The Rochester Regional Hospital Council [Reprint 2014 ed.] 9780674432277, 9780674432260

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T h e R ockester Regional H o s p i t a l Council

Published for The Commonwealth Fund by Harvard University Press Cambridge, Massachusetts NINETEEN HUNDRED FIFTY-SIX

T k e Rochester Regional Hospital Council L E O N A R D S. ROSENFELD,m.D.,M.P.H. H E N R Y B. M A K O V E R , M.D.

© Copyright 1956 by the Commonwealth Fund Distributed in Great Britain by Geoffrey Cumberlege, Oxford University Press, London Library of Congress Catalog Card No. 56-6522 Printed in the United States of America

Preface The conviction is growing in medical care and hospital administration that effective organization of services on a regional basis is essential if we are to realize maximum benefit from advances in medical science. Every scientific and technologic advance in medicine which tends to increase specialization of facilities and personnel, and to increase costs of service, also tends to increase inequities in the availability of service between metropolitan and rural areas. By establishing a framework of coordination within a region composed of a metropolitan center and surrounding rural area, an organizational device is introduced which is designed to counteract the undesirable effects of such progress. Because of the complexity of the structure of health services in most communities in this country, characterized as it is by a multiplicity of specialized voluntary and public agencies, local, state, and national, the development of an over-all framework is particularly difficult. Our problem is the development of administrative methods which would secure the values of overall planning and coordination, while at the same time retaining the values of local responsibility and initiative. In this respect, the program of the Rochester Regional Hospital Council constitutes one of the most significant developments in the country. For this reason, the Institute of Administrative Medicine was particularly pleased at being invited by the Commonwealth Fund to undertake this study. It was

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PREFACE

felt that, in addition to rendering a service of possible value to the Commonwealth Fund and the Rochester Regional Hospital Council, it would afford the Institute an opportunity to study in some detail the factors which have influenced the development of this successful demonstration. The study was initiated in January, and completed in July, 1954. The methods for the study were developed, and the report was written, by Dr. Leonard S. Rosenfeld and Dr. Henry B. Makover, Co-Directors of the study. Dr. Rosenfeld was responsible for directing the field work. In this he was assisted by Dr. Magda Shorney, Mr. Philip Schumacher, and Miss Mary Monk, who helped in visiting member hospitals and in interviewing key personnel. Mrs. Helen Culian, Medical Record Librarian of the Council, helped in accumulating statistical data from hospitals. Dr. John Silson, assisted by Miss Anne Baranovsky, was responsible for analysis of certain of the statistical data. Many other individuals and agencies contributed to the study. The Bureau of Vital Statistics of the New York State Department of Health provided information on the location of births to residents of the Rochester region. The New York State Department of Social Welfare provided financial data from reports submitted by hospitals in the region. The Joint Hospital Survey and Planning Commission of New York State made available information on hospital facilities. The Joint Commission on Accreditation of Hospitals made available records of inspection of Regional Hospitals. The Division of Public Health Methods of the U:S. Public Health Service authorized the use of a descriptive report of the Rochester Region which had been prepared in 1952 in connection with a study of regional organization of health services. Dr. Ira Hiscock, Chairman of the Department of Public Health of Yale University, who recently conducted a study of health organization in the City of Rochester, provided certain in-

PREFACE

vii

formation concerning health agencies in Rochester and Monroe County. Dr. Paul A. Lembcke of the Johns Hopkins School of Public Health was consulted on the history of the development and early organization of the Council. In addition to providing support for the study, the Commonwealth Fund made available their files covering the origin and development of the Council. The late Dr. Albert Kaiser, Medical Health Officer of the City of Rochester and Medical Associate of the Council, contributed generously of his time to discussion of various phases of the Regional program. We are very grateful to the officers and staff of the Rochester Regional Hospital Council and the trustees, physicians, and personnel of Regional hospitals and to staff members of various health and related agencies in Rochester for their cooperation in providing the great volume of information on which this report is based. We hope that the report will prove useful to the Commonwealth Fund and the Rochester Regional Hospital Council, as well as to those who are now, or may in the future be, concerned with the development of regional organization. December 8,1955 E . DWIGHT RARNETT

Professor of Administrative Medicine Columbia University School of Public Health and Administrative Medicine

Foreword by Malcolm P. Aldrich 1 Introduction THE ROCHESTER PROGRAM THE STUDY

2 Area HEALTH PERSONNEL HOSPITAL FACILITIES

3 The Council and Its Organization MEMBERSHIP THE COUNCIL AND ITS RESPONSIBILITIES RELATIONS W I T H OTHER AGENCIES FINANCING COMMENT

CONTENTS

The Council's Program of Education

57

MEDICAL EDUCATION EDUCATION O F HOSPITAL ADMINISTRATORS NURSING EDUCATION OTHER HOSPITAL PERSONNEL TRUSTEE EDUCATION COMMENT

The Council and Hospital Services

102

ADVISORY SERVICES COOPERATIVE SERVICES RELATED REGIONAL HOSPITAL SERVICES RENDERED BY OTHER AGENCIES COMMENT

The Council and Health Resources

143

HOSPITAL PLANNING AND CONSTRUCTION DISTRIBUTION OF PHYSICIANS HOSPITAL PERSONNEL

Research

169

Conclusions

181

Appendix. Member Hospitals of the Rochester Regional Hospital Council 195 Notes and References

197

Index

201

Foreword During the years 1925 to 1948 the Commonwealth Fund helped to build fourteen general hospitals in small communities some distance removed from the larger metropolitan centers. In addition to providing money for building, The Commonwealth Fund also assisted these communities in an advisory way in meeting certain organizational and operational problems connected with these hospitals, especially during their early years. The major objective of this hospital program was to demonstrate the degree to which the level of medical service and patient care in rural areas could be raised so as to compare more favorably with that available in urban centers. After the program had been in operation for twentythree years, the point of diminishing returns was being reached insofar as the experimental and demonstration aspects of the program were concerned. In 1946 the Hill-Burton Act made funds available toward such hospital construction costs, and in 1948 the rural hospital building program of the Commonwealth Fund was terminated. The interest of the Commonwealth Fund in the general availability of a high order of medical service and patient care has continued, and in some respects increased, since the ending of the rural hospital program. One of the outgrowths of the original program was a plan to determine in what ways, and to what extent, concerted voluntary action by hospitals through a representative regional organization would stimulate

FOREWORD

and encourage an upgrading in the quality of services rendered and make possible more efficient and coordinated use of the region's medical facilities. From this plan there developed the Rochester Regional Hospital Council. Three specific fields of action which offered promise for developments of this nature were: first, the joint planning of hospital building and expansion; second, the joint operation of institutional services which can be performed more efficiently by the group than by the individual institutions; and third, the pooling of clinical, administrative, and technical skills. Widespread interest in the Rochester regional hospital program convinced the Commonwealth Fund that a report of the experiment should be available for the benefit of those unable to visit Rochester to study the program in person. Accordingly, the Institute of Administrative Medicine at Columbia University was asked to make an objective survey of the operation of the regional plan and prepare a report on its organization and program, with particular attention directed toward the setting up of a balance sheet of its accomplishments and limitations. The Commonwealth Fund consulted many leaders in hospital administration and medical education during the process of drawing up the original proposal presented to the Rochester region, and was its adviser and principal financial sponsor during the initial years of operation. For this reason the Fund has purposely refrained from influencing in any way either the methods of study or the conclusions and comments contained in the survey here presented. It hopes that the facts reported will be of interest and assistance to all those concerned with the optimum utilization of present and prospective hospital facilities and with the extension and improvement of health services. President The Commonwealth Fund

MALCOLM P . ALDBICH,

T k e Rochester R e g i o n a l H o s p i t a l Council

Chapter j[

Introduction The process of regional organization is not new. It is part of a continuing adjustment to changes and trends in community life which started many years ago in industrial countries. It is an expression of the growing interdependence among communities in response to the impact of scientific and technologic advance. With increasing specialization and interdependence of individuals and groups, few communities can be self-sufficient and still maintain the average standard of living characteristic of industrial societies. Part of the process of adjustment during the past century has been an ever-accelerating growth of specialized commu-

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ROCHESTER REGIONAL HOSPITAL COUNCIL

nity institutions and agencies, voluntary and public, local, state, and national. Each of these agencies has been developed in response to needs arising from changes in social structure and advances in understanding resulting from research in the biological and social sciences. Dependence of the individual and family on the community and its institutions in time of illness and stress has replaced, to a large degree, earlier dependence on relatives and neighbors. This is a natural sequel of the change from the stable, self-contained village of the past, with its large families, to the modern urban community, with small, highly mobile family units. Community hospitals, public health departments, social welfare agencies, and systems of social insurance have developed in response to growing demands on the community. For the most part, institutions have developed individually, each in response to a newly identified need and public demand that something be done to meet the need. The result has been a plethora of specialized agencies, particularly in our larger communities, with overlapping in some areas, gaps in others, and great variations in availability of essential services in different communities. With the growth of community institutions some spontaneous coordination has developed among independent agencies to meet particular manifest needs. Although valuable, such coordination falls short of an effective and flexible system of relations capable of adjustment to changes in need and technological advance. To meet these requirements a system should be planned in terms of total needs and resources, with an understanding of the multiple factors that may affect the adequacy and efficiency of services. Such planning cannot be based on theoretical considerations alone. "Genuine planning is an attempt, not to displace reality, but to clarify it and to grasp firmly all elements necessary to bring the geographic and economic facts in harmony with human purposes."1

INTRODUCTION

5

The concept of regional planning to provide for changing social structure first had its origin in the field of housing in the nineteenth century, and that field has continued to lead in evolving a philosophy of regional organization.2 Patterns of community organization were proposed to create unity amid diversity, and to bring balance between the home, industry, and the market. In the field of health services, as in other fields, there has been a lag in the development of organizational devices designed to maintain the basically sound interrelations among the various services necessary to achieve reasonable objectives in health care in accordance with current concepts. These concepts call for comprehensiveness and continuity of service, including health promotion, disease prevention, diagnosis and treatment, and rehabilitation. To achieve this end, a high degree of coordination of care is necessary. The past three decades have seen the emergence of patterns of organization designed to meet these needs. In 1920, the Lord Dawson Report 3 adapted the concept of regional organization to health services, and recommended the development of a network of hospital facilities within which hospitals and medical services could be integrated. This principle has found application in the planning of health services in countries throughout the world. It is being applied in areas as remote from each other geographically and culturally as France and India, England and Latin America, the United States and South Africa. Although, in each case, the pattern of organization is modified in accordance with differences in resources, needs, social and political traditions, and structure, the underlying principle is the same.4 In the United States, the first significant experiment in regional organization of health services was initiated in 1931, with the organization of the Bingham Associates Fund, serving hospitals and communities in the State of Maine. The pro-

6

ROCHESTER REGIONAL HOSPITAL COUNCIL

gram was organized to overcome the isolation of practitioners in Maine by establishing an intimate working relation between community hospitals and physicians in that area and the New England Medical Center in Boston. The period since World War II has seen continuing evolution and extension of the concept of regional organization as applied to medical care and health service. The principle was incorporated in the Hospital Survey and Construction Act as a basis for planning expansion of hospital facilities.6 The Commission on Hospital Care pointed out the importance of interchange of services among hospitals.® The significance of regional organization in the care of the chronically ill was recognized by the New York State Health Preparedness Commission,7 and by four major professional organizations in a joint statement, "Planning for the Chronically 111."8 Potentialities for coordination of hospital care and public health services on a regional basis were explored in a series of monographs by Mountin and others, which were published by the Public Health Service.9 A number of programs of regional organization, varying widely in scope and pattern of administration, have been inaugurated since World War II. Among the institutions and agencies that have developed such programs are the University of Buffalo, the University of Colorado, Emory University, the Universities of Kansas, Michigan, and Minnesota (the last in close cooperation with the State Health Department), New York University, the Rochester Regional Hospital Council, Tulane University, and the Medical College of Virginia in cooperation with the University of Virginia. In most instances, the programs were designed to offer expanded opportunities for graduate and continuing medical education to meet the needs of large numbers of physicians returning from service with the armed forces. The relief of medical schools from the heavy burden of wartime responsibility and the return of many

INTRODUCTION

7

faculty members from military service made it possible for these schools to undertake such programs. Two of the programs are administered by agencies other than medical schools. These are the programs of the Bingham Associates Fund and the Rochester Regional Hospital Council. There is wide variation in the programs of the several regional plans. These differences may be traced to the nature of the agency responsible for administration of the program, the source of financial support, the traditions of the area, and the degree of acceptance of the program by the medical profession and other groups. The broadest scope of operation has been developed by the Bingham Associates Fund and the Rochester Regional Hospital Council. These programs include educational activity for physicians and other professional and nonprofessional groups, advisory services in various phases of hospital operation, assistance to communities in improving hospital facilities, and certain cooperative hospital services. In general, services developed in programs administered by medical schools are confined to graduate and continuing medical education. THE ROCHESTER PROGRAM

As a result of its work in the development of rural hospitals, the Commonwealth Fund recognized the crippling effect on medical practice of the inadequacy of hospital facilities and services.10 While it took account of the basic importance of rural hospitals, the Fund also noted certain inherent limitations in the scope and quality of service that these institutions could provide with their own resources. Lacking the specialized personnel and facilities that are generally available in larger institutions, small hospitals find it difficult to achieve the high standards of service and efficiency of administration demanded by current concepts of medical care.

8

ROCHESTER REGIONAL HOSPITAL COUNCIL

The Fund decided there was need for demonstration of methods to supplement the resources of small communities by encouraging close working relations among themselves and with a regional medical center. After some study, the Division of Rural Hospitals of the Commonwealth Fund selected the Rochester area for such a demonstration in 1945. Important among considerations in choosing this area were the existence of an outstanding medical school, an active hospital council in Rochester (the Rochester Hospital Council, consisting of six voluntary hospitals, was organized in December 1939, as the result of a survey conducted at the request of the Community Chest 11 ), the relative adequacy of hospital facilities in the region, and the generally favorable level of economic and social development.12 The School of Medicine and Dentistry of the University of Rochester was invited to submit proposals for such a program. After some consideration, the faculty decided not to assume primary responsibility for fear of overcommitting the resources of the School. By that time, some eighteen hospitals had expressed an interest in participating in such an organization. Dr. Basil McLean, then Director of Strong Memorial Hospital in Rochester, proposed that the Rochester Hospital Council assume responsibility for getting the program organized, drawing upon the resources of the large Rochester hospitals for specialized personnel and services. A group of hospitals at the regional center would thus play the role that had previously been envisioned for the Medical School and its teaching hospital. However, each of these central hospitals would be members of the Regional Council on the same footing as other hospitals, regardless of size or location. Thus, by force of circumstances, a new pattern of administration of regional health services in this country was developed. A committee was appointed by the Rochester Hospital Council to explore the problem and propose a program. After

INTRODUCTION

9

a series of conferences with representatives of the Commonwealth Fund, a new organization, the Council of Rochester Regional Hospitals, was incorporated on February 18, 1946, and an agreement with the Commonwealth Fund defining the responsibility of the two organizations was signed February. 26,1946, for a five-year period. The aims of the Commonwealth Fund in supporting the Council were to provide for: (a) Financial aid and planning for rational distribution of adequate hospital facilities throughout the region; ( b ) The promulgation of approved procedures in all departments of hospital organization and operation; (c) The development of such joint administrative services as might be considered desirable and practicable; (d) The development of consultation services in clinical and laboratory medicine, and in institutional administration; (e) The organization and administration of a continuous educational program for physicians, dentists, and hospital personnel, with emphasis on postgraduate study; (f) Such other health activities within the Region as the contracting parties mutually might agree upon from time to time. The original bylaws of the Council, drafted early in 1946, established the structure of the organization. All voluntary hospitals located within the counties included in the program were eligible for full membership; government and proprietary hospitals were eligible for associate membership. Differences between full and associate membership are discussed in Chapter 3. Provision was made for annual meetings of the corporation and a Roard of Directors was established. Ry resolution of the Board of Directors at its first annual meeting, an Administrators' Conference and a Medical Conference were created as advisory bodies. A staff was employed consisting of a part-time Executive

10

ROCHESTER REGIONAL HOSPITAL COUNCIL

Director (Dr. Albert D. Kaiser, Health Officer of Rochester), a physician as full-time Associate Director, a part-time nursing associate, an administrative assistant, and a part-time business manager, who was also Executive Secretary of the Rochester Hospital Council. The Rochester Hospital Council and the Council of Rochester Regional Hospitals continued until 1951 as two distinct but cooperating agencies, sharing office space and staff. In 1951 the two Councils were amalgamated to form the Rochester Regional Hospital Council. The services developed after the inauguration of the program in 1946, and continued after the amalgamation, included the continuing of education of physicians and various categories of hospital personnel, advisory services in the several aspects of hospital organization and administration, improvement of hospital facilities, and certain joint and cooperative services. In 1951, the Commonwealth Fund agreed to extend support for an additional three years, on a diminishing scale. Support from the Fund terminated in March 1954. THE STUDY

