovolt unit and 100 milligrams of radium. Maj. Solomon Bersack, the full-time radiologist, is said to be well qualified in X-ray diagnosis and thei’apy. The technical staff VETERANS’ ADMINISTRATION 2037 consists of three well-trained technicians. Reports of examinations are written in duplicate, one copy being filed with the patient’s chart and the other in the department. Only monthly summaries of the work done are available for review as annual reports are not prepared. The physiotherapy department is completely equipped except for mechano- therapy and is under the direction of Captain Weinberg of the orthopedic staff. Three full-time, trained technicians are employed. About 2,300 treatments are given each month to an average of about 100 to 150 patients. Complete records of treatments are kept; one copy is filed in the department and the other in the patient’s chart. Surgical department.—The facilities for surgery consist of two major operating rooms and a cystoscopic room. The treatment rooms of the eye, ear, nose, and throat department are in ward D, in the reception center, where a considerable amount iff the more minor surgery in ophthalmology-otolaryngology is done. The main operating rooms are located on the fourth floor of the main building, just above the floor occupied by the surgical wards. The department appears to he well equipped for most all types of operations. There are three graduate nurses who are responsible for the operating room service, assisted by two or three orderlies. A medical assistant is employed in all major operations. Evidence of preoperative study and a provisional diagnosis are recorded prior to all operations. The findings and technique of operations are well described on the patient’s charts and signed by the surgeons. All infec- tions of clean surgical wounds are recorded and thoroughly investigated accord- ing to regulation. Consultations are frequent as members of the surgical staff work closely together every day on the wards and are familiar with all cases under treatment. The full-time staff in general surgery and the surgical specialties consists of eight members who are under the supervision of the chief of surgery and heads of the specialty divisions. There is a separate division for ophthalmology and otolaryngology which is staffed by a chief of division and one assistant. The chief of surgery is responsible, through the chief medical officer and the manager, to the Medical Director for all surgery done in his department and the chief of ophthalmology-otolaryngology likewise is responsible for the surgery done in his division. All surgery is done by the chief of department or by assistants who he considers competent to do the operation. Additional means for the control of surgery are, limitation of privileges, routine examination of tissues removed, the closed staff organization and complete preoperative recording, including, con- sultation. A medical anesthetist has not been appointed as chief of the anesthetic service. All anesthetics are administered by staff physicians and consist of ether, nitrous oxide, local, spinal, cyclopropane, and to some extent, ethylene. Complete reports of physician examination and urinalysis are recorded before all operations. Special record forms for anesthetics are not used and the reports of anesthetics consequently are incomplete. The number of operations reported was 310 majors and 375 minors. The classification of operations was approximately as follows; Proctology, 102; thoracic surgery, 28 major and 238 minor operations; neurological surgery, 58; orthopedics, 88 ( 35 open reductions, 53 closed reductions) ; urological surgery, 64 major, 308 minor; gynecological surgery, 23; ophthalmology, 43; otolaryn- gology, 103; general surgery, 310 majors and 375 minors; plastic surgery, 10. There were also 138 cystoscopic examinations and ureterograms. Clinical material.—During, the year 1944 there were 3,983 patients admitted to this hospital, of which about 1,500 were assigned to general surgery and the surgical specialties. The hospital does not keep a classified record of surgical patients, which makes it impossible to determine how many patients were assigned to each service. All general surgical patients and a limited number of orthopedic cases are kept on 1 floor of the main building where there are 71 beds. At the time of the survey, there were 67 patients on this service. There are also some surgical patients on the B ward, i;sed by the tumor service, and a few gynecological and surgical cases on the women’s ward which has an average census of about 20 patients. The volume of surgery is not large, but there is a fairly good variety due to the various types of cases admitted, which include those assigned to the specially organized tumor service. There are some diagnostic, neurological, and chest cases which are veterans of World War I, also some veterans of the present World War are among those admitted. The hospital was designated as a diagnostic center about 15 years ago. Problem cases, for diagnosis and adjustment of compensation, were referred by other hos- 2038 VETERANS’ ADMINISTRATION pitals for thorough study by a specially selected group. In 1932 there were 1,738 problem cases studied in the hospital, whose average stay was about 15 days. The number of cases dropped 100 to 200 a year to an all-time low in 1944, when only 278 diagnostic cases were admitted. However, cases for routine treatment have increased until the census today is sufficient almost to fill the hospital. Of 295 patients in the hospital today, 10 are for diagnosis and about 60 are the chronic or custodial type, leaving about 225 routine treatment cases. Therefore, the pic- ture from the clinical standpoint has changed radically in this hospital, from a diagnostic center to a routine treatment hospital. The institution is especially designated as a center for the following services: Diagnostic center, neurological and neurosurgical for the southeastern section of the United States, tumor service for North Carolina, Virginia, parts of West Virginia and Tennessee and all of Maryland, chest surgery center except for pulmonary tuberculosis, and, finally, any problem cases. Obstetrics.—This hospital does not provide an obstetrical service. Out-patient department.—There is an organized out-patient department in the hospital representing all usual staff services. It is under the chief of department who is on full-time basis. Pharmacy.—The hospital pharmacy is under the supervision of a full-time, reg- istered pharmacist. Usually there are two assistants, but at the present time there is only one. Complete reports of drug stock and prescriptions are main- tained, and narcotic records are checked regularly by the pharmicist. Nursing.—'The nursing staff is supervised by a full-time directress of nursing. There were 49 graduate nurses on duty at the time of the survey, of which 5 were in supervisory capacity. There are also cadet nurses in training, and there are 44 attendants assigned to assist in the care of patients on the wards. Because of the shortage of attendants, 12 enlisted men of the Army have been assigned here to help with the ward work. Conferences of the entire staff of nurses are held at irregular intervals for the consideration of administrative matters. The well-furnished comfortable nurses' home, situated near the hospital, is adequate for the graduate staff. Dietary department.—The hospital has an organized department of dietetics. In addition to the chief dietitian, who is a graduate, registered dietitian, there are two assistants who have had training in this work. The dietitians are active in consultation with staff physicians in planning special diets for patients, whose medical records are available for examination in connection with that purpose. Medical social service department.-—This department is under the direction of a full-time, trained medical social worker who has, usually, one assistant, but the latter position is vacant at the present time. Investigation of social conditions of patients are made where indicated, and full reports of these investigations are on file in the department. Follow-up of discharged patients is conducted to some extent through home visits, mail, and telephone . Library.—The hospital has a medical library of 25 current periodicals and 484 standard textbooks. A librarian is in charge of this department, which is open throughout the day. Residencies.—There are no interns in the hospital and plans have not been made for establishing a program of graduate training in general surgery or the surgical specialties. Conclusions.—1. A fully equipped laboratory, with a well-qualified pathologist in charge, is maintained in the hospital. The histopathological material available for study would be the tissues from about 65 autopsies, 414 major operations and 921 minor operations annually. The laboratory also does a considerable number of chemical, bacteriological, and serological procedures. An annual report of laboratory examinations is not made, hence it was impossible to get definite sta- tistics on the above. However, a fairly good variety of material is sent to the laboratory, and it woidd seem that a resident of surgery could spend 4 to 6 months in the laboratory to good advantage. 2. The active X-ray service could probably give a resident fairly adequate in- struction in that specialty. 3. The tumor clinic, which meets weekly and admits approximately 160 new patients each year, would be available for the instruction of residents. 4. There are no facilities here for anatomical dissection or courses in surgical anatomy. 5. The lack of a cross-index of diseases and operations in the medical record department makes it impossible for the hospital to supply a complete list of major operations. E. W. Williamson, M. D.. Assistant Director. VETERANS’ ADMINISTRATION 2039 Veterans’ Administration Hospital, Atlanta, Ga (Dr. Roy H. Bryant, chief medical officer; Mr. J. M. Slaton, Jr., manager) April 24, 1944. General.—This is a general hospital, with an official bed capacity of 317, although 415 beds were set up and ready for use on the date of survey. The physical plant consists of a four-story and partial basement, modern, fireproof building. The equipment in all departments appears to be adequate for good diagnosis and the care of patients, and is of good quality. The hospital is administered by a manager, who is a layman, assisted by the chief medical officer, who is in charge of clinical work. Members of the medical staff are on either United States Medical Corps or United States civil-service status, and are appointed to this hospital by the Medical Director of the Veterans’ Administration. The medical staff functions under Federal regulations. Medical staff.