In the fall of 1953, the Commonwealth Fund approached the Institute of Administrative Medicine of the Columbia University School of Public Health, indicating that it was prepared to support a study of the Rochester Regional Hospital Council designed to evaluate its development up to that time. The Institute agreed to undertake the study, which got under way in January 1954. Methods of study were designed with the following objectives in mind: (a) To develop an objective description of the program; (b) To suggest principles of organization and administration appropriate to the appraisal of regional health services on the basis of experience in Rochester; (c) Insofar as possible, to measure the effects of the pro-

INTRODUCTION

11

gram on the facilities and professional services in the area; (d) To formulate recommendations based on the study, which might be helpful to the Council in the further development of the program. The study may be roughly divided into two parts, one, an investigation of the program, and its organization and administration, and the other, such quantitative and statistical studies of certain characteristics of the area and its institutions as the time and staff available permitted. In the course of study of the organization and program, memoranda, reports, and minutes of meetings and the like on file in the offices of the Commonwealth Fund and the Council were studied; annual reports, the report of the first five years of operation, minutes of meetings of the Board and various subsidiary bodies, the issues of the Regional Bulletin, and records of studies were reviewed. Unfortunately, records of some of the studies conducted by the Council had been discarded some time before the current study was inaugurated. Data accumulated in this manner were supplemented by interviews with officers and members of the staff and consultants, and by information accumulated in a brief study of the Council conducted the preceding year in the course of a survey of regional organization carried out by the Division of Public Health Methods of the U.S. Public Health Service. In addition, a number of related agencies in Rochester were visited to gather information concerning their program, and to explore actual and potential relations with the Council. All member hospitals were visited, and interviews were conducted with trustees, administrators, members of the medical staff, nurses, medical record librarians, accountants, interns, and others who might be directly or indirectly involved in the Council's program. These interviews were designed to yield information concerning the degree of participation in the program, any effects of the program on the operations of the hos-

12

ROCHESTER REGIONAL HOSPITAL COUNCIL

pital, and suggestions regarding desirable changes. Although the selection of persons interviewed was often dictated by availability at the time of the visit, a sufficiently large number of independent opinions was obtained to give reasonable assurance that a substantial portion of those interested in the program were represented. Statistical data concerning the activity of various aspects of the program were gleaned from Council records. Statistical studies were made of the distribution and certain professional characteristics of physicians in the Region in 1946 and 1953, of the changes in the distribution of hospital facilities, of the distribution of hospital personnel in 1946 and 1953, and of the residence of patients obtaining service in Regional hospitals. The last study, based on data obtained from hospitals, was supplemented by information on the location of births to residents of the Region obtained from the Bureau of Vital Statistics of the New York State Health Department. In an effort to obtain a picture of changes in the quality of care in Regional hospitals, without committing the study staff to a detailed investigation, which would have taken more time than was available, the contents of medical records in a sample of hospitals for the years 1946, 1949, and 1953 were studied. In addition, with permission from the hospitals, records of hospital inspections conducted by the Joint Commission or Accreditation of Hospitals were reviewed. Information on hospital expenditures was obtained from reports submitted to the New York State Department of Social Welfare. Although these data were used in drawing comparisons with Council expenditures and with volume of purchasing through the Council, detailed analysis of financial data is not presented in the report. The material was omitted because a true basis of comparison with experience of similar hospitals in other areas was not available. Throughout the analysis of organization and program in the

INTRODUCTION

13

succeeding chapters, more attention is given to apparent weaknesses than to obvious strengths. This emphasis does not reflect a failure on the part of the study staff to recognize the values of the program. The study has been viewed as an opportunity to project the potentialities of regional organization even further on the basis of detailed analysis of the experience of a successful demonstration. These projections should not be construed as criticism of what has been done, but rather as an attempt to chart a promising course for further exploration by the Rochester Regional Hospital Council, as well as by regional health agencies in other parts of the country. It is important to bear in mind the significance of the Rochester experiment. It constitutes a pioneering effort by a community agency to marshal the efforts of a large number and variety of voluntary and public agencies toward the achievement of common goals in the provision of community health services. It represents the first effort of any area in the country to coordinate a hospital program with hospital planning and construction on a regional basis. It has experimented with a wide range of services, many of which had not been tried before on so large a scale in civilian practice. In the course of the study, ample evidence was encountered of the success of these efforts. Through its various committees and advisory bodies, the program has stimulated the interest and support of community leaders drawn from a wide range of fields of endeavor. The fact that participating hospitals, on several occasions, have been willing to increase their contribution toward the support of the program confirms what was found in the course of the study, that the Regional Hospital Council has come to play a significant role in the furtherance of hospital services in the area. The balance of this report discusses the specific ways in which this has been effected.

Chapter

Area The area initially covered by the Plan included seven counties in the trading area of Rochester — Livingston, Monroe, Ontario, Orleans, Steuben, Wayne, and Yates. This region was selected on the basis of a study conducted by the Rochester Hospital Council in collaboration with the Commonwealth Fund. It comprised an area of some 4715 square miles, with a population of 714,000. In 1947, the year following the organization of the Council of Rochester Regional Hospitals, four adjacent counties — Allegany, Chemung, Schuyler, and Seneca — were added, in order that the region might correspond with the region adopted by the Joint Hospital Survey and Planning

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Fig. 1. Proposed hospital areas and subareas, Rochester Region, in relation to county boundaries and location of hospitals (according to Lembcke, 1948).

AREA

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Commission of the State. (See Figure 1.) The newly constituted region covered an area of 6836 square miles and had a population of over 958,000 in 1950. The area includes at present thirty-four general hospitals other than Federal, ten special hospitals, and 1,427 physicians. Some 50 to 60 percent of the population is covered by hospitalization insurance, chiefly under the Blue Cross. The area served by the Rochester Regional Hospital Council also corresponds to the area adopted by the New York State Departments of Public Health and Social Welfare for regional supervision of their services, except for Orleans County, which was transferred to another jurisdiction. The adoption of common service areas by several related public and voluntary agencies represents a greater unity of action than is found in most states, and provides greater opportunities for coordination of function and services. Conversely, the area of the Regional Council in no way corresponds to the areas of jurisdiction of the Blue Cross plans serving residents of the Region. The eleven counties of the Region are divided among three Blue Cross plans, those of Rochester (six counties), Syracuse (three counties), and Buffalo (two counties). The eleven counties in the area show marked variation in characteristics, so that for certain purposes of analysis it was found advisable to divide them into three groups: rural, lesser urban, and metropolitan. This was done primarily on the basis of the percentage of population living in urban communities,1 according to the 1950 census, which varied from 14.6 per cent to 86 per cent. The rural group consists of seven counties under 40 percent urban, none of which had an urban center with a population substantially over 10,000. The lesser urban group consists of three counties whose urbanicity ranged between 40 percent and 75 percent. Each of these counties had at least one large urban center with a population between 10,000 and 50,000, but did not contain a metropolitan center. They were

16

ROCHESTER REGIONAL HOSPITAL COUNCIL

all more populous than the rural counties. There was one metropolitan county, Monroe, containing the city of Rochester with a population of over 300,000, that was 86 percent urban. Selected data for the entire region and the three subgroups, the Buffalo and Syracuse regions, the Northeast region, and the entire United States, are shown in Table 1. The birth and death rates for the region, and the age distribution, indicate that the region as a whole has a stable, aging population. The median age is far higher than that of the United States as a whole or of the adjacent regions. It is particularly high in the metropolitan county of Monroe. The percentage of the population over 65 is considerably higher than that of the entire United States, and the rural area in particular has a high percentage of the population over 65. Death rates tend to be higher and birth rates lower than in other sections of the United States. The lesser urban area has a somewhat younger age distribution than either the rural or metropolitan counties, with a concomitant higher birth rate. Monroe County, with a high median age, a low percentage of the population under 5 and over 65, and low birth and death rates, appears to have a large fraction of its population in the productive age groups. This picture is similar to that noted in Onondaga County and in the Buffalo Area. The median number of years of school completed by persons over 25 in the areas indicates a fairly high degree of literacy for the Rochester Region. The educational level of the city of Rochester and apparently of the smaller cities in the region is quite high, but the degree of literacy in the predominantly rural areas is not much different from that of other parts of the United States. The high productivity of the city of Rochester, of the smaller cities, and of the surrounding rural areas is reflected in the median family income of the region. For the Rochester

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THE COUNCIL AND ITS ORGANIZATION

49

the Council could be improved, in keeping with broadening program objectives. Although the various interested professional groups are represented in the organization, they do not have equal opportunity to participate in discussion of policy. Whereas the present structure is suitable for an organization primarily concerned with problems of hospital care, it is not as suitable for over-all development of health services in the region. It was pointed out by some of the physicians interviewed that there is a feeling of isolation on the part of the physicians working with the Medical Conference; that more effective channels of communication with other branches of the organization are needed; and that there is some dissatisfaction with the limited opportunity this group has to participate in resolving questions of policy. These observations would be applicable to nursing as well. Furthermore, no representation has been accorded to dentistry as a profession, although this has been considered by the Board and its advisory bodies. Sound principles of organization would dictate representation for all major interested groups at the policy level. This would give greater assurance of adequate consideration to the special needs and interests of the various groups in formulating policy. By mixing representation on the policy-determining body it is likely that a higher degree of continuing interest among the several groups would be maintained. It would therefore seem advisable for the Corporation to consider revising the structure of its policy and advisory bodies. The Board of Directors might be reconstituted to include representation from the trustees group, administrators, physicians, dentists, nurses, social workers, and pharmacists, as well as the public at large. Such a body could then appoint special and standing technical advisory committees as occasion dictates. Annual meetings of the Corporation would, of course, continue, with representation from all member or-

50

ROCHESTER REGIONAL HOSPITAL COUNCIL

ganizations. This body would elect the Board of Directors, with representation from the public and interested groups and agencies. Standing committees could be appointed to cover broad areas, and in turn could appoint subcommittees to deal with specific phases of operation. A committee on education might be appointed with subcommittees on intern-resident education, postgraduate medical education, nursing education, and education of hospital personnel. A second standing committee might be appointed in hospital organization and operation with subcommittees on medical staff organization, medical records, accounting, credits and collections, and nursing service. A committee on community relations could deal with such questions as the blood bank, public health, and relations with social agencies as well as community education. It would seem that such an organizational structure would be appropriate to broad long-range objectives. As presently designed, the organization of the Council is in certain respects similar to the usual organizational structure of the hospital. The responsibilities of the Council, however, are much broader in scope than those of the average hospital whose principal concern is to provide hospital care of high quality. The question of long-range objectives of the program requires reevaluation by the Council. It would seem desirable to expand objectives to encompass the total health needs of the community rather than to limit its interests to intramural hospital problems. Flexibility and Coordination. In its development thus far, the organization has demonstrated its adaptability to meet new circumstances, and to coordinate its operations with those of other specialized agencies, both public and voluntary. Nevertheless, it seems likely that the flexibility and adaptability of the organization in meeting new requirements could probably be improved by changing the composition of the

THE COUNCIL AND ITS ORGANIZATION

51

Board to make it more broadly representative of the community served, as suggested above. As yet, the Council has given little consideration to the relations of general and specialized hospitals, or to the place of nursing homes and boarding homes. It would seem appropriate that the Council consider the needs of specialized hospitals in the Region, and possibly encourage all institutions in the Region, general and special, acute and chronic, government, voluntary, and proprietary, to affiliate with the Council. Some form of membership might be extended to nursing homes. Such an expansion of membership would fit in with the recent amendment to the Federal Hospital Survey and Construction Act, authorizing appropriations for the construction of chronicdisease and rehabilitation facilities. This would facilitate the comprehensive planning of hospital care for the Region, and the development of policies for direction of patients to different types of facility according to need. Staffing. For administration of the program as presently conceived, question may be raised concerning both numerical adequacy of staff and balance among the various essential disciplines. To assure adequate consideration in such areas as research and planning and professional education, it would appear that additions to the staff in the fields of nursing and medicine are desirable. A wide scope of activities in nursing education and service has been developed by the Council. A number of studies have also been undertaken. A nurse could be added to the staff of the Council, to consult on problems of nursing service and assist in nursing education and research. Such an addition would be particularly important should the Council expand its program into such fields as chronic illness, coordination of hospital and nursing-home services, and related facilities, and integration of hospital and public health service. Similarly, there is need for more medical supervision in the

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development of medical education and research in questions of medical care, and to develop closer working relations with physicians and specialized medical agencies in the community. The appointment by the Medical School of a physician, preferably with public health training and experience, who would be responsible for coordination of continuing education of physicians, for development of studies, and for supervision of intern and resident rotation, might be desirable. Such a person could be employed possibly half time by the Council and would provide a bridge between the Medical School and the community for teaching, research, and service. The Rochester Regional Hospital Council provides a good community laboratory for the Medical School in developing its program of research and teaching in community aspects of medicine. The appointment of a coordinator of continuing education, who might also do some teaching in preventive medicine, would appear a justifiable investment on the part of the Medical School. In most other regional programs, which are administered by medical schools, a full-time faculty member is generally appointed for coordination of graduate and postgraduate education. It is likely that with the facilities of the Rochester Regional Hospital Council such a person could be used more efficiently in the Rochester area than in many of the other regions in the country. With the present emphasis on the development of facilities and services for care of the chronically ill, consideration should be given by the Council to the employment of a medical social worker, either part time or full time, who would participate in education of nursing personnel in the social aspects of medical care, advise on the organization of social services, and assist in the coordination of the program of the Council with activities of related health and social agencies in the Region. Medical social work is not highly developed in the Region. Except for a few of the large hospitals in Rochester, and the two Veterans'

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hospitals, none of the hospitals in the region employed medical social workers in 1953. Such social services as may be necessary are only inadequately provided for in most of the nonurban hospitals. It is evident that there is an insufficiency of clerical personnel to handle many of the statistical operations of the Council. The result has been the use of professional time for purely clerical tasks, and the failure to maintain certain statistics such as those relating to services rendered by the Council. Consideration might therefore be given to the employment of a statistical clerk. Such additions to the staff would have obvious values for the program. They would also facilitate the recording, analyzing, and reporting on the activities of the Council and provide additional staff time for research and planning. As a demonstration project of considerable significance, the program, its services, and its progress should be reported as completely as possible in medical and public health journals and publications of other interested professional groups. It is recognized, of course, that before expanding its staff, careful consideration must be given to the long-range objectives of the Council and prospects of long-range financial support. Economy of Administration. To judge the economy of any operation, comparative experience from other areas with similar programs would be desirable. In this field, where there has been only very limited experience and where no other regional organization has been developed along similar lines, no such basis for comparison is available. A comparison between expenditures for operation of the Council and expenditures for hospital care provided by the several member hospitals has been made. In 1953 the budget provided a total of $83,839 for operation of the Council. Although there is some difference in the fiscal year of the Council and that of member hospitals, a comparison can be drawn

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with the reports of expenditures submitted by member hospitals to the New York State Department of Social Welfare for 1953. During this year the aggregate expenditure for hospital care among member hospitals (excluding Veterans Administration Hospitals) amounted to $22,109,657. The expenditure for Council operations, therefore, amounted to some 0.38 per cent of the total operating expense of member hospitals. Since the council is primarily concerned with organization and administration of services rather than with provision of services, it might be more reasonable to compare the costs of the Regional Council with administrative costs of hospitals rather than total cost of hospital service. During the fiscal year 1953, member hospitals reported an expenditure of $2,299,120 for administration. Thus Council expenditures for a similar period amounted to some 3.65 per cent of the total expenses of hospitals for administration and operation. Another index frequently used in measuring expenditures in public health is expense per capita. With a population in the area served of 958,316, according to the 1950 census, the Council in 1953 spent less than nine cents per capita. This expenditure is nominal when compared with actual and recommended levels of expenditure for maintenance of local health services, which in many areas amounts to over $2.00 per capita. It therefore seems reasonable to conclude that the operations of the Council are not excessively costly in terms of the scope of program and objectives. Were it possible to measure the value of Council operations in terms of improvement in quality and availability of service and economies, it is very likely that the result would show that the community receives the equivalent of substantially more service than is represented by the budget for Council operations. Financing. The potential sources of support for a regional program are limited. This is a new form of program, the values of which are not yet generally accepted. It is also one in which

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the area of jurisdiction does not correspond to any tax jurisdiction. There is therefore no single unit of government to which any such agency can apply for support. The problem of financing such a program is closely related to its objectives and the nature of the services rendered. Were operations limited to services of benefit directly and solely to hospitals, complete support by hospital contributions would be justified. If, however, the program is one concerned with community health services generally, a broader basis of support within the community would seem to be indicated. Until recently, the problem of equitable distribution of the cost of service has not been raised because of the substantial support that was forthcoming from an outside agency, the Commonwealth Fund. This is true of efforts at the development of regional organization throughout the country, where for the most part operations are supported by philanthropic organizations. The various alternatives for financial support for such a program would seem to be: voluntary contribution from the community served, through such agencies as the several community chests; support from tax funds from either local or state government; or continued support from philanthropic organizations. Limited support by contributions from hospitals is justified, inasmuch as certain of the services conducted by the Council are designed for improvement of economy of hospital operations. The prospect of obtaining support from local government would seem to be remote. Even were county councils convinced of the value of the service, the economic potential of local government generally is limited. From the experience of the Council so far, in attempting to raise funds to maintain its operations after the Commonwealth Fund support is withdrawn, it is evident that great difficulty will be experienced, unless further support can be obtained from philanthropic

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agencies or state government. Unless this situation changes, it is likely that the Council will be faced with the prospect of continuing operations on a much more limited scale. It has been suggested that the operations might be reduced to those characteristic of a hospital trade organization, which can be maintained by contributions from member hospitals alone. Because of the significance of the Rochester program as a demonstration of the methods and values of regional organization, it would be unfortunate were it forced to retrench at this time. There is need for experimentation in extension of the concept of regional organization by developing closer relations between the Council and other specialized agencies in the community and by expanding its program to encompass such fields as chronic illness and nursing-home operation. Furthermore, the problems with regard to professional education and relations with the University deserve the most careful consideration. At this time the Council is faced with problems of both adequacy and stability of financial support. Unless both of these needs can be met, it seems almost inevitable that operations will suffer. It would therefore appear that the needs of the region in terms of current programs as well as further experimentation should be called to the attention of the State Department of Health, and of philanthropic organizations. It is likely that some of the philanthropic organizations would be interested in certain phases of the program, such as those dealing with the coordination of the University program with the operations of the health region.