—The full-time medical staff of 17 active and 2 dental corps members is organized on the closed plan, the chief medical officer acting as chief of staff. There is fairly extensive departmentalization with heads of departments and subdivisions who are active in control of the clinical work. The consulting staff of 20 members comprises an outstanding group of local medical and surgical specialists, who are selected and recommended for appoint- ment by the chief medical officer. It was stated that some members of this group are active on the teaching faculty of Emory University School of Medicine. All of the consultants are on fee basis and are called as the need arises. The medical staff meets regularly each week throughout the year for a review of the clinical work of the hospital. The program consists of consideration of clinical cases and deaths, surgical specimens and autopsy material, the dis- cussion of medical papers and subjects, and sometimes administrative business. These meetings appear to afford a fairly adequate review of the clinical work and are regularly attended by the pathologists and radiologists. Minutes and attendance records of the meetings are kept. Departmental meetings and/or clinicopathological conferences are not held. There are no interns or residents on duty in the hospital at this time. Medical records.—A full-time, trained librarian has charge of the completed medical records, assisted by an adequate corps of trained clerks. The records are prepared by the staff medical officers and appear to be complete in jail details. Filing is by serial number, recognized nomenclatures are used, and cross-indexing according to disease and operation is up to date. The cross- indexes are used to some extent by the medical staff for group studies and other research purposes. Diagnostic and adjunct facilities.—The hospital has fully equipped and well- organized clinical and surgical pathological laboratories, in which all types of laboratory procedures are carried out. The part-time pathologist, Dr. Ricardo Mestre, is qualified by training and experience, and is a member of a national pathological society; he spends approximately half time in the department. He is assisted by four full-time, trained technicians, of whom one is registered. All tissues removed at operation are examined and full reports rendered. The radiological department is well equipped with radiographic, fluoroscopic, superficial and deep therapy apparatus. One hundred milligrams of radium is available for use, this institution being one of the cancer centers of the Veterans’ Administration. The pathologist, Dr. Ricardo Mestre, acts as roentgenologist and spends about half time in the department. He is qualified by training and experience, and is a member of the Georgia State Radiological Society. The full-time radiologist, Dr. H. S. Abrams, has excellent formal qualifications. Three full-time trained technicians are employed in the department. The facilities for physical therapy in the hospital are fairly complete, and are supervised by a member of the department of medicine. Two full-time registered technicians are employed and complete records of treatments are maintained in the department. Other adjunct facilities are basal metabolic and electi'ocardiographic apparatus and occupational therapy, all of which are completely supervised. Surgical department.—The facilities for surgery consist of two major operating rooms in the main surgical suite, and a cystoscopic room in the radiological department, sterilizing and work rooms. The various rooms are situated to best advantage, and, while the facilities are sharply limited, are said to be adequate in extent for the present needs of the hospital. The supply of surgical 2040 VETERANS’ ADMINISTRATION instruments seems to be sufficient in number and variety for any type of operation ordinarily performed in the hospital. Two graduate nurses and one orderly are assigned to the department. The full-time surgical staff consists of five members, supervised by the chief of surgery. Much of the general and orthopedic surgery is done by members of the full-time staff without much specialization, but practically all major surgery in urology, tumor surgery, and ophthalmology is done by members of the consulting staff, and a consultant is frequently employed in orthopedic surgery. A small portion of the major ophthalmology surgery, and all surgery in otolaryngology is done by the staff specialist in ophthalmology-otolaryngology. The chief of surgery is responsible, through the manager and chief medical officer, to the Medical Director of the Veterans’ Administration for all surgery done in the hospital; other members of the general surgical and specialty divi- sions necessarily share in his responsibility, however. Additional means for the control of surgery are limitation of privileges, routine examination of tissues removed, the closed-staff organization, and complete preoperative recording. Anesthetics in the department are administered entirely by members of the medical and surgical staff, supervised by the chief of surgery, Lt. Col. John A. Thurston. Local, spinal, and pentothal sodium anesthetics are used; special records are made of anethetics administered, but postanesthetic notations were not noted in examination of the medical records. Full recording of the physical examination, diagnostic laboratory procedures and the provisional diagnosis is required before the administration of an anesthetic may begin. A record of infections occurring postoperatively in clean surgical cases is on file in the office of the chief of surgery. In the event that a postoperative in- fection occurs, the incident is carefully investigated, an attempt made to ascer- tain the source of infection and corrective measures are taken. During the year 1948 there were 358 major and 449 minor operations per- formed in the hospital. Records as to the nature of these operations, collec- tively, or their division into general and specialized surgery, were not avail- able for review. Since there are no residents in the hospital, a statement as to how many operations will be performed by a resident in any year cannot be made. In the past, however, younger surgeons on a status comparable to residents have done a limited amount of major and minor surgery under super- vision. This arrangement will continue until such time as residencies may be established in the hospital, although the younger surgeons will be advanced in responsibility in surgery as ability is demonstrated. Clinical material.—Male veteran patients are admitted in all general branches of medicine and surgery, but female patients are ordinarily not admitted. Patients with communicable diseases are not admitted as a general policy, but ample means for segregation and isolation make possible the care of such patients when the need arises. The allotment of beds for surgical patients is as follows: 55 for general surgery, urological surgery, orthopedics, and proc- tology; 9 for opthalmology-otolaryngology; and 46 for tumor patients, half of the latter being for domiciliary patients. Patients are not classified as either free or paying, but all are available and may be utilized for teaching purposes. During 1948 the average daily census in the hospital was 293, and 2,993 patients were admitted. A division of patients admitted into clinical services is not available due to the fact that admissions are through the reception out- patient department to the diagnostic service and cases are thoroughly worked up before the diagnosis is announced. The nearest possible approximation of surgical patients is said to be the number of operations performed, that is, 358 major and 449 minor. In the out-patient department during 1943, for purely out-patient purposes, 1,784 patients were admitted for a total of 6,418 treatments, and 8,087 individ- uals were given 17,059 examinations, the latter probably for rating purposes. Obstetrics.—This hospital does not maintain an obstetrical service. Out-patient department.—A member of the full-time medical staff is in charge as chief of the out-patient and reception service, and four other members of the medical staff are on full-time assignment to the department. Patients are admitted in the usual out-patient sense for diagnosis and treatment in all usual deparments, as well as for rating purposes, from 8: 30 a. m. until 4 p. m.. daily except Sunday. Complete records of patient visits, physical findings and treatments administered, as well as the physical findings for rating purposes, are made and filed in the department. The appointment system is used as a means of follow-up on patients. VETERANS’ ADMINISTRATION 2041 Pharmacy .—A. full-time, registered pharmacist has supervision of the hospital pharmacy. Only pharmaceutical preparations of standard quality are used. Complete records of drug stock and prescriptions are maintained, and narcotic records and supplies are checked regularly. Nursing.—The nursing staff is supervised by a full-time directress of nursing. There was a staff of 44 graduate nurses on duty at the time of survey, 12 of whom were in supervisory capacity and 32 on general duty, allowing a nurse- patient ratio of about 1 to GVi- Conferences of the entire nursing staff are held regularly every 2 weeks for the consideration of administrative and other matters. The nurses occupy a home which is of modern, fireproof construction. There are. in addition to the graduate nurses, 52 subsidiary workers on duty who are active in the care of patients in the hospital. Dietary department.—Two dietitians are employed in the organized dietary department of the hospital. Both dietitians are graduates of approved schools of dietetics and the chief of the department is a members of the American Dietetic Association. Members of this staff are active in consultation with staff physicians in the planning and preparation of special diets for patients, whose medical records are always available for examination in connection with that purpose. The hospital kitchen, refrigerators, preparation and supply rooms were visited and found to be in sanitary condition. Medical social service department.—Two full-time trained workers are em- ployed in the department of medical social service. Social and financial inves- tigations are made of patients when indicated, and full reports of those inves- tigations are on file in the patients’ medical records and in the department. Members of the department follow up discharged patients by means of home visits, mail and telephone. Library.—The hospital has a medical library of 409 current, standard texts and receives 21 medical periodicals monthly. A full-time librarian is in charge of the medical library. Residencies.—Plans have not been drawn iip for graduate training programs in general surgery or the surgical specialties. An affiliation with a medical school for any educational purpose or for the granting of higher medical degrees has not been established. Conclusions.—This institution appears to have fairly good possibilities as a center for graduate training in general surgery inasmuch as the clinical material in admissions to the hospital seems to be sufficient for that purpose. The clinical material in admissions to the out-patient department is somewhat less than would be desired, and surgery appears to be definitely on the conservative side. It is problematical, therefore, whether or not the hospital could carry a resident through to completion of his training program, although it is probable that the resident would be given good, partial training. The chief medical officer and members of the surgical staff interviewed expressed interest in graduate training. All of these men appear capable and interested in their work. Among the points of importance to be considered in connection with the possible establishment of graduate training programs in this hospital are: The need for departmental meetings and/or clinicopathological conferences as additional means for the review of the clinical work; full-time, qualified physicians in charge of the clinical laboratory and roentgenological department, and the percentage of autopsies performed. In the latter connection, it is recommended by the American College of Surgeons that, where graduate training programs have been established or are contemplated, the autopsy percentage be at least 50 percent and as much more as possible. The foregoing points are also of importance in the field of hospital standardization. Paul S. Ferguson. M. D„ Director of Surveys. Veterans’ Administration Hospital, Hines, III. (Mr. Charles G. Beck, manager; Col. W. A. Colton (MC), chief medical officer) January 20, 1945. General.—This is a general hospital with an official bed capacity of 1,771. The physical plant consists of a four-story building of modern, fireproof construction. The equipment in all departments appears to be adequate for efficient diagnosis and treatment, and is of good quality. Construction is to begin soon on a cancer hospital of about SCO beds, which will function in conjunction with, and be located 2042 VETERANS’ ADMINISTRATION immediately north of, this hospital. It is planned that, eventually, the perma- nent buildings of Vaughn General Hospital, of about 1,000-bed capacity, located immediately east of this institution, will become a part of the Veterans’ Adminis- tration Facility. The hospital is administered by a manager who is a layman, assisted by the chief medical officer and the clinical director. Members of the medical staff are on either United States Army Medical Corps or United States civil-service status and are assigned to this hospital by the medical director of the Veterans’ Admin- istration. The medical staff functions under Federal regulations. Medical staff.-—The full-time medical staff of 69 active and 6 dental corps members is organized on the closed plan, the chief medical officer acting as chief of staff. There is extensive departmentalization, with heads of departments and subdivisions who are active in control of the clinical work. The consulting staff of 17 members comprises an outstanding group of clinicians and teachers of the four medical schools in Chicago and represents all of the medical and surgical specialties. The consultants are on part-time salary basis, and visit the hospital regularly. The medical staff meets each week throughout the year for a review of the clinical work of the hospital. The program consists of consideration of diagnoses and treatment, clinical cases in general, deaths, and occasionally administrative business matters. Departmental meetings in all departments and clinicopatho- logical conferences are held weekly throughout the year. These meetings appear to afford an adequate review of the clinical work and are attended by representa- tives of the pathological and radiological departments. Minutes and attendance records of the general staff meetings are kept. There are no interns or residents on duty in the hospital at this time. Medical records.-—The medical records ase prepared by the staff officers and appear to be complete in essential details. A full-time librarian has charge of the completed records and is assisted by a large corps of trained clerks. Filing is by serial number, a recognized nomenclature is used, and cross-indexing ac- cording to disease is up to date. The cross-indexes, as far as developed, are used to some extent by the staff officers 4or group studies and other research purposes. Diagnostic and adjunct facilities.—The hospital has fully equipped clinical and surgical pathological laboratories in which all types of laboratory procedures are carried out. The full-time pathologist, Dr. W. L. McNamara, is well qualified, while his full-time assistant, Dr. R. J. Rogers, is qualified by training and experience. Thirteen full-time, trained technicians are employed, and two of them are registered with the national registry. All tissues removed at operation are examined and full reports rendered. The radiological department is well equipped with radiographic, fluoroscopic, and superficial and deep therapeutic apparatus. A large quantity of radium is available for use. Dr. C. W. McClanahan is the full-time roentgenologist in charge of the department and he has a full-time assistant, Dr. J. T. Brackin. The full-time radiologist, Dr. Harry Slobodin, has two full-time assistants, Drs. G. A. Williams and G. A. Mednick. All members of the departmental staff are qualified by certification of the American Board of Radiology. A large group of trained, full-time technicians, of whom two are registered, is employed. The facilities for physical therapy in the hospital are complete and are super- vised by Dr. H. C. Mitchell, a member of the neurological staff. An adequate corps of trained, full-time technicians is employed and complete records of treat- ments are maintained in the department. Other adjunct facilities are basal metabolic and electrocardiographic appa- ratus, and occupational therapy, all of which are competently supervised. Surgical department.-—The facilities for surgery are of good quality although somewhat limited for a hospital of this size. There are five major operating rooms in the surgical suite, two cystoscopic rooms in the urological department, one major operating room in the department of ophthalmology-otolaryngology, and sterilizing and workrooms. The supply of surgical instruments is extensive in number and variety and is said by the staff surgeons to fulfill their needs. Eight graduate nurses, four student nurses, and seven orderlies are assigned to this department. The full-time staff in general surgery and the surgical specialties consists of 16 members, supervised by the chief of department and heads of specialty divi- sions. There is specialization among members of the group for plastic, ortho- pedic, urological, and thoracic surgery, also in ophthalmology-otolaryngology; members of the general surgical group perform all operations in gynecology and VETERANS’ ADMINISTRATION 2043 tumor smgery. One of the surgical consultants does all of the lobectomies and most of the thoracoplasties in thoracic surgery. The chief of surgery is responsible, through the manager and the chief medical officer, to the Medical Director of the Veterans’ Administration for all surgery done in the hospital; other members of the general surgical and specialty divisions necessarily share in his responsibility, however. Additional means for the control of surgery are, limitation of privileges, routine examination of tissues removed, the closed staff organization, and complete preoperative recording. Anesthetics in the department are administered entirely by members of the surgical staff, supervised by Dr. H. I. Lipson, a member of the general surgical group. The usual types of anesthesia are used, including cyclopropane and pentothal sodium; special records of anesthetics administered are not made. Full recording of the physical examination, diagnostic laboratory procedures, and the provisional diagnosis is required before the administration of an anesthetic may begin. A record of infections occurring postoperatively in clean surgical cases is maintained in the office of the chief of surgery. The incident is carefully in- vestigated whenever a postoperative infection occurs, the source of infection de- termined if possible and corrective measures taken. During the year 11)43 there were 1,968 major and 3,585 minor operations per- formed in the hospital. Records as to the nature of these operations, collectively, or their division into general and specialized surgery were not available for review. Since there are no residents in the hospital, a statement as to how many operations will be performed by a resident in any year cannot be made. In the past, however, younger surgeons on a status comparable to residents have done a limited volume of major and minor surgery under supervision. This arrangement will continue until such time as residencies may be established in the hospital, although the younger surgeons will be advanced in responsibility in surgery as ability is demonstrated. Clinical material.