Chapter

X k e Council's P r o g r a m of Education One of the principal values that regional cooperation has to offer is in the field of continuing and special education of the various groups responsible for the provision of health services. Today the rapid advances in medical science and technology, and increasing specialization and complexity in organization of service, create a proportional increase in the need for effective educational facilities and methods. Planning on a regional basis assures more effective use of the specialized fa-

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cilities and resources of the Region in meeting the educational needs of individual communities. The various educational services developed by the Council are described in this chapter. It must be borne in mind that other services, such as advisory and consultation services, have important educational values. For the purpose of clarity in presentation, however, these are described in Chapter 5. MEDICAL EDUCATION

Clinical Conferences. In November 1946, the Council arranged for regular visits to community hospitals by consultants who would meet with members of the medical staff to discuss a phase of medicine of interest to general practitioners. This service was offered to hospitals outside of Rochester, Clifton Springs, and Elmira. These larger institutions were excluded on the premise that the various medical specialties are represented on their staffs, and thus provide resources adequate to support an active program of medical education. The supervision of this activity has been the responsibility first of the Committee on Medical Staff Organization and Activities, and later of the Committee on Postgraduate Medical Education of the Medical Conference. Lists of available consultants, consisting of faculty members of the Medical School and specialists from larger centers, are compiled by the responsible committee of the Medical Conference. These lists are sent to staffs of participating hospitals in the fall of each year and they select consultants and subjects for the year. Consultants are paid an honorarium of $50 a visit by the Council. There has been a gradual increase in the numbers of hospitals participating in the program, in keeping with expansion of membership. No records of attendance at these meetings were available at the offices of the Council. Table 8 gives the

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average numbers of hospitals participating and the number of conferences from 1946 to 1953. In the course of the Survey, interviews were held with eight consultants who have participated in the program of clinical conferences. Four of these indicated that attendance was good, averaging about 80 per cent of the medical staffs. Three noted that attendance was poor, and one that it varied with the hospital. Poor attendance was attributed to apathy among the medical staff, poor scheduling (clinical conferences scheduled on the same night as other functions, such as meetings of the County Medical Society), and weather. One consultant noted that the elderly and the young members of the medical staffs were more likely to attend than the middle-aged group. This may be attributed to the fact that these physicians have more time. TABLE 8. Participation in Medical Conferences, 1946-1953. Υ ear

1946 1947 1948 1949 1950 1951 1952 1953

Number of hospitals

10 12 14 14 15 15 16 16

Number of conferences »

13 58 83 73 85 90 84 67

• Data for 1946-1950 from "Some Facts and Figures About the Rochester Hegional Hospital Council" (October 17, 1951).

Four of the consultants felt that certain real values have been achieved as a result of these conferences. Among these values have been increased understanding of the problems of general practice by consultants themselves, which is useful to them in their teachings of medical students; a larger number of cases referred for consultation and the exercise of better judgment in referring cases; an evident increase in pride in the local institution; an improvement in laboratory facilities and

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staff as a result of the efforts of the Council; and general improvement in communications between practitioners in rural and urban areas. There was general agreement among the consultants on the lack of opportunity for clinical discussion and the apathy of local medical staffs with regard to preparation and presentation of appropriate cases. They suggested that topics are not always wisely chosen. Physicians at times request talks on certain aspects of medical practice because of deficiencies on the part of several of the staff members. However, at these talks those physicians who stand to benefit most often do not attend. It was suggested by some that the time and effort might better be spent in developing more formal programs of graduate and postgraduate medical education. Clinic teaching days and postgraduate courses were thought to assure a better return for investment. It was also felt that the situation could be greatly improved by having available on the staff of the Council a physician who would be responsible for supervising this phase of the program, and that the University should assume a more direct responsibility for planning and organizing this service. As was the case among consultants, opinion among medical staffs of member hospitals was divided with regard to the value of the clinical conferences. Somewhat greater interest was expressed by physicians on staffs of hospitals of less than 60 beds than in larger institutions. This may be attributable to the fact that the larger hospitals have a greater number of specialists on medical staffs, and the need for advice on specialized problems is met to a greater extent than in smaller institutions, where, generally, staff physicians are general practitioners. In about half the hospitals, physicians indicated that conferences were well attended, and were of definite value in

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introducing new ideas and improving the interest and sense of responsibility among the members of the medical staff. However, at other hospitals, physicians stated, as did some consultants, that the sessions were too didactic, and that there was limited participation by local physicians. In one community it was stated that until clinical conferences were started by the Council educational programs had been organized by the local medical society. These were suspended when the Council organized its educational program. Initially, there was some reserve on the part of medical staffs with regard to this and other services offered by the Council. This was attributed to widespread fear among members of medical staffs that the Council represented an effort by the Medical School to dominate medical practice in this area. This fear was gradually overcome as hospitals and their staffs gained experience with, and confidence in, the Council. Although the Medical Conference has maintained an active interest in clinical conferences, there has been comparatively little continuing professional supervision of their development. Since the retirement of the full-time Associate Medical director of the Council in 1950, responsibility for arranging schedules of conferences has been assigned to the Regional Medical Record Librarian. Although members of the Medical School faculty have participated actively in the program, the Medical School itself has assumed little responsibility for its development and supervision. The concern of the Medical Conference over this phase of the Council program is reflected in the repeated discussions recorded in its proceedings. These reflect both the importance that the Medical Conference attaches to these conferences, and the difficult problems that have been encountered. At the meeting of the Medical Conference on October 12, 1947, it was noted that more participation by local medical staffs and presentation of clinical material would be desirable. At meet-

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ings in April 1953, and again in December 1953, it was again recommended that case histories be prepared and presented by the local staff, and that special problems and deaths be discussed. Postgraduate Courses. A second phase of the program developed for the continuing education of physicians in the area consists of formal courses and clinic teaching days in Rochester, Clifton Springs, and Elmira. These courses are developed by staffs of the larger hospitals with the aid of the Council, and are devoted to consideration of a major aspect of clinical medicine, presented from the point of view of the basic sciences and various clinical specialties. Sessions include lectures and clinical demonstration on subjects of interest to the general practitioner. The first clinic teaching day was held at the Bath Veterans Administration Hospital on November 11, 1946, in conjunction with a meeting of the Steuben Medical Society. Since that time, most of the clinic teaching days have been held by the Rochester General Hospital, Highland Hospital, St. Mary's, Genesee, and Strong Memorial Hospitals in Rochester; by the Clifton Springs Sanitarium; and by St. Joseph's Hospital in Elmira. Attendance at these courses has varied widely, depending on the content and on scheduling. Records of attendance have not been kept by the Council. The first five-day postgraduate course was organized at the Rochester General in April 1947, and was repeated in October of that year. These courses were devoted to diagnostic procedures and consideration was given to dietary needs, laboratory procedures, electrocardiography, basal metabolic evaluation, rapid psychiatric evaluation, and x-ray interpretation. Nine physicians, six from Monroe County, attended the first course, and nineteen, six from Monroe County and thirteen from outside of the County, attended the second course. Courses vary in length from one to five days. Physicians often find it difficult to get away for a period of more than

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two days at a time. Responses to a questionnaire sent to all physicians in the area in 1950 indicated that the majority preferred courses requiring their absence from their community for no more than two days at a time. Consideration has therefore been given to arranging courses on a one-day-a-week basis, covering a number of weeks. Many of the courses and institutes are designed to take up problems of current interest in the Council program. For example, an institute on the use of blood and blood derivatives was given at the Strong Memorial Hospital in 1948 at the time of the initiation of operations of the Regional Blood Bank and concurrently with the publication by the Council of a brochure on the use of blood and blood derivatives. While courses are arranged by the host institutions, the Council helps by sending notices to physicians in the Region, by publication of announcements in the Regional Bulletin, sent to all physicians in the area, and by contributing toward the defrayal of costs. Early in the program the Council paid a stipend to physicians attending most of the sessions. This practice was discontinued in 1948, as it apparently did not influence attendance, and the funds used for this purpose were more urgently needed to support other activities. In the past no tuition has been charged, although several hospitals are considering making a nominal charge in the future. Few statistical data are available concerning these programs, and it is not possible to give a complete accounting of the number of courses and clinic teaching days from the beginning of the program. However, enough information is available for the years 1947, 1948, 1952, and 1953 to give some indication of the scope and activity of the program. During 1947 and 1948 six five-day courses, one three-day course, and one two-day course were held. Two of the courses were on diagnostic procedures and two on therapeutics; the course on blood and blood derivatives was given twice, and

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the remaining two were devoted to pediatrics and the management of diabetes. Peak attendance of 76 was reached at the two-day institute on the use of blood held in 1948. In 1952 and 1953 thirteen courses were held, only three of these lasting more than one day. For the most part, the subject matter of these courses was limited to a specific disease, form of therapy, or specialty. Attendance of 150 physicians was attained at three separate one-day courses on ACTH-cortisone, heart disease, and the diagnosis and treatment of stomach ulcers. On the whole, clinic teaching days were fairly well attended. Physicians in the larger hospitals (150 beds and over), particularly those from hospitals in Rochester, found the clinic teaching days to be of greater value than did the physicians in the smaller hospitals. A number of physicians interviewed in larger institutions were enthusiastic about their value. Among medical staffs of smaller institutions, however, a number of physicians felt that these courses were of limited value. At a few hospitals, physicians felt that conferences were too didactic. Distance was a deterrent factor in only two or three instances. The need for more medical supervision by the Council and more cooperation from the University was stressed. In spite of these reservations, it was the consensus among physicians that these programs should be continued. It seems worth reemphasizing that these activities represent a continuation and expansion of efforts which had been carried out by medical societies, the Rochester Academy of Medicine, and individual hospitals before the inauguration of the Council. The Council and its Medical Conference have introduced a factor of regional coordination, planning, and sponsorship that did not previously exist. In addition to courses with which the Council is immediately concerned, it keeps the medical profession in the Region advised through its Regional Bulletin and circulars, of other

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postgraduate educational opportunities in New York State. Courses organized by the University of Buffalo, by the New York State Health Department, by the College of Surgeons, and by other agencies are publicized in this manner. There is, however, no information concerning the degree of participation of physicians from the Region in such courses. The program of postgraduate education of the Council was approved by the Committee on Postgraduate Education of the New York State Academy of General Practice. Participation in these courses may be counted as credit for continuation of membership in the Academy. Hospitals planning clinic days advise the New York Academy so that physicians can receive credit for attendance. Fellowships. In January 1947, the Medical Conference recommended the offering of three fellowships a year to physicians for study in a specialized field. These fellowships, which carried a stipend of $250 a month, were designed to make it possible for smaller communities to have the services of physicians with more specialized training in some of the major fields of medicine. The Council was particularly interested in ensuring that there be physicians on staffs of smaller hospitals with some special training and competence in the general fields of internal medicine, obstetrics, and pediatrics. Training was to be given in larger hospitals in the Region. Provision was made for two to four months of training. Although most physicians expressed an interest in a shorter period, it was found that it would be almost impossible to arrange for training for shorter periods of time, since hospitals in the Region were not geared for this type of program. There was very little call for two to four months' fellowships. One fellowship was granted in 1947 for a surgeon from a smaller hospital to be trained in pathology at St. Mary's Hospital in Rochester. A second fellowship was granted in 1948 for six months' training in internal medicine at Cornell

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University. Because of the lack of interest shown in such training, long-term fellowships were discontinued in 1948 and a limited amount of money was set aside for stipends for physicians seeking one to two weeks of training. A token stipend of $50 for one week and $100 for two weeks of training was provided for. As conditions for receipt of such support, the physician must enroll in a formal course or work with a qualified preceptor, and the need for the training was to be certified by the president of the medical staff of the hospital with which the physician is affiliated. In 1948, four awards of this sort were made. In all, 25 stipends were awarded between 1947 and 1950, in such fields as allergy, anesthesia, arthritis, cardiology and electrocardiography, chest diseases, cytological diagnosis of cancer, dermatology, endocrinology, hematology, internal medicine, obstetrics and gynecology, operative surgery, oral surgery, surgical pathology and surgical physiology.1 No further requests have been received since 1950. In general, physicians indicate that they are too busy to take advantage of the offer. This is consistent with the general falling off of demand for postgraduate training throughout the country, a demand which reached its peak after the close of hostilities in World War II. Other Activities Related to Continuing Education of the Physician. In addition to the services organized by the Council directly, the Regional Council has been instrumental in developing or stimulating other educational activities in medicine. Following is a brief description of several of these services. (a) Rochester Regional Society for Laboratory Medicine. The Rochester Regional Society for Laboratory Medicine was organized in 1946 following a meeting of laboratory physicians called by the president of the Medical Conference. The organization had originally been planned to serve Rochester

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alone, but the presence of the Regional Council focused attention on the need for some such organization on a regional basis. All professional personnel interested in laboratory work in the Region are eligible for membership in the Society. There are 36 members, 20 of whom are pathologists — eight from the City of Rochester. Although the Regional Society for Laboratory Medicine is independent of the Regional Council, it cooperates with the Council in its program. The Society meets four to five times a year at Rochester, Clifton Springs, or Canandaigua. At these meetings, stress is placed on clinical pathology. It holds postgraduate seminars for laboratory technicians (to be discussed later), and is considering methods for stimulating the development of better standards in county laboratories, including the possibility of distributing unknowns to these laboratories. It was suggested by the president of the Society that a future possible area of interest would be the coordination of training of medical technologists in the Region. At present there are three schools of technology in the Region (The Rochester General Hospital, St. Mary's Hospital, and a school in Elmira). A good centralized facility would relieve individual hospitals of the need to train technicians. The present system is costly and probably does not achieve the standards of training which would be possible at a centralized facility. (b) Rochester Regional Diabetes Association. This Association was organized in 1947 as a subdivision of the American Diabetes Association. Any physician in the area interested in diabetes is eligible for membership. Several meetings are held each year to discuss diabetes and allied subjects. Although this organization is likewise independent of the Council, its activities are coordinated with the educational program of the Council. Intern and Resident Rotation. With the organization of the Medical Conference, an Intern and Resident Committee was

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appointed. This Committee explored the possibility of arranging for the assignment of interns from the larger hospitals in Rochester to member hospitals in other parts of the Region. It was decided that the program should be initiated in rural hospitals having at least 100 beds, of which there were four in the Region outside of Rochester, Clifton Springs, and Elmira. These were the Geneva General Hospital, the F. F. Thompson Hospital in Canandaigua, the Corning Hospital, and St. James Mercy Hospital in Hornell. The establishment of similar affiliations with smaller institutions would be considered after sufficient experience had been gained. It was felt that such affiliations would be advantageous to both the intern and the affiliated hospital. For the hospital, the presence of an intern would assure more adequate medical care, and should prove stimulating to the medical staff. For the intern, a period of rotation through a smaller hospital would give him a greater understanding of the work of the general practitioner in a small community, and an opportunity to observe the patient in closer relation to his environment than is possible in a large city. It was agreed that in any such arrangement the center hospital would continue to maintain responsibility for supervision of the intern's education. The affiliated hospital was to comply as closely as possible with the standards for approved internships adopted by the Council on Medical Education and Hospitals of the American Medical Association. A member of the medical staff of the affiliated hospital was to assume responsibility for supervising the work of the intern and would be appointed to the Intern and Resident Committee of the Council. A stipend of $75 a month was to be paid to the intern during his period of assignment to the affiliated hospital, using funds provided by the Council for the first few years of affiliation. The recipient institution was responsible for furnishing maintenance.