—Male veteran patients are admitted in all branches of medicine and surgery but only a moderate number of female patients are ad- mitted desjjite the fact that certain classifications of them are eligible for treat- ment; hence, there is a marked shortage of clinical material in adult female diseases, as well as those among children. Patients with communicable diseases are not admitted as a general policy, but ample means for segregation and isola- tion make possible the care of such patients when the need arises. The num- ber of beds for the various classes of surgical patients could not be ascertained, but 30 beds are set aside for medical and surgical conditions among women patients. Attention is called to the extensive facilities for the treatment of cancer, both in the hospital and in the reception out-patient department. Patients are not classified as either free or paying, but all are available‘and may be utilized for teaching purposes. During 1943 the average daily census in the hospital was 1,534 and 10,194 pa- tients were admitted. A division of patients admitted into clinical services is not available due to the fact that patients are admitted through the reception out-patient department to the diagnostic service and thoroughly worked up before the diagnosis is announced. The closest possible approximation of surgical patients among those admitted is said to be the number of surgical operations performed, which is given above. In the out-patient department during 1943, for purely out-patient purposes; 14,788 patient visits were registered and 38,186 examinations were made. Autopsies during 1943 were 400/1,126, or 36 percent. Complete protocols are on file in the surgical pathological laboratory for all autopsies performed. Obstetrics.—This hospital does not maintain an obstetrical department. Out-patient department.—The reception out-patient department is staffed by a chief of service and 11 assistants. Patients are admitted in the usual out- patient sense for diagnosis and treatment, and for rating purposes, from about 8:30 a. m. until 4: 30 p. m., daily except Sunday. Complete records of patient visits, physical findings and treatments administered, as well as the physical findings for rating purposes, are on file in the department. The appointment system is utilized as a means of follow-up on patients. Pharmacy.—A full-time, registered pharmacist has supervision of the hospital pharmacy. All pharmaceutical preparations used are of standard quality. Complete records are maintained of drug stock and prescriptions, and narcotic supplies and- records are checked regularly. Nursing.—The nursing service is supervised by a full-time directress of nurs- ing. There was a staff of 173 graduate nurses on duty at the time of survey, 2044 VETERANS’ ADMINISTRATION 24 of whom were in supervisory capacity and 149 on general duty, allowing a nurse-patient ratio of about 1 to 9. An accredited school of nursing for cadet nurses in the last 6 months of their training is conducted by the hospital, with faculty and all facilities for instruction, and 10 pupils were enrolled on the date of survey. Conferences of the entire nursing staff are held monthly for the consideration of administrative and other matters. The graduate and pupil nurses occupy homes which are of modern, fireproof construction. There are, in addition to the graduate and pupil nurses, 277 subsidiary workers on duty who are active in the care of patients in the hospital. Dietary department.—The organized dietary department of the hospital em- ploys 13 dietitians. All members of the group are graduates of approved schools and the chief and nine assistants are members of the American Dietetic Associa- tion. Student dietitians are received for instruction in the department. Members of this group are active in consultation with staff physicians in the planning and preparation of special diets for patients, whose medical records are always available for examination in connection with that purpose. The hospital kitchens, refrigerators, preparation and supply rooms were visited and found to be in sanitary condition. Medical social-service department.—A full-time, trained directress has charge of the medical social-service department, and five qualified assistants are em- ployed. Investigations of social conditions among patients are made when indi- cated and full reports of these investigations are on file in the patients’ medical records and in the department. Discharged patients are followed up by means of home visits, mail and telephone. Library.—A medical library of about 1,000 standard, current texts is main- tained and 40 medical periodicals are received monthly. Heretofore, the hospital librarian has been in charge and the medical library has been open from 2:30 to 4: 30 p. m. daily. It is anticipated that a full-time, qualified librarian will be placed in charge in the event that residents are assigned to the hospital and that the library will be open throughout the day. Residencies.—A graduate training committee of the medical staff, consisting of the chief medical officer, the clinical director, the chief of surgery, the path- ologist and chief of the radiological department has been appointed. A conference was held with the committee by representatives of the graduate training depart- ment of the college on October 16, 1944, at which time a specimen program of graduate training in general surgery was drawn up. Copies of the specimen program have been furnished to the Medical Director of the Veterans’ Admin- istration and to the authorities of this hospital, for consideration and adaptation to their needs. It is believed that this program, as outlined, may be applied, with certain modifications, to all of the 20 veterans’ hospitals under survey. Thus far an affiliation with a medical school for any educational purpose or for the granting of higher medical degrees has not been established. Conclusions.—The Veterans’ Administration hospital at Hines offers excellent opportunities for graduate training in surgery and certain of the surgical special- ties. The hospital is well organized for this purpose and the administration and medical staffs have a fine attitude toward an educational program in graduate training. There is an abundance of good teaching material in both in-patient and out-patient services and a large volume of surgery is done each year. An addi- tional advantage to carrying out a teaching program is the very active and care- fully selected consulting staff, consisting of the best teachers from the four medical schools in Chicago. Paul S. Ferguson, M. D., Director of Surveys. Veterans’ Administration Hospital, Indianapolis, Ind. (Lt. Col. Earl H. Hare, chief medical officer; B. C. Moore, manager) January 27, 1945. General.—This is a general hospital with an official bed capacity of 345. The physical plant consists of two buildings, of three to five stories, modern, fireproof construction. The equipment in all departments appears to be adequate for good diagnosis and care of patients, and is of good quality. The hospital is administered by a manager who is a layman, assisted by the chief medical officer and a clinical director. Members of the medical staff are on United States civil-service status and are assigned to this hospital by the VETERANS’ ADMINISTRATION 2045 medical director of the Veterans’ Administration. The staff functions under Federal regulations. Medical staff.—The full-time medical staff of 14 active members is organized on the closed plan, the chief medical officer acting as chief of staff, assisted by the clinical director. There is basic departmentalization, with departmental heads who are active in control of the clinical work. The consulting staff of 10 members comprises an outstanding group of local medical and surgical special- ists, some of whom are said to be on the faculty of the Medical School of the University of Indiana. Consultants are on fee basis and are called to the hospital as the need arises. It was stated that the medical staff meets regularly throughout the year for a review of the clinical work of the hospital, but only 40 weekly meetings had been held in the 12 months preceding the date of survey. According to the minutes recorded, the program for many of the meetings was composed entirely of administrative-business discussions, but there has been at least one meeting monthly in which there was discussion of clinical cases in general, deaths, ques- tions of diagnosis and treatment. The general nature of the programs left the impression that an attempt was being made to carry out the letter, rather than the spirit, of hospital standardization, inasmuch as the clinical work of an in- stitution of this size cannot be adequately reviewed short of weekly meetings devoted entirely to the clinical review. Departmental meetings and cliuico- pathological conferences are not held. There are no interns or residents on duty in the hospital. Medical records.—The medical records are prepared by the staff medical officers and appear to be complete in all essential details. A full-time, trained librarian has charge of the completed records, assisted by a large corps of trained clerks. Filing is by serial number, a recognized nomenclature is used, and cross- indexing according to disease is up to date. The cross-indexes are used to some extent by the members of the medical staff for group studies and other research purposes. Diagnostic and adjunct facilities.—The hospital has fully equipped and well- organized clinical and surgical pathological laboratories, in which all types of laboratory procedures are carried out. The space allotted to the department appears to be small and cramped, but is said by the pathologist to be sufficiently large to carry on efficient work. The part-time pathologist, Dr. A. J. Bown, is qualified by training and experience and spends about half-time in the depart- ment. He is assisted by three full-time, trained technicians, two of whom are registered. All tissues removed at operation are examined and full reports rendered. The roentgenological department is well equipped with radiographic and fluoroscopic apparatus. The pathologist, Dr. A. J. Brown, also acts as roentgen- ologist and spends about half-time in the department. His qualifications as roentgenologist consists of training and experience. One full-time, trained technician is employed in the department. The department is an extremely active one and the volume of work done is far too great for one technician to care for promptly and efficiently; hence, sufficient technical help should be employed to render prompt and efficient service to patients and members of the medical staff. Complete physiotheraphy facilites are provided in the hospital and are super- vised by Dr. D. K. Adams, the full-time physiotherapy officer. Two full-time registered technicians are employed and complete records of treatments are maintained in the department. Other adjunct facilities are basal metabolic and electrocardiographic apparatus, and occupational therapy, all of which are competently supervised. Surgical department.