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In June 1946, approval for the program was received from the American Medical Association, subject to later review. The first affiliation was developed between the Rochester General and Geneva Hospitals in August 1946, whereby interns would be assigned for six-week periods. The Rochester General Hospital appointed an additional intern for this purpose. In July 1948, another intern was assigned, and this arrangement has continued in force except for a lapse in 1952 when the central hospital could not fill its intern roster. In January 1947, St. Mary's Hospital in Rochester assigned an intern to the Corning Hospital, but had to discontinue this arrangement in April 1947, because of the shortage of interns. In July 1948, the Corning Hospital affiliated with Strong Memorial, but it was not possible to maintain a continuing supply of interns, and the service was later discontinued. In May 1947, the Strong Memorial Hospital assigned assistant residents to the F. F. Thompson Hospital in Canandaigua for periods of six to twelve weeks. Such assignments were, however, irregular until 1952, when an intern was assigned for continuous service at the affiliated hospital. In October 1947, an affiliation was arranged between the Genesee Hospital and the St. James Mercy Hospital in Hornell, whereby interns would be assigned for periods of two months. In July 1948, this arrangement was modified, a surgical resident being assigned in place of an intern. This affiliation was later discontinued because of shortage of house staff in the center hospital. In order to enable hospitals in Rochester to assign assistant residents and residents to affiliated hospitals, the approval of the New York State Department of Education and the Veterans Administration was obtained. The Park Avenue Hospital in Rochester affiliated with the Rochester General Hospital and interns were assigned in rotation. Furthermore, the Strong Memorial Hospital has made

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arrangements with other Rochester hospitals for the assignment of residents for part of their training. In the course of visits to the Medical School and to the member hospitals in Rochester and elsewhere that have been participating in the program of intern rotation, the experience with this program was discussed with members of the medical staffs and with the interns involved. The opinions expressed can be evaluated only if the program is viewed with the objectives of the various groups in mind. The objective of the Council is to improve the quality of medical care and to widen the educational horizon for all concerned. The medical staffs of the member hospitals, particularly in the nonurban areas, like those in hospitals everywhere, desire the services of an intern staff. The central hospitals and the Medical School view the program as an opportunity to diversify the intern's training. The intern is interested in gaining as much experience and teaching as possible and tends to view this period in the smaller hospital as one that should give him responsibility and an opportunity to observe the work of the family practitioner, an experience different from that gained in a large teaching hospital. In the opinion of those interviewed, the rotation program seems to be lacking to some degree in all these respects. Medical staffs in the participating hospitals appreciate the help of the interns, but feel that there should be more of them, to stay for a longer time. There is some evidence that they are more concerned with the service than with the opportunity to teach, although a few members could be found on every staff who take teaching obligations seriously. This lack is reflected in the opinions of the interns. Those interviewed found the experience of limited value. The reasons given were that neither the sending hospital nor the receiving hospital had established clear definitions of responsibility for teaching. The program was considered to be lack-

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ing in educational value except in surgery, where the intern was given more opportunity to be first assistant than at larger hospitals. There was often insufficient opportunity to discuss cases with the attending physician. Library facilities were deficient. Case conferences, held about once a week, were not organized well. The interns felt that they were at times given too much responsibility and that during their stay in the affiliated hospitals their contact with the center hospitals was almost completely lost. Finally, the center hospitals themselves were not entirely satisfied with the program. The scarcity of house staff constitutes a continuing problem. Members of the medical staff concerned with the program welcomed the opportunity for the interns to work with general practitioners in rural areas, but they were disappointed with the failure of the participating hospitals to plan for the educational program, and some doubt was expressed concerning the level of practice to which the interns were sometimes exposed. EDUCATION OF HOSPITAL ADMINISTRATORS

The Council has had a substantial influence on the improvement of professional competence of hospital administrators. The Administrators' Conference provides a forum for discussion of common problems. Furthermore, through the development of recommended standards for hospital organization and through the work of the staff of the Council with boards of trustees, several hospitals appointed trained administrators upon the retirement of previously untrained persons filling these positions. Various advisory services provided by the Council and the availability of consultation on special problems has supplemented formal training of administrators. Studies and reports of the Council have further assisted administrators to identify and understand special problems and to compare performance in their institutions with that in other in-

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stitutions in the area. Furthermore, the Council, through the Regional Bulletin and special circulars, keeps administrators in the area informed of requirements of official and voluntary organizations concerned with hospital service and with special reports and meetings of interest to administrators. The practice has been adopted of publishing in the Bulletin abstracts of reports of current interest, such as that of the Commission on Financing of Hospital Care and reports concerning procedures in hospital accreditation. All of these activities contribute toward the maintenance of professional competence among hospital administrators, and have been particularly significant with regard to breaking down the isolation of the administrator of the smaller institution. Postgraduate Courses. Early in the program, methods were discussed to ensure administrators of smaller institutions an opportunity for formal training. Consideration was first given to providing fellowships to the American Hospital Association Institutes on Hospital Administration. It was decided, however, that this would provide opportunity for relatively few administrators and that it would be more desirable to arrange an annual course in Rochester. The first such course was arranged during the spring of 1947. It was conducted jointly by the University of Rochester and the Council. The Council pays tuition ($26.00 per registrant) and the University underwrites overhead costs. University credit is given. Full-day sessions are held every other Friday throughout the spring term. Courses are designed for administrators of smaller hospitals. When the program was initiated, the staff of the Council approached presidents of the boards of trustees of affiliated hospitals, explaining the purpose of these courses and the desirability of having the administrators participate. As a result, there has been good participation in these courses, as indicated by the following annual enrollments:

THE COUNCIL'S PROGRAM OF EDUCATION 1947 1948 1949 1950 1951 1952 1953

73

18 19 17 16 14 16 23

By 1953, 30 administrators, assistant administrators, and department heads had received certificates for one or more courses. In addition to attendance by regular enrollees, other personnel frequently attend individual sessions. In 1953, some 60 administrative personnel participated in sessions. The curriculum is designed to meet needs as determined by suggestions received and by observations of Council personnel. In general, the course is directed at practical problems of current interest and is most suitable to the untrained administrator of the smaller hospital. Persons especially qualified in various aspects of hospital administration are invited to conduct seminars. The majority of hospital administrators find these spring seminars very useful. They are of more direct value to those administrators who lack formal training and whose experience in the field is limited. However, many with training and experience attend because of the opportunity afforded by seminars to keep up with development in the field, and to discuss problems with colleagues and specialists in various aspects of hospital administration. Administrators of large hospitals generally do not attend; nevertheless, auxiliary administrative personnel frequently participate and find the sessions of definite value. For this reason, the sessions are equally popular among large and small institutions. Although persons invited to lecture to the group are well qualified, administrators agree that the time devoted to in-

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formal discussion is even more valuable than formal exercises. As a result of those discussions, a number of administrators remark that they find that problems they encounter are not confined to their institutions and they gain confidence in their relations with medical staff and boards of trustees. Fellowships. Stipends of $50 are provided by the Council to help administrators and other hospital personnel attend institutes organized by the Hospital Association and other agencies. Several hospital administrators have taken advantage of these fellowships, and 85 fellowships had been granted to other personnel in the hospitals by October 1951. Persons from 18 different hospitals took advantage of these fellowships. Most of these fellowships, however, have been taken by personnel from larger hospitals. The fields of interest represented in these fellowships were as follows: Medical records 18 Hospital engineering Training nurses' aides and Hospital housekeeping other personnel 18 Public relations Accounting 16 Laundry management Dietetics 10 Pharmacy Personnel supervision 7 Anesthesia

5 3 3 2 2 1

NURSING EDUCATION

The Council has extensive interests in the field of nursing education and service. Studies, advisory services, recruiting activities, institutes and conferences, fellowships for special study, in-service training, and planning of formal education for undergraduate and graduate nurses and practical nurses have all contributed toward the improvement of professional competence and efficiency of nursing personnel in the Region. In developing a program of educational activities the staff of the Council has worked in close cooperation with other interested agencies. The Nursing Associate of the Council is

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also chairman of the Division of Nursing Education of the University of Rochester, making possible close coordination of effort with this institution. In addition, the Council cooperates with the State Health Department, the Genesee Valley Nurses Association, the Genesee Valley League for Nursing, the Community Nursing Council, and other organizations. The Nursing Associate is a member of the Advisory Committee of several of the schools of nursing in the area. She is chairman of the State Committee on the Nursing Aide In-Service Training Project, which is sponsored by the New York State League for Nursing, the State Hospital Association, and other State organizations. The Regional program of nursing education was inaugurated by the Council staff under the aegis of the Committee on Nursing of the Administrators' Conference. Although, from time to time, consideration has been given to the possibility of establishing an advisory body on nursing, equivalent to the Administrators' and Medical Conference, this question has been resolved in favor of placing the responsibility for development of nursing services in the Administrators' Conference. The Regional Nursing Group. Early in 1949, upon recommendation of the Nursing Committee, a Regional Nursing Group was organized. It is composed of two staff or head nurses from the nursing staff of each member hospital. Public health nursing is also represented. Representatives to the Group are appointed for one year. The Group is primarily concerned with the discussion of nursing problems in hospitals and public health nursing agencies, and nursing education. From 1946, when the Council was established, through 1953, there were 57 meetings of representatives of nursing staffs, with an attendance of 35 to 150 at each meeting. Some of the meetings have been held at central points in the Re-

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gion, while others are divided into several meetings of smaller groups (three to four) held at convenient points in the Region, to make it easier for nurses to attend. Recommendations formulated by the Regional Nursing Group are considered by nursing service directors in planning their programs, and, in many hospitals, are discussed at meetings of the nursing staff. The objectives of the Nursing Group are: (a) To improve care of the patient, by providing a forum for exchange of experience, by conducting studies to facilitate coordination of services both within hospitals and with community agencies, and by developing awareness on the part of the professional nurse of her responsibility as leader of the nursing team. (b) To improve education of nurses, by stimulating interest in new developments in nursing education and service, by identifying areas of research feasible in everyday work situations, and by advising on the educational program of the Council. (c) To promote improved working relations through increasing understanding of the contributions of the various professional groups. Among the results of the activities of the Group have been the inauguration of staff education programs in hospitals that had not previously had them, and the stimulation of more extensive use of auxiliary nursing personnel and experimentation with nursing teams. A system of referral of patients from hospital to public health nursing service has been inaugurated, and instruction of patients has been improved. Most of the nurses interviewed indicated that meetings of the Nursing Group were very useful. This was true of nurses at large, as well as those at small institutions. Geographic location bore no relation to opinion expressed. In general, nurses find these meetings stimulating, and of help in keeping up with professional developments in nursing. Meetings give nurses an

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opportunity to discuss common problems. Many directors of nursing indicate that staff nurses assigned to represent the hospitals report at nursing staff meetings organized for that purpose. Minutes of the group meetings are sent to directors of nursing and at several hospitals directors have instituted programs of in-service training as a result of the activities of the Group. In general, it is felt that meetings have helped improve the professional status of nurses, and have raised the morale of nursing staffs. Nursing staffs of the Veterans Administration hospitals at Bath and Canandaigua find meetings of the Nursing Group especially helpful in that they provide an opportunity for association with other nurses. As is the case with most Council services, the Brigham Hall Hospital, a private psychiatric institution, has not found activities of the Nursing Group very useful because of their specialized program and requirements. Several criticisms and suggestions were made. A few nurses suggested that there has been too much emphasis on organization of nursing teams at the expense of other pressing problems in nursing. Nurses at some of the smaller hospitals feel that problems of team nursing are of greater interest to the larger hospital. Some indicated a preference for more lectures and fewer informal discussions. A problem encountered in smaller hospitals is that nursing staff is often limited and at times it is difficult to release staff nurses to attend meetings. Nursing Conferences and Institutes. One- to two-day institutes dealing with special problems have been organized in response to needs as indicated in discussions of the Nursing Group, and by requests from nursing directors. Four to eight such institutes are held a year. Attendance, which ranges from 30 to 150, is sometimes limited in order to encourage free discussion. For the past several years, two-day institutes have been arranged for head nurses and supervisors. Institutes are planned to deal with subjects of current inter-

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est. For example, one-day institutes have been held on such subjects as team nursing, orthopedic nursing, care of newborn infants, nutrition, and in-service instruction. Occasionally these institutes are repeated in several areas of the Region. At other times they are given in Rochester or in a city in the southern part of the Region. All nursing personnel, including institutional, private duty and public health nurses, are invited to attend. In many instances student nurses attend the institutes. In October 1951, a two-day institute on the care of premature infants was held in anticipation of the opening of the Statesponsored premature center at the Rochester General Hospital. In the same month, an institute on the nursing team was jointly sponsored by the Council, the University of Rochester, and the University of Buffalo. Changing patterns of nursing service, the nursing team and its functions, and problems in introducing team nursing were among the subjects discussed. Since then, more than a dozen conferences and institutes have been held on a range of subjects, including responsibilities of the head nurse, rehabilitation, and public health nursing. Some of these institutes and conferences are jointly sponsored by the Council and the University of Rochester, the University of Buffalo, the New York State Department of Health, and other interested agencies. Attendance at these meetings has fallen off in the past few years. This is attributed to the development of staff education programs in individual hospitals. Although, at the time the Council was started, there were no hospitals with organized programs of nursing education, at present, all but three of the member hospitals have such programs. Usually, they take the form of monthly meetings, with lectures and discussions. Approval of the educational opportunities afforded by institutes and postgraduate programs for nurses seemed closely correlated with the degree of participation in these activities. Distance and lack of time seemed to be greater deterrents to

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participation by nurses than they were to the other groups. Consequently, the nearer the hospital was to Rochester, the more enthusiastic were the responses elicited from the nurses. Among the nurses of those hospitals in the rural areas that had participated in institutes, only a few found them to be of direct value. In two of the small hospitals a definite improvement in the operating room and obstetrical services was noted and attributed to the postgraduate training of their nurses in these specialties. In two other hospitals where several nurses had attended the conferences on the care of prematures, the experience was considered of great value. The nurses of all the larger hospitals, particularly those in Monroe County, participated quite actively in the educational program and generally regarded it as highly valuable. Committee of Nursing Directors. The Committee of Nursing Directors frequently devotes part of its meetings to discussions of current problems facing nursing generally. At the first meeting of this Committee, in April 1953, Dr. E. L. Koos, of the Department of Sociology of the University of Rochester, discussed social studies and their impact on nursing. At their meetings in April 1954, a discussion of the conference technique with particular reference to its application to in-service training was arranged. This discussion was held in anticipation of the initiation of work of a Regional Committee on In-Service Training which has been established as part of a national program sponsored by the American Hospital Association and related agencies and professional organizations. The Committee of Nursing Directors therefore provides another channel for continuing education of the nursing profession of the Region. Fellowships. In November 1946, the Nursing Committee of the Administrators' Conference arranged with the Strong Memorial Hospital and the University of Rochester for the offering of two four-month graduate courses, one in Operating

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Room Supervision and Techniques, and one in Obstetrical Nursing, for qualified personnel from member hospitals. The courses were arranged in spring and fall semesters by the Department of Nursing Education of the University. Practical aspects of training are given at the hospital. Three college credits are given for work at the hospital, and six for instruction taken at the University. The Council offered fellowships which provided for payment of tuition, a stipend of $200 by the Council, and full maintenance from the Strong Memorial Hospital. Between 1947, when the program was initiated, and 1951, when the last applications were received, twenty fellowships were granted, as follows: Year

Number

Year

Number

1947 1948 1949

8

1950 1951

3

4 3

2

Most of the applications came from nurses in Rochester. The relatively small number of applications from nurses in rural hospitals may be attributed to several factors. Many nurses are married, and find it difficult to be away from home for protracted periods of time. Furthermore, with the marginal staffing of many small hospitals, staff nurses carry a wide range of responsibility, and cannot be spared from their duties. Some fear of inability to measure up to required academic standards has been encountered among nurses in rural hospitals. A higher proportion of nurses in rural areas do not have degrees, and are therefore not eligible for graduate study. Expansion of Nursing Education, University of Rochester. The Division of Nursing Education was established in the Department of Education of the University of Rochester in 1941. Courses were offered leading to a B.S. degree with a

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major in nursing education, designed to develop head nurses, supervisors, and instructors in schools of nursing. In 1947, the University approached the Council with a request for financial aid to enable the Department of Nursing Education to expand its curriculum and enrollment. The University requested underwriting up to an amount of $7000 a year for a five-year period. The support requested would cover an estimated one-half of the cost for the period. Because of past financial experience, the University was reluctant to undertake such expansion without assurance of financial assistance. The Commonwealth Fund agreed to the granting of support to the University, if necessary, up to an amount of $7000 a year for the first two years, with decreasing support thereafter. Money was to come from a supplementary budget allowance of the Council. With this support, the University inaugurated a program designed to: (a) strengthen the existing program in nursing education; (b) establish courses in clinical nursing for graduate nurses in supervisory positions; (c) establish instruction in public health nursing; (d) establish a program in industrial nursing. The courses were well received and the actual cost to the Council amounted to only $1812 during the first four years. With a minimum expenditure the Council was thus able to stimulate the development of needed educational facilities. Undergraduate Nursing Education. During the 1930's many hospital schools of nursing were closed because of the financial status of the hospitals and because rising standards of nursing education increased the costs of training. Continuing trends toward improvement of standards of nursing education and the inauguration of a system of accreditation of nursing schools as well as economic pressures still threaten many established schools of nursing. At the same time, nonurban hospitals have

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difficulty maintaining adequate nursing services as graduates of urban schools of nursing tend to remain in larger cities. Early in the program of the Council, consideration was given to the possibility of organizing a central school of nursing for instruction in the nursing sciences. Clinical instruction would continue to be given in local hospitals by the established nursing schools. It was felt that such an arrangement would lead to an improvement in the standards of nursing education in the basic sciences and at the same time would relieve smaller schools of nursing of the expense of attempting to maintain adequate instruction in the sciences. Furthermore, students who received their clinical training in smaller hospitals would be more likely to remain in these institutions. In 1951, a Special Committee on a Centralized Nursing School was appointed to study this possibility, and a number of meetings were held with representatives of the University. Although several of the schools in the Region expressed an interest in such a program, no steps were taken because the University was reluctant to commit its resources for this purpose. As a result of further discussions and further consideration of the matter, the University adopted a different position in March 1953. Affiliations were arranged with the Rochester State Hospital School of Nursing and the Willard State School of Nursing, and central training in the basic sciences was inaugurated at the University in December 1953. This instruction is under the direction of the University School of Nursing. Medical School facilities are used for instruction. The first-year curriculum includes instruction in the basic sciences, English, psychology, and sociology. The student, during this period of instruction, returns to her home hospital for one day a week. Twenty-two students enrolled in the first course. Other hospitals are free to join the program. There seems to be reasonably good assurance that some of the other

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nursing schools in the Region will take advantage of this program, since many can no longer afford to support the full cost of nursing education. A similar program had been in operation in Buffalo for a number of years. Although under this program costs to the individual student increased, this did not appear to affect enrollment at the school. In addition to the Council's efforts to establish a central program of instruction in the basic sciences in nursing, periodic conferences are held dealing with nursing education. These are attended by nursing educators and members of advisory committees and faculties of schools of nursing. Problems of curriculum, organization and training, affiliations, and methods of education are considered. These meetings have helped to reduce the professional isolation among schools of nursing and have provided a forum for discussion of common problems. Practical Nursing Training. As part of its efforts to stimulate team nursing, the Council has given attention to improvement in the quality of training of practical nurses, and to the recruitment of students for this field. Training is given at the Rochester School of Practical Nursing, established in 1939, under the jurisdiction of the Adult Branch of Vocational Education of the Rochester Board of Education. Part of its support comes from State and Federal funds as provided by the Smith-Hughes Act. The course is given in a year; five months are devoted to preclinical training and six months to hospital training. Graduates are eligible for admission to State licensing examinations in practical nursing. The school has an enrollment of 40 students. Some 400 students had been graduated by February 1954. About 60 percent of the graduates go into hospital practice. Until 1949, schools of practical nursing were not permitted to use the clinical facilities in hospitals that conducted programs for the preparation of professional nurses. An experi-

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mental program was started in March 1949, whereby students in the Rochester School of Practical Nursing received experience in Rochester General and Genesee Hospitals. Both of these hospitals conducted basic professional schools of nursing. At present only Genesee Hospital and the Monroe County Infirmary are used. The Nursing Associate of the Council has acted as coordinator. Such an arrangement has the very practical advantage of promoting a basic understanding of the values and methods of team nursing. Since the inauguration of this policy, the Genesee Hospital has employed much larger numbers of practical nurses, resulting in more adequate nursing at less cost. In-Service Training of Nurses' Aides. The Council has attempted to promote the utilization of nursing aides as part of the nursing team. Problems and methods of in-service training as applied to this group have been discussed at meetings of Nursing Directors. In May 1954, a Regional Committee on the Nursing Aide In-Service Training Project was appointed by the Genesee Valley League for Nursing as part of a nationwide effort to improve standards of training for this group of personnel. An outgrowth of this Committee's activities has been the appointment of a nurse who will give part time to the development of the project in the Rochester Region. OTHER HOSPITAL PERSONNEL

The Council has attempted to arrange educational services for other hospital personnel in response to identifiable needs. Following is a brief summary of the nature of training in several areas of hospital operation. Medical Records. In 1946, the American Association of Medical Record Librarians, aided by a grant from the National Foundation for Infantile Paralysis, commenced a series of intensive one-week courses throughout the country. Courses were designed primarily for previously untrained persons em-

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ployed in medical record work. The first course was given in Rochester, September 9 to 13, 1946. The Council paid tuition for one person from each member hospital and contributed toward the maintenance of students from outside of Rochester. Some 22 persons attended, of whom 16 represented 11 member hospitals. The remainder came from hospitals outside of the then existing region.2 Since 1950, a series of biweekly seminars for medical record librarians have been held on the same day as the classes in hospital administration meet. This arrangement makes it easier for record librarians to get to Rochester. At these seminars subjects of importance in the work of the medical record librarian are considered, including medical terminology, coding and indexing according to standard nomenclature, medicolegal problems, daily admission and discharge routines, and statistics. Average attendance is 15 to 20, representing 12 to 15 hospitals. A number of persons responsible for medical records in affiliated hospitals have been trained in this manner, and several have been registered by the Committee on Education and Registration of the Association of the American Medical Records Librarians. The Association agreed to allow six weeks' credit toward registration for record librarians participating in these seminars. The Council has provided fellowships for medical record librarians who wish to attend conferences and institutes on this subject. The Council contributes $50 toward the cost of attending. From 1946 to 1953, a total of 28 such fellowships were granted, 16 of them in 1946. Meetings and conferences are also arranged by the Council for medical record librarians to consider special problems. As an example of this activity, an institute on the new edition of Standard Nomenclature of Diseases and Operations was arranged by the Region in February 1952, attended by nine record librarians from six hospitals. The institutes and courses for medical record librarians were

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extensively used by the librarians in almost all of the hospitals. Although several from small hospitals felt that the courses were too detailed and were often "over their heads," they were considered to be very helpful by the majority of medical record librarians. Improvement in the record systems was attributed in large part to this aspect of the educational program. Hospital Accounting. In this field, as with medical records, a very substantial part of the education conducted by the Council is in the form of on-the-job training in the course of visits to hospitals by the Accounting Consultant of the Council. Nevertheless, certain educational functions have been developed by the Council. In 1946, a two-day institute on hospital accounting was conducted by the Council. Twenty-four accountants and business managers from member hospitals attended. The institute was held in Rochester and appropriate subjects, including practical problems and demonstrations, were presented by qualified persons. In 1947, biweekly conferences for hospital accountants were organized. Attendance from hospitals outside of Rochester was, however, poor and these conferences were discontinued. Institutes organized for the discussion of specific problems were found to be more successful and these have been conducted periodically since 1946. Two workshops were organized in 1952 under the auspices of the Committee of Accounting of the Administrators' Conference. About 15 representatives of some 10 hospitals attended these two-day workshops. In September 1953, monthly meetings of Rochester hospital accountants were organized at their request. Among other topics of consideration at these meetings is the revision of the accounting manual. In September 1953, a workshop for hospital accountants and business office personnel from small hospitals was organized in Dansville. Credits and collections, accounts receivable and

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reserves, inventory, and State reimbursement formulas for welfare patients were among the problems discussed. A similar two-day workshop for personnel from larger hospitals was held in Rochester in October 1953. This workshop included consideration of the accountant's responsibility, of equipment and depreciation, of admission functions, and of accounting as a tool of management. Twenty-nine representatives of nine hospitals attended, and they judged the meeting so useful that it was recommended that it be repeated in six months. In April 1954, the first workshop of the year was organized under the joint sponsorship of the Council and the Rochester Regional Chapter of the Association of Hospital Accountants. Thirty-nine representatives of 16 hospitals were enrolled for the workshop, including accountants, business personnel, and some trustees. Three similar workshops covering accounting and fiscal problems of both large and small institutions are planned for the remainder of the year. A second workshop on uniform accounting and collection problems with third-party agencies was held in Geneva in June 1954. Thirty-five representatives of 13 hospitals attended. Several similar meetings are being planned. After each meeting, participants are requested to submit comments and suggestions on a prepared form. Only nine accountants in the region have not attended one or more institutes or workshops, and the rest have found them to be well organized, helpful, and usually interesting. Their suggestions are used by the Council staff in planning programs for future meetings. In addition to organized educational programs, the Council has from time to time supported fellowships to make it possible for personnel of member hospitals to participate in educational programs organized by other agencies. Laboratory Technicians. The Council has done relatively little directly with regard to the training of medical technolo-

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gists. Several years ago, a consultant in laboratory service was appointed to visit laboratories and to give guidance in methods. There was, however, no call for this service. The State Department of Health provides some supervision in bacteriology and pathology in county laboratories. There is no provision of this sort in the field of chemistry. Several noteworthy efforts at organizing educational services for laboratory technicians have been made. Several technicians have received fellowships for special training, and arrangements were made in 1948 whereby 26 laboratory technicians from Regional hospitals were given individual instruction on typing and cross matching at the time the Regional Blood Bank was established. With assistance from the Council, the Regional Society for Laboratory Medicine (a chapter of the State Association) has organized a program of seminars for laboratory technologists in the area. About four seminars a year are arranged. Meetings are held on Sundays to assure maximum attendance, which averages 50 to 60 at each meeting. Mornings are devoted to discussion of laboratory procedures in chemistry, and afternoons, to bacteriology and hematology. Panels of discussants are drawn from the membership of the Regional Society of Laboratory Medicine. The Council provides an honorarium of $50 a day to consultants, and also furnishes lunch for those who attend. The Council gives this support in place of offering consultation services. It has been suggested that the Council employ an itinerant technologist who could substitute for personnel in local laboratories for periods during which they could work in a laboratory at the center, and thus improve their knowledge of new procedures. Although such a program was successfully developed by the Bingham Associates Fund, it was found difficult to recruit technologists willing to undertake such an assignment, since it involves a great deal of travel. An arrange-

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ment whereby technologists would be exchanged between hospitals in Rochester and local laboratories might be worth exploring. Opportunities for training of other categories of hospital personnel have been arranged principally through provision of stipends for attendance at institutes organized by the American Hospital Association and by other agencies. Such stipends have been granted for institutes on dietetics, personnel supervision, hospital engineering, hospital housekeeping, public relations, laundry management, pharmacy, and anesthesia. In addition to fellowships, Regional institutes have occasionally been organized in specialized fields of hospital operation. Such institutes have been arranged for dietitians of Regional hospitals in cooperation with the Rochester Dietetic Association, and for engineers and maintenance personnel. It was suggested that similar institutes should be organized for other hospital personnel, such as housekeepers. TRUSTEE EDUCATION

The various activities of the Council directly or indirectly promote understanding among trustees of hospital operations and trustee responsibilities. Of special significance are meetings of the Board of Directors, attendance by Council staff members at meetings of boards of trustees, institutes for trustees, the Regional "Newsletter to Trustees" and the monthly Bulletin, analyses of professional activities, and uniform financial reports. Institutes. The importance of trustee education was recognized early in the program. A region-wide demonstration for hospital trustees was arranged in 1946. In addition, appropriate literature was sent to trustees. However, it was felt that these activities were not making a deep impression and other methods were adopted. Informal institutes for hospital trustees were inaugurated in 1948, employing group discussion

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techniques learned at the National Training Laboratory in Group Dynamics. These were started as Regional institutes and were later arranged on a subregional basis. Two subregional institutes for trustees were held in 1948 and 1949. Meetings were devoted to the use and interpretation of uniform accounting reports, and the relations between policies and administrative practice, and costs. Other topics discussed were the responsibilities of the trustee, relations between governing board and medical staff, and the board's responsibility for the quality of medical care. In 1950, a joint meeting of trustees, physicians, and administrators was held, devoted to problems of mutual interest. Over 100 persons attended. At several of the meetings on hospital finance, accountants and other business office personnel participated. Ten meetings were held from 1948 to 1953, with a usual attendance of 15 to 20. Information. The Council publishes (in processed form) two circulars of interest to trustees. The Regional Bulletin has been published since May 1946, and has appeared monthly since 1949. Each issue of the Bulletin carries reports of current Council activities, announcements of developments of general interest in the field of hospital care, and summaries of reports of current interest. In September 1953, a monthly "Newsletter to Trustees" was first published (in processed form) and distributed to members of the governing boards of member hospitals. Designed to keep trustees abreast of developments in the hospital field as related to the activities of the Council and Regional hospitals, it supplements other publications in the field, such as Trustee, published by the American Hospital Association. Several of the trustees interviewed at the time of visits to hospitals indicated that the "Bulletin" and "Newsletter" were read carefully and are of substantial value. For the most part, however, they evoked little enthusiasm.

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Annual reports covering the first three years of operation were published and widely distributed among hospitals and other interested agencies to disseminate information concerning the progress and program of the Council. During the first few years of operation, quarterly and then monthly reports of activities were prepared for the information of Directors and of the Commonwealth Fund. This practice was discontinued in 1953. COMMENT

Under the best of circumstances, appraisal of the values and effectiveness of educational programs is extremely difficult. In a program such as that represented by the Rochester Regional Hospital Council, where so many groups and disciplines have been involved, it is not possible to do more than to record impressions concerning the values of various educational activities. On the whole, there can be little doubt that the educational efforts of the Council have been valuable. They have helped to promote greater understanding among the various professional and nonprofessional groups, not only as to their own activities, but by providing greater insight into the problems and objectives of other groups and agencies. As might be expected, the program appears to have been more effective in some fields than in others. Because of limitations in methods of measurement, as well as in the time and resources available to this study, it would be hazardous to attempt to draw comparisons among the several fields in which educational activities have been developed. Each group differs with regard to the scope of its responsibilities, the numbers of persons involved, and the nature of their educational requirements. In general, the task is easier, and objectives can be more clearly defined, among those groups whose responsibili-

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ties are confined to the discharge of well-defined technical functions. There seeems to be little question that the educational programs for medical record librarians and accountants have been effective, and that the methods developed for these purposes have been appropriate. This is borne out both by the opinions of record librarians and bookkeepers and accountants interviewed at the hospitals, and by the improvements in records and accounts that have been made at many of the member hospitals. Review of a sample of medical records for the years 1946, 1949, and 1953 shows a substantial improvement in form, content, and currency. In the field of accounting, a number of hospital administrators express real satisfaction with the improvements that have been made in records of income and expense and in the usefulness of accounting statements. Several of the hospitals have been able substantially to better their financial status as a result of these improvements. In the field of hospital administration, the educational activities of the Council have apparently been productive. At both large and small institutions, the annual seminars in hospital administration have filled a need for interchange of experience and for discussion of common problems. Programs have been well organized, and the faculty has been carefully selected. At the smaller, nonmetropolitan hospitals, where the hospital administrator has frequently not had an opportunity for formal training, these seminars have tended to overcome this handicap and have given these administrators greater assurance in dealing with the myriad problems in operating a hospital. The three groups referred to above consist, in general, of full-time employees of hospitals who can usually be relieved of their duties to attend meetings. Furthermore, the numbers in each group are limited, making it possible for the Council to reach virtually all persons in these categories. The problem of evaluating the educational services for nurs-

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ing personnel and physicians is much more complex. These are both professional groups with wide ranges of responsibility and a high degree of specialization within each profession. Furthermore, they are both large groups whose members are subject to urgent demands on their time, frequently making it difficult for them to attend organized educational exercises. Nursing Education. Although the activities of the Nursing Group are discussed in an earlier section of this chapter, the purposes of this Group are primarily educational. On the whole, the Nursing Group has been well received and has had a perceptible influence on hospital operations. Member hospitals have been well represented, and the organization of staff educational programs among the hospitals has provided a means for wider dissemination of points discussed at meetings of the group. It was observed that interest in and attendance at nursing institutes had been dropping off during the year preceding the study. This was attributed to the growth of educational activities in individual hospitals. Consideration might be given to experimentation with seminars on topics of special interest held at individual larger hospitals, or among groups of smaller hospitals, organized by the faculties of some of the nursing schools in the area. In the light of trends in nursing and medical care, such topics as social aspects of nursing and medical social service needs, nursing care of the chronically ill, rehabilitation, and coordination of hospital and public health nursing services would be appropriate for such discussions. The courses that have been arranged in surgical and obstetrical nursing have resulted in improvements in techniques and services at some of the smaller hospitals. Care of the prematures in at least two hospitals was similarly improved as a result of Regional educational activities. The effects of such programs could probably be enhanced with more adequate advisory services. More extensive use of consultants from the

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University, from nursing schools distributed through the Region, and from specialized agencies might be considered, as well as increasing the nursing staff of the Council. The emphasis placed in nursing education on the training and use of subprofessional nursing personnel has undoubtedly borne fruit. Annual studies of nursing time conducted by the Council reveal a very substantial increase in the utilization of practical nurses throughout the Region. Whereas graduate nursing personnel per 100 beds increased from 27.2 to 28.5 between 1946 and 1953, practical nursing personnel increased from 1.2 to 5.1. Although the specific effects of education and demonstrations in these areas could be determined only by carrying out control studies in other areas, it seems fair to assume that the program of the Region has stimulated both a greater and a more effective use of the practical nurse as part of the nursing team. Medical Education. The Council has made a very substantial investment in furthering medical education. The Medical Conference has devoted a great part of its energies to this field and the faculty of the Medical School and members of the staff of larger hospitals in the Region have cooperated in furthering this objective. Because of the complexity of medical practice and of problems of method and evaluation, the whole field of continuing education of the physician is still in an experimental stage. Problems of medical staff organization in hospitals, motivation of the physician, and his professional status in the community are involved. No universal pattern has been developed that would be applicable to all areas. The pattern developed in each area must take into account the resources and organization of facilities, the environment in which the physician practices, and the physician's interests. For these reasons, it is more important than ever that adequate professional and educational supervision be available in the development of such a program.