—The facilities for surgery consist of one major room and a fracture room in the main surgical suite, a cystoscopic room in the roentgenological department, sterilizing and work rooms. While these facilities would appear to be very limited, they are conveniently situated and are said by the surgeons to be adequate in extent for the present needs of the hospital. The supply of surgical instruments is extensive and seems to be sufficient for any type of operation ordinarily performed by the surgical staff. Two graduate nurses and one orderly are assigned to the department. The full-time surgical staff consists of four members, sttpervised by the chief of department. The chief of the service and one assistant do all of the general surgery, including orthopedics and gynecology, one member performs all opera- tions in urological surgery, and the fourth member is the specialist in opthal- mology-otolaryngology with responsibility for all surgery in that combined spe- 2045 2046 VETERANS’ ADMINISTRATION cialty. It appears that the services of the surgical consultant are seldom employed as far as the performance of operations is concerned. The chief of surgery is responsible, through the manager, chief medical officer and clinical director, to the Medical Director of the Veterans’ Administration for all surgery done in the hospital; other members of the general surgical and specialty divisions necessarily share in his responsibility, however. Additional means for the control of surgery are, limitation of privileges, routine examina- tion of tissues removed, the closed-staff organization, and complete preoperative recording. Anesthetics in the department are administered by members of the surgical and medical staffs and are supervised by Dr. V. F. Tremor, chief of surgery. The usual types of anesthesia are used, including pentothal sodium: Special records are not made of the anesthetics administered. Full recording of the physical examination, diagnostic laboratory procedures and the provisional diagnosis is required before the administration of an anesthetic may begin. Any infections occurring postoperatively in clean surgical cases are recorded in the office of the chief of surgery. In the event that a postoperative infection occurs, the incident is carefully investigated, the source of infection determined if, possible, and corrective measures taken. During the year 1943 there were 500 major and 682 minor operations per- formed in the hospital, including those in ophthalmology, otolaryngology. It was stated that all surgical material, with the possible exception of opthal- mology-otolaryngology, would be available for use in the training of residents. Records as to the nature of the operations performed, collectively, or their division into general and sepcialized surgery, were not available for review. Since there are no residents in the hospital, a statement as to how many opera- tions will be performed by a resident in any year cannot be made. In the past, however, younger surgeons on a status comparable to residents have done a limited volume of major and minor surgery under supervision. This arrange- ment will continue until such time as residencies may be established in the hos- pital, although the younger surgeon will be advanced in responsibility in surgery as ability is demonstrated. Clinical material.—Male veteran patients are admitted in all general branches of medicine and surgery, but the admission of female patients is sharply limited at present. Patients with communicable diseases are not admitted as a general policy, but ample means for segregation and isolation make possible the care of such patients when the need arises. There is no specific number of beds allotted to the care of surgical patients. Patients are not classified as either free or paying, but all are available and may be utilized for teaching purposes. During 1943 the average daily census in the hospital was 210, and 2,430 pa- tients were admitted. A division of the admissions into clinical services is not available due to the fact that patients are admitted through the reception out- patient department to the diagnostic service and thoroughly worked up before the diagnosis is announced. The closest possible approximation of surgical patients among those admitted is said to be the number of surgical operations performed, which is 500 major and 682 minor. In the out-patient department during 1943, for purely out-patient purposes, 1,648 individuals were given 2,387 treatments and 3,538 patients were admitted for a total of 8,152 examinations, the latter probably chiefly for rating purposes. Autopsies during 1943 were 39/192, or 20 percent. Complete protocols are on file in the surgical pathological laboratory for all autopsies performed. Obstetrics.—The hospital does not maintain an obstetrical service. Out-patient department.—The clinical director of the hospital is in charge of the out-patient .reception service, assisted by other members of the full-time' medical staff. Patients are admitted in the usual out-patient sense for diagnosis and treatment, and for rating purposes, from about 8 a. m. until 4: 30 p. m., daily except Sunday. Complete records of patient visits, physical findings, and treatments administered, as well as the physical findings for rating purposes, are made and filed in the department. The appointment system is used as a means of follow-up of patients. Pharmacy.—A full-time registered pharmacist has supervision of the hospital pharmacy. All pharmaceutical preparations used are of standard quality. Complete records of prescriptions and drug stock are maintained, and narcotic records and supplies are checked regularly. Nursing.—The nursing staff is supervised by a full-time directress of nursing. There was a staff of 33 graduate nurses on duty at the time of surgery, 6 of whom were in supervisory capacity and 27 on general duty, allowing a nurse-patient VETERANS’ ADMINISTRATION 2047 ratio of about 1 to Conferences of the entire nursing staff are held regularly each week throughout the year, for the consideration of administration and other matters. The nurses occupy a home which is of modern, fireproof construction. There are, in addition to the graduate nurses, 39 subsidiary workers on duty who are active in the care of patients in the hospital. Dietary department.—Two dietitians are employed in the organized dietary department of the hospital, both of whom are graduates of approved schools of dietetics and members of the American Dietetic Association. Members of the department are active in consultation with staff physicians in the planning and preparation of special diets for patients, whose medical records are always available for examination in connection with that purpose. The hospital kitchen, refrigerators, preparation, and supply rooms were visited and found to be in sanitary condition. Medical social service department.—The department of medical social service employs one full-time trained worker, who makes investigations of home con- ditions when indicated. Full reports of these investigations are on tile in the patients’ medical records and in the department. The department follows up discharged patients to some extent through the media of mail and telephone. Library.—The medical library consists of 269 current standard textbooks and 16 medical periodicals are received monthly. A full-time librarian has charge of the medical library. Residences.—Plans have not been drawn up for graduate training programs in general surgery or the surgical specialties. An affiliation with a medical school for any educational purpose or for the granting of higher medical degrees has not been established. Conclusions.—The possibilities of the Veterans’ Administration hospital in Indianapolis as a center for graduate training in general surgery appear to be rather limited. The quantity of clinical material in admissions to the hospital justified the establishment of a program, but the material in admissions to the out-patient department is limited and the treatment of patients by surgery seems to be definitely on the conservative side. The medical staff appears to be well organized, but fellowship in the college is not represented among members of the surgical group. It is my opinion that this institution is not qualified to take on a resident for training in a 4-year program; however, it should be considered in the over-all program in veterans’ hospitals as eligible to give partial training. There is every probability that a resident would receive good training during 1 or 2 years of residency. Among the points to be considered if a graduate training program is to be established in this institution are: The adequate review of the clinical work of the hospital in general staff meetings and the holding of departmental meetings and/or clinicopathological conferences; cross-indexing of the medical records according to operation; full-time, qualified physician specialists in charge of the clinical laboratory and roentgenological department; a sufficient number of trained technicians in the roentgenological department to render prompt and effi- cient service; the possibility of additional space being needed by the clinical laboratory and in the surgical facilities; and the percentage of autopsies. It is recommended by the American College of Surgeons that the autopsy percentage in hospitals where graduate training programs are functioning or are contem- plated should be at least 50 percent and as much more as possible. All of the fore- going considerations are likewise of importance in the field of hospital standard- ization. Paul S. Ferguson, M. D., Director of Surveys. VETERANS’ ADMINISTRATION HOSPITAL, WADSWORTH, KANS (Col. Charles M. Pearsall, manager; Dr. Gail D. Allee, chief medical officer) March 21,1945. General.—This is a general hospital with an official bed capacity of 742. The physical plant at the time of survey consisted of four hospital buildings of four to six stories and basement, modern, fireproof construction. The buildings located on the home-hospital grounds, formerly used for domiciliary purposes, have been vacated and some of them are being renovated and remodeled for hos- pital purposes; in addition, several new brick, fireproof buildings are being built, making a total of 14 buildings, renovated and new, with a bed capacity of 1,130. 2048 VETERANS’ ADMINISTRATION These beds, and 120 beds in the general-hospital portion of the institution, are to be occupied by neuropsychiatric patients. It is expected that 400 beds in the new construction will be ready for occupancy within 00 days from the day of survey. The equipment in all departments appears to be adequate and is of good quality. 4 The hospital is administered by a manager, who is a layman, and is assisted on the clinical side by a chief medical officer and clinical director. Members of the medical staff are on either United States Army Medical Corps or United States civil-service status and are assigned to this hospital by the Medical Director of the Veterans’ Administration. The medical staff functions under Federal regulations. Medical staff.—The full-time medical staff of 29 active members is organized on the closed plan, the chief medical officer acting as chief of staff. There is basic departmentalization with departmental heads who are active in the control of the clinical work. The consulting staff of three members includes a general sur- geon, a specialist in ophthalmology-otolaryngology, and a roentgenologist, all from nearby cities and all of whom are on fee basis. The medical staff meets regularly each week throughout the year for a review of the clinical work of the hospital. The program consists of the consideration of clinical cases and deaths, tissue specimens and autopsy materials, discussion of medical subjects related to the care and treatment of patients, and sometimes administrative matters or medical motion pictures in addition. These meetings appear to afford a fairly adequate review of the clinical work and are regularly attended by the pathologist-radiologist. Minutes and attendance records for the general-staff meetings are kept. Departmental meetings or clinicopathological conferences are not held. There are, at present, no interns or residents in the hospital. Medical records.—The medical records are prepared by the staff medical offi- cers and appear to be complete in all details. A full-time, trained librarian has charge of the completed records, assisted by a large corps of trained clerks. Filing is by serial number, recognized nomenclatures are used, and cross-indexing according to disease is up to date. The cross-indexes, as far as developed, are used but little by the medical staff for group studies or other purposes. Diagnostic and adjunct facilities.—The hospital has fully equipped clinical and surgical pathological laboratories in which all of the usual types of laboratory procedures are carried out; some of the more unusual serological tests, however, are sent to the veterans’ hospital at Hines, 111. The part-time pathologist, Maj. S’. F. Hoge, is qualified by training and experience and spends approximately half time in the department. He is assisted by four full-time, trained techni- cians, two of whom are registered. All tissues removed at operation are exam- ined and full reports rendered. The roentgenological department is well equipped with radiographic and fluoroscopic apparatus. The pathologist, Maj. S. F. Hoge, also acts as roent- genologist and spends about half of his time in this department. He is qualified for roentgenology by training and experience. One full-time, trained technician is employed in the department. The facilities for physical therapy are complete and are supervised by Capt. M. Hoberman, orthopedist on the surgical staff. Two full-time, trained techni- cians are employed and complete records of treatment are maintained in the department. Other adjunct facilities are basal metabolic and electrocardio- graphic apparatus, and occupational therapy, all of which are competently supervised. Surgical department.—The facilities for surgery consist of two major operating rooms, plaster rooms, cystoscopic room in the roentgenological department, one major operating room for ophthalmology-otolaryngology, sterilizing and work rooms. The various rooms are situated for the greatest convenience and appear to afford adequate surgical facilities for the present size of the hospital. The supply of surgical instruments is extensive and probably is sufficient for any operation the surgeons may be called upon to perform. One graduate nurse is regularly assigned to the department and additional nurses are available when surgery is to be done. The full-time general surgical staff consists of four members, supervised by the chief of surgery. The general, orthopedic, urological, and neurosurgery is done by members of the full-time staff without much specialization. The one ophthal- mologist-otolaryngologist on the surgical staff does all of the surgery in that combined specialty. VETERANS’ ADMINISTRATION 2049 The chief of surgery and the ophthalmologist-otolaryngologist are responsible, through the manager and the chief medical officer, to the Medical Director of the Veterans’ Administration for all surgery done in the hospital; other members of the surgical staff necessarily share in their responsibility, however. Other means for the control of surgery are, limitation of privileges, routine examina- tion of tissues removed, the closed staff organization, and complete preoperative recording. All anesthetics in the department are administered Ijy members of the sur- gical staff and are supervised by Maj. J. B. Griffin, a staff surgeon. The usual types of anesthesia are used, including pen tot ha 1 sodium; special records are made of anesthetics administered and there are some postanesthetic notations recorded. Full recording of the physical examination, diagnostic laboratory procedures, and the provisional diagnosis is required before the administration of an anesthetic may begin. Infections occurring postoperative!y in clean surgical cases are recorded in patients’ medical records, whereas there should be a complete, centralized record of these infections in the office of the chief of surgery or elsewhere in the hospital. Daring the year 1944 there were 240 major and 296 minor operations per- formed in the hospital. Records as to the nature of these operations, collec- tively, or their division into general or specialized surgery, were not available for review. Since there are no i-esidents in the hospital, a statement as to how many operations will be done by a resident in any year cannot be made. In the past, however, younger surgeons on a status comparable to residents have done a limited volume of major and minor surgery under supervision. This arrange- ment will continue until such time as residencies may be established in the hos- pital. although the younger surgeon will be advanced in responsibility in surgery as ability is demonstrated. Clinical material.—Male veteran patients are admitted in all general branches of medicine and surgery, and female patients are admitted only for emergency conditions. Patients with communicable diseases are not admitted as a general policy, but ample means for segregation and isolation make possible the care of such patients when the need arises. While there are no beds allotted to the various types of surgical patients, at present, 200 beds are reserved for all surgical patients. Patients are not classified as either free or paying, but all are available and may be utilized for teaching purposes. During 1944 the avex-age daily census of the hospital was 489, and 3,536 patients were admitted. A division of patients admitted into clinical services shows that the following were admitted for surgical treatment: 536 in general surgery, 8 in plastic surgery, 138 in proctology, 8 in thoracic surgery, 11 in neurological sur- gery, 82 in orthopedic surgey, 41 in urological surgery, 15 in ophthalmology, 21 in otolaryngology; in addition, 241 acute fractures were admitted for treatment and 11 open reductions were performed among them. In the out-patient department during 1944 there were 27,319 patient visits, of which 3,178 visits were in general surgery and the allied surgical specialties. Autopsies dxxring 1944 were 64/251, or 26 percent. Complete protocols are on file in the surgical pathological laboratory for all autopsies performed. Obstetrics.—An obstetrical service is not maintained in the hospital. Out-patient department.—The reception out-patient department is staffed by a chief of service and four assistants, all members of the full-time medical staff. Patients are admitted in the usual out-patient sense for diagnosis and treatment, and for rating purposes, from 8: 30 a. m. until 4: 30 p. in., daily except Sunday. Complete x’ecords of patient visits, physical findings, and treatments adminis- tered. as well as the physical findings for rating purposes, are made and are on file in the department. The appointment system is used as a means of follow-up on patients. Pharmacy.—The hospital pharmacy is supervised by a full-time, registered pharmacist. Only pharmaceutical preparations of standard quality are used. Complete x*ecords of drug stock and prescriptions are maintained, and narcotic records and supplies are checked regularly. Nursing.—The nursing staff is supervised by a full-time directress of nursing. There was a staff of 68 graduate nurses on duty at the time of survey, 8 of whom were in supervisory capacity, and 60 on general duty, allowing a nurse- patient ratio of about 1 to 7. Conferences of the entii‘e nursing staff are held monthly for the consideration of administrative and other matters. The nurses are housed in a home that is of modern, tii'eproof construction. 75183—45—pt. 5 14 2050 VETERANS’ ADMINISTRATION There are, in addition to the graduate nurses, 79 subsidiary workers on duty who are active in the care of patients in the hospital. Dietary department.—Three dietitians are employed in the organized dietary department of the hospital. All are graduates of approved schools of dietetics and all are members of the American Dietetic Association. Members of the de- partmental staff are active in consultation with staff physicians in the planning and preparation of special diets for patients, whose medical records are always available for examination in connection with that purpose. The hospital kitchens, refrigerators, preparation, and supply rooms were visited and found to be in sanitary condition. Medical social service department.—One full-time, trained investigator is employed in the department of medical social service. Her work is confined to medical social-service investigations among the syphilitic patients, and full reports of these investigations are on file in the patients’ medical records and in the department. The department follows up discharges through the health department of the State of Kansas, which sends reports to the health depart- ments of other States if indicated Library.