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Although clinical conferences as organized among the member hospitals would seem to hold out many potential values, it seems evident that these values have not been fully achieved. They should provide an opportunity for intimate contact and exchange between general practitioners and specialists in various fields. Too often, however, they have been didactic in nature, there being virtually no presentation of clinical cases and rather limited participation on the part of medical staffs. Whereas at some hospitals attendance at conferences is good, and participation in discussion is active, at other institutions this is not the case. None of the participating hospitals has instituted ward rounds with clinical consultants. It seems evident that the program in recent years has had inadequate professional supervision. Although plans for the clinical conferences are discussed at the Medical Conference, there is need for a responsible medical educator who could study the experience at clinical conferences and plan accordingly. Observations should be made concerning the interests of medical staffs with regard to fields of specialization, the relation of the type of presentation to interest evoked, and methods of presentation. It is likely that there are variations in the effectiveness of teaching of different consultants. The most careful consideration must, of course, be given to criteria for selection of consultants for these assignments. In other regional programs where clinical conferences are arranged with medical staffs of individual hospitals, similar difficulties have been encountered. In the course of appraising the value of such conferences, consideration should be given to the possibility of organizing these meetings in cooperation with the County Medical Society. In several regional programs, regular clinical meetings are arranged at several points in the area covered, a method that would seem to fall between the clinical conference at member hospitals and clinic teaching days. This might provide a more economical and effective

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approach, particularly if it were supplemented with intensive advisory service for medical staffs designed to stimulate the development of educational programs at each member hospital. Another step that might be taken in attempting a detailed evaluation of these programs is the maintenance of records of attendance at clinical conferences. At those hospitals where attendance is poor, it is questionable, both educationally and economically, whether conferences should be continued. Continuing postgraduate education demands the assumption of responsibility by the student as well as the instructor. The most practical arrangement would seem to be the development of close cooperation with the University for supervision of this and other aspects of medical education. It would seem appropriate for the University to appoint a member of the faculty who would be responsible for the coordination of graduate and postgraduate medical education, and who would act as medical education consultant to the Council. Should such a person be appointed, it would be advantageous for him to arrange visits to other regions such as Buffalo, the Bingham Associates Fund, the University of Michigan program, and the New York University program, to observe their approaches to continuing education of the physician. Postgraduate courses and clinic teaching days were, on the whole, well accepted by the medical profession. Attendance at these exercises has been reasonably good and would seem to justify the expenditure of time and effort on the part of the hospitals that have undertaken arrangements of these courses. The Council assumes limited responsibility for these courses; the principal responsibility, within the general framework of planning of the Medical Conference, is taken by the host hospital. Nevertheless, in this instance, too, the program would probably benefit by having available the services of a medical education consultant or coordinator of graduate and postgraduate

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education. Attendance at the several courses should be recorded and periodic studies made of the distribution of physicians who attend these courses. Do the same physicians attend a number of courses or is there wide participation among the physicians in the Region? Are clinic days and postgraduate courses attended by local physicians or by physicians from a wider area? These are questions that would have some importance in deciding the relative weight to give to formal postgraduate education and to local clinical conferences. Intern and Resident Rotation. The program of intern-resident rotation among member hospitals has experienced problems common to similar programs in other parts of the country. The shortage of interns makes it difficult to assign interns to participating hospitals outside of Rochester. At most of the nonmetropolitan hospitals, the majority of patients are private, which means that there is an inevitable limitation in the responsibility of the intern. In addition, most local hospitals are not as well equipped, nor are they geared for graduate education, as are hospitals at the Regional Center. There is also evident a reluctance on the part of medical staffs of Rochester hospitals to interfere with the operations of participating hospitals, and some fear on the part of participating hospitals of domination by the larger hospitals at the Center. As a result of these problems, the program of rotation of interns has not fully achieved the objectives as originally conceived. This fact has been recognized by the Medical Conference, and the Committee on Interns and Residents has been engaged in an intensive study of the situation with a view to improving it. Steps designed to overcome the deficiencies of the program should be pursued vigorously. It must be recognized by all parties that both the Center and participating hospitals have important responsibilities in the maintenance of high educational standards. Only with maintenance of such standards can a sufficient number of interns be recruited to these programs.

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Intern and resident rotation in other areas has met with varying success, depending to a large extent on the degree of responsibility assumed for the maintenance of educational standards. Effective patterns for rotation of residents and interns have been developed at the University of Michigan 3 and New York University.4 Although the programs administered by those centers differ in certain important respects from that of the Rochester Regional Hospital Council, examination of their experience would probably be fruitful. At both institutions there is one center hospital, the university hospital, concerned with the program, in contrast with the Rochester program, where a group of hospitals in Rochester share responsibility. As a result of university affiliation, full-time faculty members are available for planning and supervision. Both programs provide for affiliation with larger institutions for training of residents. In the case of Michigan, there is also provision for affiliation with smaller hospitals for training of interns interested in general practice. In both cases certain minimum standards relating to staff organization, education, records, and the like have been adopted by the center that must be met by participating hospitals before they are eligible to receive interns or residents on rotation. Written agreements are drawn with the participating hospitals which are reviewed and renewed periodically. Members of the faculty visit participating hospitals regularly to review the work of the intern or resident assigned and to confer with staff members of the participating hospital. At New York University, the participating hospital appoints an educational coordinator, who for the first two years receives an honorarium from the University and is responsible for coordination of the educational program at the institution. In addition to the two centers mentioned above, such exchange has been in operation at the Bingham Associates Fund, the Medical College of Virginia, and the University of Colorado. In any such arrangement, both the center hospital and the

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affiliated hospitals voluntarily assume certain responsibilities. Only through the closest cooperative effort can the dual objectives of improving medical service at the affiliated hospitals and of providing the intern with broader educational opportunities be achieved. Should high educational standards be maintained, there would be obvious advantages for the center hospitals and participating hospitals, for residents and interns, and for the local community. In some of the programs mentioned, interns and residents who have been rotated to community hospitals have, at the completion of their training, settled in these areas to practice medicine. Trustee Education. The development of an educational program for trustees presents serious problems. Boards of trustees are composed of persons drawn from many walks of life, often the busiest people in the community. For the most part, they come from fields other than the health professions. Yet they have the responsibility for making important policy decisions in hospitals and selecting key administrative personnel as well as in making decisions concerning medical staff organization and appointments. It is therefore important for trustees to understand as completely as possible the functions of the hospital, the scope of their responsibility, and the responsibilities and competencies of the various professional groups involved in the rendering of hospital services. It would be extremely difficult to evaluate the effects of an educational program for members of boards of trustees. Such a study might be approached by means of interviews with members of the board, either individually or in groups, in an area in which they have been subjected to an educational program. The results could be compared with results of interviews in a similar area in hospitals where no such education has been instituted. Because of the limited time available for completion of this study, such an evaluation was not possible. Although some of the meetings organized for boards of

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trustees had only limited attendance, the efforts were justified. A combined meeting of trustees, physicians, and administrators in 1950, which was attended by over 100 persons, would seem to be a productive approach to the education not only of trustees but of the other groups as well. There seems little question that the formal efforts at trustee education and education incidental to participation in the proceedings of the Board of Directors and various committees have had an effect. This is evident in the high degree of enthusiasm that many of the trustees display with regard to the operations of the Council. The Council should be encouraged to continue this pioneering effort. Probably one of the more effective approaches to trustee education is the meeting with boards by members of the Council staff and consultants. This practice, which has been used by the Council in the past, should be continued and possibly expanded. By discussing principles of hospital and health service organization and operation in terms of problems faced by boards of trustees, a more intimate knowledge of these matters can probably be developed than through lectures and discussions, which are inevitably on a more abstract plane. It is obvious that the Council has undertaken a most ambitious program of education. Although results are difficult to measure, it is generally acknowledged that a well-designed program of education is a good investment. Were all individuals involved in the process of providing community health service completely conversant with principles pertaining to their specific responsibilities, there would be little need for many of the controls designed to maintain minimum standards of quality. When combined with advisory services, joint hospital services, and other forms of assistance, the efforts of an educational program are enhanced. It is also obvious, of course, that some of the educational efforts of the Council have been more successful than others.

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Within the boundaries of resources available to the Council, the Board of Directors and the various advisory bodies must make choices concerning the most productive approaches. Some of the devices suggested may be useful to the Board in future deliberations. Education of the Community. Although the Council has expended considerable effort in the education of persons directly associated with hospitals, there has been little consideration given directly to the education of the general community concerning the nature and importance of hospital services and the role of the Council. This would seem to be a deficiency in the program, since ultimately, either directly or indirectly, the Council must look to the community for support. Furthermore, as patterns of health service increase in complexity, the need increases for effective means of informing the public on the best use of facilities and services. Careful consideration should be given to this problem and to available methods for approaching it. Such devices as the publication for wide distribution of attractive annual summaries of activities and accomplishments should be considered. Furthermore, it would seem that a closer working relation with public health agencies and an orientation of public health personnel to the activities of the Council might be productive in providing a more general understanding of the Council's program. In the course of the study, some effort was made to assess the knowledge and understanding of the general public of the operations of the Council. These informal discussions suggested that there is very little understanding in the community at large of what the Council does. Although community education is a difficult process, it is nevertheless important, and it deserves careful planning.

Chapter

^

X k e Council and Hospital Services The Council has been of substantial help to hospitals in several ways. Through consultants, it has been able to supplement the staffs of individual hospitals in defining and resolving problems and improving organization and operation. In certain areas where advantage could be taken of the aggregate needs of hospitals to improve the efficiency of operation, the Council has assisted hospitals by organizing cooperative services. The Council has also cooperated with other agencies

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in organizing specialized services designed to improve the availability, quality, and efficiency of these services. ADVISORY SERVICES

As an important adjunct to its educational program, the Council has made available consultants in various phases of hospital operation. These consultants visit member hospitals to help them review their needs, put into effect recommendations of the Council, and meet standards recommended by various standardizing agencies. In certain fields, such as hospital administration, nursing, medical records, and accounting, the Council has employed personnel to consult and advise on problems and needs. In other fields the Council uses as consultants specialists in various aspects of hospital operations in Rochester. Consultation services in such fields as dietetics, laboratory procedures, and hospital construction have been obtained in this way. Consultation services in medical staff organization have been made available by the Medical Conference. Advisory services are for the most part designed to meet the needs of smaller institutions which do not have the variety of specialized personnel required to cope with complex problems. Much time is devoted to giving in-service training, at these hospitals, to personnel who have not had an opportunity to obtain formal training in their branch of activities. From time to time, larger institutions call on the Council to help meet special problems, such as designing methods for study of the cost of operating-room procedures or of maintaining a nursing school. Administrators and other personnel in hospitals throughout the region often request information and advice by telephone. The Council has therefore developed into a clearing house for general information to which hospital personnel throughout the region can turn. In the course of interviews at member hospitals, it was often remarked that being associated

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with the Council is a great advantage in that an orderly procedure has been established whereby hospitals can get information on a wide range of subjects in case of need. Where members of the Council staff cannot answer specific questions, they have access to persons associated with various member hospitals who are equipped to help. Hospital Organization and Administration. Administrators and other hospital personnel receive advice and consultation on problems of hospital organization and administration from each other, from members of the Council staff, and from consultants called in on special problems. Specific questions are often discussed at meetings of the several executive and advisory bodies and working committees. The Council's advisory services range from full-scale surveys of organization and management to the provision of information that may be readily available and can be supplied by telephone. The Council's advisory services on hospital and medical staff organization have also included the recommendation of standards by the Board of Directors. "Standards for Admission and Maintenance of Membership" were recommended by the Medical and Administrators' Conferences and adopted by the Board of Directors in June 1947. These standards define the responsibilities of the board of trustees, the administrator, and the medical staff. They include provisions concerning medical records and compliance with State and local regulations. Member hospitals were expected to comply with these standards by June 1949. In September 1947, the Board of Directors approved a statement on "Suggested Qualifications for Medical Staff Membership and Hospital Privileges" which was prepared by a joint committee of the Medical and Administrators' Conferences. This statement set forth general principles governing medical staff membership and criteria for limitation of privileges in specialized fields. It proposed that staff privileges

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should be available to all physicians in the area in accordance with their training. Participation in medical staff educational activities should be obligatory. Minimum division of the medical staff into medicine, obstetrics, surgery, radiology, and anesthesia was recommended and indications for consultation were outlined. A third document, "Basic Hospital Rules and Regulations," was prepared by the Council staff in consultation with the Medical and Administrators' Conference in 1947. This statement was adapted from existing models prepared by the American College of Surgeons and by authorities in the field of hospital administration. It was recommended for use by medical staffs of member hospitals in reviewing and revising bylaws and rules and regulations. It was directed particularly at the smaller hospitals where hospital organization was not as highly formalized as in large urban institutions. The Council's advice and help in establishing and recommending standards of admission to membership and of medical staff organization were of decided value to the small hospitals. Many used them, at least to some extent, to improve their organizational structure, and in drafting or modifying by-laws and staff organization. Several administrators stated that their hospitals would have eventually adopted many of the recommended changes but that the process was hastened by the Council's help. At one of the smaller hospitals, for example, the administrator observed that staff and trustees saw no reason to adopt any changes in staff rules or organization, but, after joint meetings of trustees and medical staff were held as a result of Council urging, a number of valuable changes were brought about. On the other hand, a few representatives of smaller hospitals felt that the standards were too complex for small hospitals and for that reason might be unattainable even if desirable. Many large hospitals, such as those in Rochester, found

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the advice of the Council unnecessary since they had adopted the recommended practices without Council help. However, one large institution was briefed by the Council on standards before the hospital was inspected by the Joint Commission on Accreditation of Hospitals, and this was found to be extremely helpful. In this instance the Council advised the hospital concerning the organization of a tissue committee in ample time for the hospital to have one in operation a full year before examination by the Joint Accreditation Commission. The consensus was that the efforts of the Council to improve standards of organization and administration were helpful even though all hospitals could not meet the standards or fulfill all the requirements of good organization. The Council has been of assistance to the hospitals on other phases of hospital organization and operation as well. In 1947, the Council conducted a survey among the hospitals of practices used in the terminal sterilization of infant formulas. Hospitals were advised of approved procedures and the Council staff and consultants were able to help several to convert their facilities to provide for adequate sterilization. In response to questions with regard to policies governing charges for oxygen therapy, a survey of practices in the region was conducted, including a study of costs and charges. More uniform policies whereby charges would approximate costs of oxygen therapy were recommended to the hospitals. Several hospitals requested advice on care of premature infants. A survey was conducted into deaths and physical facilities and personnel available for such care among the several hospitals. This survey was conducted in 1947, before a premature center was established at the Rochester General Hospital. Information was circulated regarding parenteral-fluid preparation. A survey of practices among the hospitals was conducted and comments were invited regarding the possibility

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of establishing a central facility for preparation of parenteral fluids in the Region. This project did not materialize, since many of the hospitals were satisfied with currently available sources of such fluids. Advice was provided regarding aid available through the State and the Tuberculosis and Health Association for routine admission chest films. A survey indicated that four hospitals in 1947 were providing such a service. As a result of the advice and study, several other hospitals in the Region have instituted this practice. The Council was able to provide advice to a number of hospitals regarding purchases of equipment, such as radiology and kitchen equipment. Recommendations were based on a study of the needs of each institution. As a result, these hospitals were able to realize substantial savings by purchasing appropriate equipment and by omitting items considered to be beyond the requirements of the hospital. After the initiation of the Central Purchasing Program in 1948, it became obvious that purchasing practices in many of the smaller hospitals were inadequate. No inventory was kept and many emergency purchases, at increased costs, were made locally in order to meet urgent needs. The Council has given advice on uniform purchasing procedures, forms, and inventory methods, designed to facilitate anticipation of needs and to reduce emergency purchasing. In 1948, considerable time was spent by the staff in studying the possibility of developing an affiliation between the Lakeside Memorial Hospital, a small hospital serving the western part of Monroe County, and the Rochester General Hospital. The smaller hospital agreed to limit services to general care and to refer more difficult cases to the larger institution. It was proposed that the medical staff in each of the hospitals would have privileges in the other. This arrangement was not made because of difficulties in arranging for medical staff privi-

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leges at the Rochester General for members of the Lakeside Memorial staff. The Council's consultation services in specific problems of hospital administration have been widely used and are much appreciated, as is evidenced by the opinions of administrators, trustees, physicians, and hospital personnel. The smaller hospitals have had periodic visits from the consultants in the general field of hospital administration, ranging from one to four times a year. Recommendations on staffing, organization, and financing have been put into effect. At one hospital, a substantial deficit was eliminated as a result. The larger hospitals, particularly those in Rochester, do not require regular visits and do not express as great an interest in the advisory services. However, most of the large hospitals call the Council whenever they wish advice or information on special problems and the opinion was general that the advice obtained was usually valuable. A number of administrators observed that, as a result of the opportunities to associate with other hospital administrators and personnel in the Region, they felt free to call them or to visit, in order to discuss such problems as wage scales, personnel policies, and relations within the hospital. Administrators of larger hospitals in Rochester are often called upon for informal advice by their nonmetropolitan colleagues. Medical Records. The Council's role in aiding member hospitals to improve medical records started as a follow-up of the Institute organized by the American Association of Medical Record Librarians in 1946. The Council facilitated attendance at this Institute by providing stipends for personnel from member hospitals. Following the Institute, several hospitals were visited by members of the Council staff and assistance was given in reorganizing record procedures. In 1947, a Committee on Records, Reports, and Statistics of the Administrators' Conference was appointed. This Com-

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mittee was responsible for developing standard nomenclature suitable to hospitals in the region, for planning training, and providing consultation services. Standard forms and a uniform system for reporting professional and hospital service data were developed by the Committee during its first year of operation. Soon after its appointment, the Committee undertook the development of a "Medical Records Manual." In November 1948, Section I of this manual, describing the Unit Record System, was published and distributed to member hospitals. In this section of the manual, various statistical and administrative records necessary to maintain adequate control of hospital operations are described. The description of procedures represents an adaptation and interpretation of standard recording methods to meet the needs of hospitals in the area. The record system has been widely used by the hospitals and by the medical record librarian as a basis for instruction of medical record personnel in member hospitals. It is characteristically difficult for small hospitals to maintain competent medical record personnel. The turnover is great, and this fact, added to the difficulty that small hospitals encounter in recruiting qualified medical record librarians, accounts for the serious problem of maintaining competent supervision in this area of hospital operations. Many smaller hospitals assign to the task a regular staff member, who devotes part time to this responsibility. In several hospitals, medical secretaries have been successfully employed for this purpose. During the first part of 1948, a qualified medical record librarian was employed by the Council to visit hospitals and to assist in installing a standard system. This activity was suspended when funds for the project were exhausted. In 1949, however, a full-time medical record librarian was employed and she has continued in service ever since. The Council announced that the medical record librarian was available to visit

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hospitals to consult on methods of improving the system of medical records. During her visits to hospitals, the Medical Record Librarian reviews the system and recommends changes suited to the needs and resources of the institution. At the same time, she is able to supplement the training of the hospital's record librarian on an individualized basis. Although standard procedures are recommended, hospitals are not urged to install a complete system, such as coding according to standard nomenclature, until they are equipped to handle the work load involved. In addition to recommending methods, the record librarian gives assistance to hospitals during periods of illness of the regular record librarian. At the time of initiation of the program, there were only two registered medical record librarians in hospitals outside of the City of Rochester. At the time of the study, the number of qualified record librarians had been increased to four. From 1949 to 1953, the Medical Record Librarian made a total of some 665 visits to member hospitals outside of the City of Rochester. The number of visits to individual hospitals varied widely, depending on the hospital's needs and its interest in improvement of medical records. Thus, the number of visits to hospitals varied from an occasional visit to 45 visits. Furthermore, the length of time spent on these visits also varied widely, the Medical Record Librarian at times working intensively at an individual hospital for a period of a number of months. All of the smaller hospitals except two (one of which is a special hospital) used the advisory services in medical records on a rather regular basis and were visited several times a year. All were favorably impressed by the help given and many expressed the opinion that improvements in their system of medical records were directly attributable to help from the Council. The observation was often made by record

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librarians that "everything I know was learned through the Council." The larger hospitals called the Council occasionally for advice on a particular problem concerning medical records, but on the whole they are relatively self-sufficient and used such service episodically. There were no adverse comments. A survey of medical records was carried out during the course of the study to determine the extent of improvement, if any, in the content of medical records, among a sample of hospitals outside of Rochester. A random selection of twentyfive records was studied for each of the years 1946, 1950, and 1954, in a sample of hospitals with a bed capacity of less than 100 and in hospitals with 100 to 200 beds. The histories and physical examinations were classified as good, fair, poor, or none. Progress notes, laboratory reports, consultations, x-ray reports, and so on were counted. Operations, deliveries, and pathological reports were also counted. Although the number of records examined was small, some trends may be noted. Records in the smaller hospitals in 1946 were very deficient in notes on histories, physical examinations, progress, operations and anesthesia, and laboratory procedures. Coding, filing, and preparation of face sheets were quite deficient. This is attributable in part, at least, to the turnover of personnel in small hospitals. The larger hospitals had a somewhat better experience except for similar deficiencies in operative and anesthesia reports. Ry 1950, records in both small and large hospitals had improved considerably, the smaller hospitals showing a rather sharper improvement, particularly in methods of coding and filing. The recording of progress notes, laboratory procedures, and pathological reports showed marked improvement. Other impressions gained from the study may be summarized as follows: (1) In some of the small hospitals, even in 1946, occasional

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records reflected in their completeness the diligence of some physicians. (2) In one hospital in 1946, x-rays were read by an x-ray technician. A radiologist has been on the staff for the past few years, owing to the influence of the Council. (3) In all the years studied, the large hospitals had a greater number of acceptable records. In 1946, 25 percent of all records reviewed had inadequate records of history and physical examination, as compared to about 8 per cent in hospitals of 100-200 bed capacity. (4) The number of progress notes has steadily increased over the years in all hospitals. (5) Consultation notes in hospitals of less than 100 beds were infrequent in 1954. In larger hospitals, over 10 percent of the patients had a consultation that was recorded. (6) In all hospitals there were some records that had no diagnosis. The greatest number was found in 1946 in small hospitals, where they constituted 8 percent of the total. (7) In all hospitals, over 20 percent of all records had no urinalysis recorded. This was true of all periods. In fact, the number of recorded urinalyses decreased in both large and small hospitals in each subsequent study year. (8) Hemoglobin determinations and complete blood counts were recorded in 75 percent of the charts in the larger hospitals in 1954, showing a decided improvement over the previous periods. No such change occurred in the smaller hospitals. The number of other laboratory examinations has steadily increased, particularly in the smaller hospitals. (9) The number of x-rays per patient has not changed appreciably. (10) Missing operating-room notes were more numerous in 1946 than in 1954. Aside from the study of records, it was evident from other observations that, as a result of the program to improve medi-

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cal records through visits and consultations, the record systems in a number of hospitals had improved substantially. Whereas many of the hospitals had only a very inadequate medical record system with a large backlog of incompleted records at the time of the initiation of the program, this situation has been largely rectified. Although it is said that in 1946 and 1947 it was not uncommon to find 100-bed hospitals that had backlogs of as many as 4000 delinquent records, some dating back as long as two years, records at most hospitals are now up to date.1 Accounting. Because of the widespread financial and accounting problems in hospitals, attributable to rising costs, and the rapid increase in third-party payments, there was general interest in the development of Council activities in this area early in the program. Operations in hospital accounting constituted an extension of the work that had been started by the Rochester Hospital Council. Before the organization of the Regional Council, the Rochester Hospital Council had developed a system of uniform reporting of accounts which was adopted by Rochester hospitals in order to facilitate negotiations with Blue Cross, the State, county welfare departments, and other third-party payment agencies. On recommendation of the Committee on Accounting of the Administrators' Conference, this system was adopted by the Council, which recommended it for installation by member hospitals on a voluntary basis. Early in the program the accountant of the Rochester Hospital Council acted as Accounting Consultant for the Regional Council. With the amalgamation of the two Councils in 1951, a full-time accountant was made available to assist member hospitals, in addition to supervising accounting functions of the Council. Requests for consultation vary from simple problems to the installation of a completely new accounting system. In the

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latter case, it is the practice of the Consultant to work with the hospital employees until they are able to take over and operate the new system. The Consultant meets on request with the board of trustees and board committees of member hospitals to advise on problems in accounting and finance. He also has been called upon to assist in setting up and maintaining the New York State prescribed accounting records for expenditures of funds appropriated under the provisions of the Hospital Survey and Construction Act. The Consultant also prepares special bulletins based on abstracts of current literature relating to questions of general interest to Regional hospitals. These bulletins have covered such questions as taxation of employees, welfare reimbursement rates, and the like. As of the end of 1953, the six hospitals in Rochester and five hospitals outside of Rochester had adopted the uniform accounting report. In 1954, three additional hospitals put the system into effect. These hospitals demand a major part of the time of the Consultant, as, unlike the city hospitals, they cannot afford to employ fully qualified accountants. A comparison of reports received from these hospitals is prepared by the accounting office and circulated to all member hospitals. As a result of Council efforts, an accounting system for Blue Cross payments has been developed for Rochester hospitals. Other Blue Cross plans have since adopted similar procedures. From 1948 to 1953, the Accounting Consultant made over 300 hospital visits. Frequency and length of visits to individual hospitals varied widely, in accordance with need and with requests. During this period, numbers of visits to member hospitals varied from zero to forty-five. Practically all of the hospitals were impressed with the value of the Accountant's visits and help. A sizable number attributed marked improvements in their present accounting system to this service. Only one small hospital felt that the Consultant's

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advice was too complex for their needs. Occasional calls for advice on special bookkeeping or accounting problems by small or large hospitals always elicited a prompt and helpful response. One large hospital in Rochester undertook a study of the costs of operating-room care, and received substantial help from the Council in developing methods. Nursing Advisory Services. Nursing institutes and meetings of the Nursing Group and Committee of Nursing Directors provide an opportunity for consultation with the Nursing Associate of the Council. In addition, the Nursing Associate meets from time to time with the Administrators' Conference, the Medical Conference, and with individual boards of trustees to discuss questions of policy. Each month the Nursing Associate visits several hospitals at their request to review and advise on problems of nursing staff organization and on relations between nurses, administrators, and medical staff. She is often called upon to study and to make recommendations on the relation between nursing schools and hospitals, and on the content of the nursing curriculum. She is also asked to help orient newly appointed directors of nursing service. Recause of the extensive program of nursing education that has developed, and the fact that the time of the Nursing Associate is divided between the Council and the University, it has not been possible for her to visit hospitals as regularly as is done by some of the other staff members of the Council. Consideration has been given by the Council to the possibility of employing another full-time nurse, but this decision has been deferred for financial reasons. Recause of the relatively small number of visits by the Nursing Associate, and the greater complexity of nursing services, advisory services in this field have had much less effect on operations than in other fields. In general, larger institutions feel relatively self-sufficient, and have little need for

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special consultation. Most of the small hospitals indicated that this service was of some help, several attributing the organization of a nursing staff education program to the help of the. Council. Nevertheless, among these institutions, it was suggested that more frequent visits would enhance the value of this service. Dietetics. Using a consultant in dietetics from one of the larger hospitals in Rochester, a limited number of visits to member hospitals has been arranged by the Council to review problems in dietetics and menu planning in member hospitals. From 1949 to 1953, ten such visits were made. This is not a regular service provided by the Council, but is arranged on request from member hospitals. Diagnostic Facilities and Services. Early in the program plans were made for providing advisory services in radiology and clinical pathology. Study of the situation revealed that most nonurban member hospitals, which were too small to maintain their own laboratories, had the use of county laboratories. In this respect, rural hospitals in New York State are particularly fortunate since the State Health Department provides the equipment and pays 50 percent of the cost of operation of county laboratories which are responsible for public health and medical laboratory service. In many cases the laboratories are located within the hospital. Although this arrangement is inferior to one in which the hospital maintains its own laboratory, it probably constitutes the only way many smaller hospitals can have laboratory services approaching a degree of adequacy. The State supervises the bacteriological and serological work done at these laboratories. As noted previously, consideration is being given by the Regional Society for Laboratory Medicine to the possibility of providing some supervision of standards of clinical laboratory and chemistry services among Regional hospitals. In several instances where member hospitals were without

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adequate laboratory service, the Council helped arrange for a county laboratory. Such an arrangement was made in Orleans County, the laboratory serving the two hospitals in that county. During the first year the Council offered the advisory services of a consultant in clinical laboratory work, but there was little demand for this service and it was discontinued. Similarly, consideration was given to offering consultation services in radiology. It was found that most of the hospitals in the Region had the services of a competent radiologist available. In several instances where services were not available, the Council was instrumental in making such arrangements. Under the circumstances, there was no demand for consultation services in the field of radiology. Planning. A number of institutions that have undertaken plant expansion and improvement found the advice made available through the Council of real value in planning facilities and developing specifications concerning equipment to be purchased. In several instances this advice made substantial economies possible, and has resulted in greater efficiency. COOPERATIVE SERVICES

Central Purchasing. In September 1946, a Purchasing Committee was appointed by the Administrators' Conference to study purchasing practices and to explore the possibility of an agreement among hospitals on major items of supply suitable for purchase through a centralized system. Participation in joint purchasing, on a voluntary basis, was initiated in November 1947. In May 1949, a purchasing agent was employed by the Council. The Council took joint membership in the Hospital Bureau of Standards and Supplies, and a revolving fund was set up with contributions from participating hospitals at a rate of $2.50 a bed. A study conducted by the Council in 1950 showed that savings realized by hospitals through joint purchasing ranged from 3 to 5 percent in large

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hospitals and from 16 to 25 percent in hospitals of 50 beds and under; the average was about 10 percent. The revolving fund established through hospital contributions proved inadequate, and authorization was received from the Commonwealth Fund in June 1950 to transfer $50,000 from the Capital Grants Fund for this purpose, with the understanding that it would not increase the commitments of the Commonwealth Fund. The number of hospitals participating in the program gradually increased from 16 in 1947 to 24 in 1953. A limited number of items of supply are purchased through the Council, as well as major items such as x-ray and kitchen equipment. When the program began, an attempt was made to operate on a commitment basis; that is, hospitals were asked to commit themselves to a certain volume of purchases of specific items for a given period. This did not prove satisfactory. Continuing efforts have been made to induce hospitals to standardize their supplies so that quantity orders could be placed. Purchase of canned foods through the Joint Purchasing Program was investigated, but found to be impractical. The expansion of joint purchasing to cover fuel, parenteral fluids, and certain forms of insurance did not materialize because of difficulties in achieving general agreement among interested parties. Hospitals submit requisitions to the Council, and orders are drawn by the Council on a vendor. Payments are made to the vendor out of a revolving fund when the vendor's invoice is received. In turn, the Council bills the hospitals, and shipments go directly from the vendor to the hospital. Since its inception the volume of purchases made through the Joint Purchasing Fund has gradually increased from $229,933 in 1949 to $408,179 in 1953. In 1949, 4.4 percent of expenditures for supplies 2 and equipment was spent through the Joint Purchasing Program. In 1953, this increased to 5.3

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percent. There is considerable variation in the utilization of the service by the member hospitals, as shown in Table 9. In general, the smallest use of this service occurs in the hospitals with capacities of 300 beds and over. TABLE 9. Percent of nonsalary expenses of member hospitals incurred through the joint purchasing program, 1953.

Beds

Hospital

All hospitals 1-50

51-100

101-200

201-300

301 +

Dollar volume of purchases

$408,179.56

Arnold Gregory Lakeside Lyons Medina Seneca Falls Shepard Relief Group total

6,999.83 6,622.86 893.93 5,179.32 5,298.84 7,466.48 32,461.26

Bath Bethesda Cuba Dansville Jones Park Avenue Soldiers & Sailors Group total

9,998.89 4,320.34 809.38 12,852.43 16,284.24 12,447.09 2,954.51 59,666.88

Arnot-Ogden Corning Geneva St. James Thompson Group total

40,758.92 24,695.97 25,535.42 8,308.47 22,753.27 122,052.05

Clifton Springs Genesee Highland St. Joseph's Group total

34,013.94 18,164.16 61,103.90 30,741.28 144,023.28

Rochester General St. Mary's Strong & R.M.H. Group total

Expenditures for supplies and miscel.