—The medical library in the hospital consists of 398 current, standard texts and 29 medical periodicals are received monthly. A full-time librarian is in charge of the medical library. Residencies.—Plans have not been drawn up for graduate training programs in general surgery or the surgical specialties. An affiliation with a medical school for any educational purpose or for the granting of higher medical degrees has not been established. Conclusions.—The Veterans’ Administration hospital in Wadsworth appears to be sufficiently well organized as to administration and surgical staff to warrant consideration of the establishment of a graduate training program in general surgery. The volume of clinical material in admissions to the hospital and the out-patient department is probably sufficient for adequate training but the treat- ment of patients by surgery appears to be on the conservative side and the volume of surgery done is somewhat less than would be inquired for a fully developed program. It is my opinion that, at present, this hospital is eligible to take part in the over-all graduate training program but can scarcely undertake complete training of surgeons. Members of the surgical and diagnostic staff appear to he interested in their work but expressed only mild interest in the possibility of graduate training in surgery coming to their hospital. The chief of surgery is a fellow of the American College of Surgeons. The points of importance to be considered in connection with the establishment of a program of graduate training in surgery in this hospital are: Surgical de- partment meetings and clinicopathological conferences at regular and frequent intervals; cross-indexing of the medical records according to operation; qualified full-time physicians in charge of the clinical laboratory and X-ray departments; a substantial increase in the autopsy percentage, inasmuch as an autopsy per- centage as near to 50 percent as possible is recommended by the American College of Surgeons for hospitals where graduate training programs are being conducted or are contemplated; complete, centralized recording of infection occurring postoperatively in clean surgical cases. The foregoing points are also of importance in the field of hospital standardi- zation. Paul S. Ferguson. M. D., Director of Surveys. Veterans’ Administration Hospital, Minneapolis, Minn. (Maj. Harry E. Bank, chief medical officer; Mr. C. D. Hibbard, manager) March 22, 1945. General.—This is a general hospital with an official bed capacity of 786. The physical plant consists of five buildings of two to five stories, modern, fireproof construction. Equipment in all departments appears to be adequate and is of good quality. The hospital is administered by a manager who is a layman, assisted by the chief medical officer and the clinical director. Members of the medical staff are on either United States Army Medical Corps or United States Civil Service status and are assigned to this hospital by the Medical Director of the Veterans’ Administration. The medical staff functions under Federal regulations. VETERANS’ ADMINISTRATION 2051 Medical staff.—The full-time medical staff of 53 active and 4 Dental Corps members is organized on the closed plan, the chief medical officer acting as chief of staff. There is basic departmentalization, with heads of departments who are active in control of the clinical work. The consulting staff of four mem- bers includes local surgical specialists and an anesthetist of outstanding ability. Some members of this group are on the faculty of the medical school of the Uni- versity of Minnesota, and all are part-time, salary basis and visit the hospital regularly. The medical staff meets regularly each week throughout the year for a review of the clinical work of the hospital. The programs consist of consideration of clinical cases and deaths, pathological tissues and autopsy material, discussion of medical subjects of importance in the care and treatment of patients, some- times administrative business and occasionally medical motion pictures. These meetings appear to afford a fairly adequate review of the clinical work and are regularly attended by the pathologist and radiologist. 'Minutes and attendance records of the meetings are kept. Departmental meetings and clinicopathologi- cal conferences are not held. There are at present no residents or internes in the hospital. Medical records.—A Dill-time, trained librarian has charge of the completed medical records, assisted by a large corps of trained clerks. The records are pre- pared by the staff medical officers and appear to be complete in all details. Filing is by serial number, recognized nomenclatures are used, and cross-indexing ac- cording to disease is up to date. The cross-indexes, as far as developed, are said to be used but little by the medical staff for group studies or other purposes. Diagnostic and adjunct facilities.—The clinical and surgical pathological labo- ratories of the hospital are fully equipped and well organized, and all types of laboratory procedures are carried out. The full-time pathologist, Maj. William Hentel, is qualified by training and experience. He is.assisted by a corps of seven full-time, registered technicians. All tissues removed at operation are examined and full reports rendered. This department appears to be in need of additional space, inasmuch as the equipment is crowded in the present space, which delays the carrying out of procedures and may, to some extent, affect the accuracy of the technicians’ work. The roentgenological department is well equipped with radiographic and fluo- roscopic apparatus. The full-time roentgenologist, Capt. H. A. Myers, is qualified by training and experience. Four full-time trained technicians are employed in the department, two of them registered. Facilities in the physical therapy department of the hospital are complete and are supervised by Dr. L. C. Jensen, a member of the orthopedic surgical staff. Five full-time, trained technicians are employed and two of them are registered. Complete records of treatments are maintained in the department. Other adjunct facilities are basal metabolic and electrocardiographic appa- ratus, and occupational therapy, all of which are competently supervised. Surgical department.—The facilities for surgery consist of two major oper- ating rooms, a cystoscopic room in the urological department, one minor room for ophthalmology-otolaryngology, sterilizing and work rooms. The supply of surgical instruments seems to be sufficient in extent and variety for any type of operation usually performed in the hospital. Five graduate nurses and one orderly are assigned to the department. The present facilities for surgery are entirely inadequate as regards operating space and safeguarding against cross infection. The two major operating rooms are both very small; there is not a sufficient number of scrub-up sinks; the sur- geons’ dressing room is not more than 8 by 8 feet in size and the nurses’ work- room and the anesthetic storage room are much too small for the purpose in- tended. The doorways leading into the operating rooms, the surgeons’ dressing room, and the scrub-up space, from the corridor of the surgical suite, are not closed by doors or by any other means. As a result there is no privacy in oper- ating or dressing rooms, offering the temptation to the surgeons to scrub inade- quately, and making no provision for the prevention of cross infection. Larger, more extensive and more suitably appointed facilities for surgery should be provided. The full-time, general surgical staff consists of six members, supervised by the chief of surgery. Most of the general and orthopedic surgery is done by members of the full-time staff, without much specialization, while the urological surgery is done by the full-time, urological surgeon. A fair portion of the gen- 2052 VETERANS’ ADMINISTRATION eral and orthopedic surgery, and all of the thoracic surgery, is done by members of the consulting surgical staff. There is one ophthalmologist-otolaryngologist on the staff who does all of the surgery in that combined specialty. The chief of surgery and the ophthalmologist-otolaryngologist are responsible, through the manager and the chief medical officer, to the Medical Director of Ihe Veterans’ Administration for all surgery done in the hospital; other members of the general surgical and specialty divisions necessarily share in their respon- sibility, however. Additional means for the control of surgery are limitation of privileges, routine examination of tissues removed, the closed staff organization, and complete preoperative recording. Anesthetics in the department are administered entirely by members of the surgical staff and are supervised by Lt. Michael Petras. The usual types of anesthesia are used, including cyclopropane, ethylene, and pentothal sodium; special records are made of anesthetics administered and there are some post- anesthetic notations recorded. Full recording of the physical examination, diag- nostic laboratory procedures, and the provisional diagnosis is required before the administration of an anesthetic may begin. A record is not kept of infections occurring postoperatively in clean surgical cases in the hospital. A definite plan should be formulated and adopted whereby a complete record would be kept of all postoperative infections, an attempt would be made to ascertain the source of infection, following which positive corrective measures should be taken. The record of infections, investigation of them, and the corrective measures taken should be maintained in the office of the chief of surgery or other convenient place in the hospital. Operations performed in the hospital during the year 1944 numbered 450 major and 3,356 minor. Records ak to the nature of these operations, collectively, or their division into general and specialized surgery, were not available. Since there are no residents in the hospital, a statement as to how many operations will be performed by a resident in any year cannot be made. In the past, however, younger surgeons on a status comparable to residents have performed a limited number of major and minor operations under supervision. This arrangement will continue until such time as residencies may be established in the hospital, although the younger surgeons will be advanced in responsibility in surgery as ability is demonstrated. Clinical material.—Male and female veteran patients are admitted in all general branches of medicine and surgery. Patients with communicable diseases are not admitted as a general policy, but ample means for segregation and isolation make possible the care of such patients when the need arises. Beds for surgical patients are allotted as follows: 81 for general surgery and ophthalmology- otolaryngology, 89 for orthopedic surgery, and 78 for urological surgery. Patients are not classified as either free or paying, but all are available and may be utilized for teaching purposes. The average daily census of the hospital during 1944 was 618, and 3,789 patients were admitted. An approximate division into clinical services of the patients admitted indicates that the following were admitted for surgical treat- ment: 746 in general surgery, 7 in plastic surgery, 115 in proctology, 49 in thoracic surgery, 139 in orthopedic surgery, 48 in urological surgery, 4 in gynecological surgery, 37 in ophthalmology, and 138 in otolaryngology; in addi- tion, 72 acute fractures were admitted and 10 open reductions were performed among them. In the out-patient department during 1944, for purely out-patient purposes, there were 11,556 patient visits. An approximate division of the visits into general surgery and the surgical specialties was not available. Autopsies during 1944 were 122/289 or 42 percent. Complete protocols are on file in the surgical pathological laboratory for all autopsies performed. Obstetrics.—The hospital does not maintain an obstetrical service. Out-patient department.—The out-patient department is staffed by a chief of service and several assistants. Patients are admitted in the usual out-patient sense for diagnosis and treatment, and for rating purposes, from 8 a. m. until 4: 30 p. m. daily except Sunday. Complete records of patient visits, physical findings, and treatments administered, as well as the physical findings for rating purposes, are made and filed in the department. The appointment system is used ns a means of follow-up on patients. Pharmacy.—A full-time, registered pharmacist has supervision of the hospital pharmacy. All pharmaceutical preparations used are of standard quality. Com- VETERANS’ ADMINISTRATION 2053 plete records of drug stock and prescriptions are maintained and narcotic records and supplies are checked regularly. Nursing.—The nursing staff is supervised by a full-time directress of nursing. There was a staff of 85 graduate nurses on duty at the time of survey, 13 of whom were in supervisory capacity and 72 on general duty, allowing a nurse-patient ratio of about 1 to 7. Conferences of the entire nursing staff are held regularly each month for the consideration of administrative and other matters. The nurses are housed in a home that is of modern, fireproof construction. There are, in addition to the graduate nurses, 101 subsidiary workers on duty who are active in the care of patients in the hospital. Dietary department.—Five dietitians are employed in the organized dietary department of the hospital. All of the dietitians are graduates of approved schools and the chief and two of her assistants are members of the American Dietetic Association. Members of the departmental staff are active in consulta- tion with staff physicians in the planning and preparation of special diets for patients, whose medical records are always available for examination in con- nection with that purpose. The hospital kitchen, refrigerators, preparation, and supply rooms were visited and found to be in sanitary condition. Medical social-service department.—Four full-time workers are employed in the department of medical social service, three of whom are said to be qualified by formal training. Social and financial investigations are made of patients when indicated, and full reports of these investigations are on file in the patients’ medical records in the department. The follow-up of discharged patients is chiefly through visits to their homes, allowing first-hand investigation. Library.—The hospital maintains a medical library of about 200 current, stand- ard texts and receives 28 medical periodicals monthly. A full-time librarian is in charge of the medical library. Residencies.—A committee of the medical staff, of which the chief medical officer is chairman, has been appointed for graduate training purposes, but it was stated that nothing has been done toward drawing up programs in general surgery or the surgical specialties. An affiliation with a medical school for any educa- tional purpose or for the granting of higher medical degrees has not been established. Conclusions.—This institution would appear to be eligible for inclusion among those in which the establishment of a graduate training program in general surgery may be considered, inasmuch as the surgical staff is well organized and admin- istered, the volume of clinical material in admissions to the hospital and out- patient department, and the volume of surgery, are sufficient for the purpose. It is probable that a full 4-year program could be carried out, and especially so when the facilities of the University of Minnesota Medical School are available to supplement the instruction given by the surgical staff of the hospital. Dr. O. H. Wangensteen, professor of surgery, and Dr. E. T. Bell, professor of path- ology of the medical school, were interviewed during the visit and they were posi- tive in their opinion that the authorities of the medical school would cooperate fully in a graduate training program in this hospital. The chief of surgery is a fellow of the American College of Surgeons. He and several of his assistants were interviewed and all appear to be high-class men. All were extremely in- terested in the possibility of a graduate training program being established in the hospital. Points of importance to be considered in connection with the establishment of a graduate training program in this institution are: surgical departmental meet- ings an"TJSON, M. D., Director of Surveys. Veterans’ Administration Hospital, Kecoitghtan, Va (Lt. Col. John E. Kelly, chief medical officer; Col. Keith Ryan, manager) May 19, 1945. General.—This is a general hospital with an official bed capacity of 538. The physical plant consists of a four- to six-story and basement, modern, fireproof building. The equipment in all departments appears to be adequate for efficient diagnosis and treatment and is of good quality. The hospital is administered by a manager who is a layman, assisted by the chief medical officer and a clinical director. Members of the medical staff are on United States civil service status and are assigned to this hospital by the 2080 VETERANS’ ADMINISTRATION Medical Director of the Veterans’ Administration. The medical staff functions under Federal regulations. Medical staff.—The full-time medical staff of 15 active and 3 Dental Corps members is organized on the closed plan, the chief medical officer acting as chief of staff, assisted by the clinical director. There is basic departmentalization with departmental heads who are active in control of the clinical work. The one consultant is a specialist in urology from a nearby locality, who is on part- time, salary basis and visits the hospital twice weekly. The medical staff meets regularly each week throughout the year for a review of the clinical work of the hospital. Programs consist of the consideration of patients admitted, diagnoses and treatment, clinical cases in general, deaths for general review, and rarely administrative matters. Clinicopathological confer- ences are held weekly throughout the year. These meetings appear to afford an adequate review of the clinical material and are regularly attended by the pathologist-radiologist. Minutes and attendance records of the general staff meetings are kept. Departmental meetings are not held on account of the small size of the medical staff. There are at present no interns or residents on duty in the hospital. Medical records.—A full-time, trained librarian has charge of the completed medical records, assisted by a large corps of trained clerks. The records are prepared by the staff medical officers and appear to be complete in all essential details. Piling is by serial number, recognized nomenclatures are used, and cross-indexing according to disease and operation is up to date. The cross- indexes are used to some extent by the medical staff for group studies and other research purposes. Diagnostic and adjunct facilities.—The hospital has fully equipped and well- organized clinical and surgical pathological laboratories, in which all usual types of laboratory procedures are carried out; some of the more unusual serological tests are carried out for this laboratory by the department in the San Francisco and Hines Veterans' Hospitals, however. The part-time pathologist, Dr. B. Miller, is qualified by training and experience, and spends about half-time in this department. He is assisted by three full-time, trained technicians, two of whom are registered. All tissues removed at operation are examined and full reports rendered. The roentgenological department is well equipped with radiographic and fluoro- scopic apparatus. The pathologist, Dr. B. Miller, also acts as roentgenologist and spends approximately half-time in the department. He is qualified for roetgenology by training and experience. Two full-time, trained technicians are employed. The facilities for physical therapy in the hospital are fairly complete and are supervised by the pathologist-radiologist. Two full-time, trained technicians are employed, of whom one is registered, and complete records of treatments are maintained in the department. Other adjunct facilities are basal metabolic and electrocardiographic apparatus, and occupational therapy, all of which are competently supervised. Surgical department.—The facilities for surgery consist of one major and one minor general operating rooms, a fracture room, one major room for ophthal- mology-otolaryngology, a cystoscopic room in the roentgenological department, sterilizing and work rooms. The various rooms are situated to good advantage and are said by the surgeons to be adequate in extent for the present size of the hospital. The supply of surgical instruments appears to be sufficient in num- ber and variety for any type of operation ordinarily performed in the hospital. Two graduate nurses and one orderly are assigned to the department. The full-time surgical staff consists of five members, supervised by the chief of surgery. The general surgery, and all specialized surgery with