$7,700,538.00

5.3

338,966.00

11.6 8.7 1.5 11.0 12.8 13.3 9.58

685,970.00

9.1 5.2 1.5 17.6 17.2 6.3 4.0 8.70

1,110,195.00

9.3 14.6 16.1 4.9 12.9 10.99

1,855,004.00

7.3 3.1 14.5 8.1 7.76

3,955.32 46,020.77 49,976.09

%

0.5 3,710,403.00

2.1 1.35

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Several hospitals stated that savings due to Joint Purchasing were large enough to pay for Council dues. Reasons given for not using it more were the desire to give some orders to local merchants, delay in deliveries, and the absence of full lists of items purchasable. Several thought that the service should be expanded, with revised lists being sent periodically to all hospitals. In general, the larger hospitals in Rochester use the service to a much lesser extent and do not find it too helpful, since they purchase in sufficient volume to obtain favorable rates. One of the large hospitals, however, stated that the purchasing service of the Council obviated the need to employ a purchasing agent in the hospital. The Council's purchasing agent also advised hospital personnel on the setting up of standard inventory systems. Many hospitals were able to economize by improving their purchasing practices and system of inventory. As a result of knowledge gained concerning the status of the market in hospital supplies and equipment, the Council was able to advise hospitals on equipment purchases in connection with plant expansion, effecting substantial savings in many instances. Analysis of Professional Activities. In 1948, in addition to other activities designed to improve medical records, a start was made in developing a system for routine reporting of professional activities to the Council. Hospitals were invited to submit copies of standard monthly reports of professional activities from which the Council compiled a comparative analysis of experience in the various hospitals. At this time, eight hospitals participated. The system was gradually improved and extended to cover twenty-four hospitals. Comparative analyses of professional activities among member hospitals have been published periodically, at first semiannually, and since 1950, annually. Copies of these reports are distributed to administrators, boards of trustees, and medical staffs of

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participating hospitals. Methods for accumulation and reporting of statistical data were outlined in the "Medical Records Manual" developed in 1948 and patterned after the system used in rural hospitals aided by the Commonwealth Fund in other areas. Professional activities are reported under several main headings and are compared with standards recommended for hospital performance. Included are data on complications, deaths and diagnostic procedures, and classification of deaths by service. Deliveries according to types of intervention, surgical operations, use of laboratory for tissue diagnosis, blood transfusions and special laboratory and other diagnostic services are also reported. The system was developed to provide an instrument for the boards of trustees and medical staffs of hospitals, whereby the quality of care might be measured and compared. It is interesting to note that the system of reporting and analysis of professional activities developed by the Regional Council was studied by representatives of the Southwest Michigan Hospital Council, and used by them as a basis for planning a system of continuing medical audit among hospitals in that organization. In the opinions of trustees, hospital administrators, and physicians, the analyses of professional activities seemed to be of rather limited value. Fully half of the hospitals made little use of these data. The chief criticisms were that they were difficult to interpret because of lack of comparability among hospitals and because they are published too long after the end of the year. In a few hospitals, the collection and reporting of statistics was considered too time-consuming, but in general this was not a problem. On the other hand, some of the physicians and trustees in the small hospitals were interested in comparing their own performance with that in other hospitals. Administrators at several hospitals stated that in spite of deficiencies in the reporting system, the analyses distributed by

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the Council are of value as a focus for discussion with boards of trustees and medical staffs concerning factors affecting quality of care. Uniform Accounting. In November 1946, the Administrators' Conference recommended adoption of the "Uniform Accounts Reporting Manual" developed by the Rochester Hospital Council for use by such non-Rochester hospitals as wished to participate in the program of uniform reporting. Eight hospitals have installed or are installing the system, in addition to the six hospitals using the system in the City of Rochester. The system provides for uniform reporting of the status of accounts, including analysis of change in operating surplus, gross comparable profit or loss, net income from patients, other hospital income, analysis of allowances given patients, analysis of expenses, analysis of salaries, capital expenses, and other items of expense. At six-month intervals, the Accounting Consultant of the Council prepares an analysis of income, expense, and the status of funds of all participating hospitals. This provides financial information in greater detail than has been available in the past to most of these institutions. The analysis of accounts is of most direct interest to those institutions which participate in the reporting program. Those who use this service find it helpful in spite of limitations due to the lack of uniform accounting procedures. Administrators at some of the small hospitals described the periodic analyses of accounts as "excellent." They provide a more adequate perspective from which to judge hospital expenditures. This is helpful in interpreting costs and needs to boards of trustees. Although acceptance of the uniform accounting report system has been slow among non-Rochester hospitals, the number participating has continually increased. Most of the hospitals that have adopted the system are located in the six-county area covered by the Rochester Blue Cross Program. Only two hospitals outside of this area participate in the program, prob-

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ably because the requirements of the Syracuse and Buffalo Blue Cross programs covering these counties are different. In addition to analyzing accounting reports, the Council maintains a staff to conduct cost accounting among the six Rochester hospitals, a function previously carried by the Rochester Hospital Council. This relieves the individual hospitals of the responsibility of maintaining staff for this purpose, and assures a greater uniformity in reporting. The Blue Cross organization accepts audited reports prepared by the Council as a basis for payment. Because of this uniform system of cost accounting, Rochester hospitals have been able to establish a more realistic and satisfactory basis of payment with thirdparty payment agencies. On the basis of experience in Rochester, other areas have since adopted similar practices. Closely related to uniform accounting has been negotiation with third-party payment agencies, concerning rates of payment and services. In general, problems related to payment by such agencies as Blue Cross, the Department of Social Welfare, State agencies, and commercial carriers are considered by the Rochester Sub-Regional Committee representing Rochester hospitals. Policies established by this group of hospitals are often adopted by other hospitals in the Region as well as by hospitals in other areas. As a result of the uniform accounting system and of negotiations with the Rochester Hospital Services Corporation, a cost basis of payment has been adopted. The policy provides for payment of hospital care at the rate for semiprivate accommodations plus fifty cents a day for use of equipment. A floor and ceiling of payment have been established at 10 percent below and 10 percent above rated average cost. Questions of benefits and exclusions are discussed with the Sub-Regional Committee of the Council. Thus, in 1953, when the Rochester Hospital Service Corporation proposed the introduction of a comprehensive contract, problems entailed in payment for special

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drugs, x-rays, and maternity benefits were discussed with the Sub-Regional Committee, and the requirements of the Blue Cross organization and Rochester hospitals were reconciled. The Sub-Regional Committee appointed a committee to develop and to maintain drug lists to be used in the administration of hospital payments. Representatives of the Blue Cross state that there has been a vast improvement in the accounts of hospitals as a result of the activities of the Council. Similarly, the Sub-Regional Committee has conducted negotiations with the Monroe County Board of Supervisors concerning rates of payment for beneficiaries and with the State Director of Budget with respect to the State reimbursement formula for treatment of the physically handicapped and for vocational rehabilitation. The Council has conducted special studies of such items as charges for antibiotics, room charges, and so on, where it became necessary to clarify points in negotiations. On the basis of improved financial records, in 1948 the Monroe County Board of Supervisors agreed to pay Rochester hospitals on the basis of costs. This was a development of major importance in the State, with obvious nationwide significance. Because of the special problem presented by migratory farm laborers, a committee was appointed in 1952 to explore this problem with the regional representative of the State Department of Social Welfare. State policy provides for reimbursement of Welfare Departments at 100 percent of the cost of hospital care for migratory laborers. Although no general policy has been developed by county welfare departments, the situation is improving. Recruiting of Nurses. During World War II, the Community Nursing Council of Rochester was concerned with nurse recruitment. This interest continued during the postwar period. In 1947, funds for the Nursing Council were allocated to the Rochester Regional Hospital Council by the Community

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Chest. The organization, however, continued to maintain its identity, concentrating its energies on raising money for nursing scholarships and for recruiting. In 1952, it was decided that the recruiting efforts were not fully effective, and the Council employed a full-time nurse to develop a recruiting program and to coordinate with the work of the Community Nursing Council. This nurse represents nursing at "career days" organized by high schools, and visits schools to talk to students who are interested in nursing; she helps organize open-house day for nursing schools in Rochester, and prepares publicity. The Rochester Advertising Council helps in this as a public service. Out-of-town nursing schools are helped to organize open house, although each school is responsible for preparing its own publicity. Although it was generally observed that the nurse recruiting program is too new for evaluation, at several of the hospitals with nursing schools the number of applicants has increased, and large numbers of prospective candidates have been attracted to open-house days. Furthermore, the availability of a Regional recruiting nurse has relieved the nursing staffs of these institutions of the responsibility for visiting high schools each year. The nurse is also responsible for assisting in the selection of applicants for nursing scholarships, provided by women's auxiliaries in each of some four counties. Monroe County established seven scholarships, Ontario five scholarships, Wayne and Seneca one scholarship each, generally available to students from those counties. A manual for guidance and vocational counselors was prepared, which included a description of the various diploma and degree nursing schools in the region. The Community Nursing Council has under consideration a proposal to become a regional organization, the objectives of which would be "to promote and participate in activities designed to increase the quality and quantity of nursing care in

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the community, and to interpret to the public and others the functions of nursing and stimulate their interest and support in programs of nursing education and service." Credit and Collections. A Credit and Collections Department was originally organized by the Rochester Hospital Council in 1943 and has been continued as a service of the Rochester Regional Hospital Council. It has been extended to serve five Northern Tier hospitals outside of Rochester, in addition to the six city hospitals. A standard credits and collection manual and procedures were developed by the Credits and Collections Committee of the Sub-Regional Committee of the Council. The manual was adapted by a Southern Tier subregional Credits and Collections Committee with the aid of the Credits and Collections Manager of the Council. This service is self-supporting. The policy has been to charge 10 percent of accounts referred within 60 days, 25 percent for accounts collected between two months to six months, and 30 percent for accounts collected after six months. Charges by the Credits and Collections Service for accounts turned over to attorneys are reduced to 5 percent. The credit and collections service met general approval among those hospitals in the Northern Tier which use it. It has substantially reduced the number of uncollectable accounts, and relieves hospitals of a considerable financial burden. In addition to collections, the Sub-Regional Credits and Collections Committee is also concerned with negotiations with third-party payment agencies. Such negotiations have helped clarify relations with the workmen's compensation carriers, with the Bureau of Health and Accident Underwriters, and with other commercial carriers, and with the Welfare Department. Work has been done with independent insurance carriers to arrange to have payments made to the hospital rather than to the patient in the case of indemnity insurance. Standard

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procedures for determining eligibility of workmen's compensation cases have been developed and adopted by all regional hospitals, thus facilitating the processing of these accounts. The manager of the credits and collections service is also available for consultation with individual hospitals on special problems. Duplicating Service. In September 1950, in response to a request from Rochester hospitals, the Council established a duplicating service to provide for certain printing needs of member hospitals. Member hospitals were asked to contribute toward a revolving fund to support this service. When these funds proved insufficient, they were added to by transfer of funds from the revolving fund of the purchasing program. All orders from hospitals are accepted, although some of the work must be done on a subcontract basis, because of the type or volume of work. All Council printing is done by the duplicating department. Hospitals using the service are billed on a cost basis plus a percentage for overhead. It is the objective of this service to provide printing at a cost less than commercial rates. Thus far the volume of printing has not been sufficient to maintain the service, and it has been operating at a deficit. At the time of the study it was pointed out that the volume of orders by hospitals through the service would have to be increased or the service might have to be discontinued. Other Services. In addition to the cooperative services described in detail, the Council also provides help for member hospitals in a number of other ways. Negotiations with nurses concerning rates of pay among Rochester hospitals are conducted by the Sub-Regional Committee. Periodic applications for increase in rates are considered by this Committee in terms of general cost-of-living increase and policies governing nursing salaries in other areas. As a result of negotiations, it has been agreed that, after a certain period of service, increases would be made on the basis of

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merit rather than length of service. A committee has been appointed to develop a system of merit rating suitable to nursing. The Sub-Regional Committee is used as the channel for negotiations with the Eastern Ambulance Service, which provides ambulance service for Rochester and the surrounding area. Proposed legislation that affects hospital and medical practice is often discussed at the meetings of the Sub-Regional Committee and the Council. Resolutions of these groups are passed on to appropriate State agencies and probably carry more weight than do communications from individual hospitals. BELATED

REGIONAL HOSPITAL

SERVICES RENDERED

BY

OTHER

AGENCIES

In addition to auxiliary hospital services administered by the Council for all Regional hospitals, several related services have been organized by other agencies on a Regional basis. In the case of the regional blood bank the Council played a significant role in getting it started, and continues to cooperate actively with the Red Cross, the responsible agency, in its continuing operations. The Council has played a less direct, but nevertheless significant, part in the initiation and operation of the other programs described in this section. Blood Bank. In September 1946, a committee was appointed by the Medical Conference of the Council to consider the possibility of forming a regional blood bank. Joint sponsorship by the Red Cross, the Health Bureau of the Department of Public Safety in Rochester, the State Department of Health, and the Council of Rochester Regional Hospitals was proposed. Approval of the idea was obtained from county medical societies by the Medical Conference Committee and the cooperation of hospitals maintaining blood banks was assured.

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In June 1947, the American Red Cross adopted the Rochester Regional Blood Program as a national project to be set up in January 1948. It was agreed that the national organization would allocate $100,000 for this purpose and the local chapter of the American Red Cross would furnish $25,000. In November 1946, the Board of Directors, on the recommendation of the Medical Conference and the Administrators' Conference, passed the resolution that a Regional Blood Bank be established. In November 1947, the Medical Conference appointed a committee to set up standards for blood use. A manual on "The Use of Blood and Blood Derivatives" was drafted and distributed to all physicians and hospitals in the area. The distribution of this manual was coordinated with institutes on the use of blood. Technical aspects were taken up at a meeting of the Regional Society for Laboratory Medicine. The Rochester Regional Red Cross Blood Program was initiated in 1948 as a pilot program of this sort in the United States. Twelve counties are included in the area of service, including the eleven covered by the Rochester Regional Hospital Council and the County of Wyoming. The latter county was included because of the frequency with which residents of Livingston County go to Warsaw, in Wyoming County, for service. The National Red Cross furnished the equipment, at an estimated cost of $25,000 to $30,000. The Rochester Chapter of the American Red Cross is custodian of the Program. Seventeen other chapters in the Region are affiliated and all contribute financially. Each local chapter has a medical advisory committee appointed by the County Medical Society. The Rochester Chapter has a six-man advisory committee. Each local chapter has a Blood Chairman. Blood Chairmen meet once a month on a coordinating committee concerned with nonmedical phases of the program. The Region is split into northern

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and southern tiers for these meetings. The Rochester Regional Hospital Council acts as a channel for relations with hospitals. Furthermore, the Medical Conference has maintained a continuing interest in the standards of service. Collections are made at the center and by two mobile units. About one-sixth of the volume of blood collected annually is collected at the center, and the remainder in other parts of the Region. Routine laboratory work on all specimens includes serological tests, typing, and Rh typing. Plasma from whole blood too old to use is drawn off and sent to a pool for fractionation (Squibb Laboratory). Certain blood fractions are available to the Region from these laboratories, including serum albumin and antihemophilic globulin. Blood is stored at the center in Rochester and is distributed to hospitals upon request. The program serves thirty-nine general and special hospitals and three Federal hospitals in the Region. Hospitals order a small supply of frequently used types to keep on hand, and the Sheriffs Association cooperates in the emergency distribution of blood, which can be carried to the farthest point in the Region in an hour and a half by means of a sheriffs' relay. Hospitals are supplied with equipment to do emergency bleedings when necessary. In addition, hospitals are supplied with a file of donors, according to blood type, to be used in getting additional rare blood when necessary for emergencies or disaster. Reports submitted by the general hospitals indicate that there was a marked increase in the utilization of blood transfusions between 1946 and 1953. The increase was much more marked among small than among large hospitals, as indicated by Table 10. This increase and tendency toward equalization of the utilization of transfusions among institutions of different size may be attributed in large part to the availability of the Regional Blood Bank. Since the rate of utilization of transfusions tends to level off in institutions of over 200 beds, where

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blood is most readily available, their experience may be accepted as standard. The Regional service has, therefore, contributed substantially to the approach by smaller hospitals toward the achievement of good standards of practice in this regard. TABLE 10. Number of transfusions per 100 discharges. Number of bed»

All hospitals Under 50 51-100 101-200 201-300 Over 300

Percentage of transfusions 1946

1953

8.6 3.2 8.6 10.2 9.2

21.2 13.4 15.4 19.3 23.3 24.2

Trustees, members of the medical staff, and administrators are unanimous concerning the values of the Regional Blood Bank. At all hospitals it constitutes a convenience, and at many of the smaller institutions, which did not have blood-banking facilities, it constitutes a lifesaving service. There were no instances in which needed types of blood were not available. Furthermore, at some of the larger hospitals, which had previously maintained a blood bank, the change has resulted in a financial saving. At a number of hospitals, however, physicians were not aware of the close relation between the Council and the Regional Blood Bank. Hospitals have no financial responsibility in the program. In general, they collect $5.00 per unit for the first two units of blood administered in 24 hours. There is some variation in this policy, however. Physicians may charge a fee for administration of blood. All transportation charges are paid by the Red Cross. Some 60,000 pints of blood are collected annually, 36,000 pints being allocated for civilian use and the remainder turned

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over to the Army for military use. Cost of operation amounts to about $5.50 a pint. This cost includes everything — laboratory services, processing, and transportation. The Government reimburses the program for blood made available for military use at a rate of $3.00 a pint. The National Red Cross plans to diminish its support for the program over the next three years. It may become necessary to request hospitals to contribute toward the cost of distribution and supplies; this possibility was discussed at a meeting of the Sub-Regional Committee in January 1954, and the hospitals were amenable to the idea. The Rochester Regional Blood Program was the first of its sort in the United States. Since that time programs have been developed in a number of other areas. Similar programs have been established in Buffalo and Syracuse. There are, however, variations in the policies adopted. Premature Center. From time to time at meetings of the Medical Conference there was discussion of the desirability of having one or more premature centers organized in the Region. Such a proposal was made at the meeting of the Medical Conference in September 1947. No progress, however, was made toward the organization of such a center until December 1951, when such a facility was organized by the Rochester General Hospital with State aid. The center serves the City of Rochester and ten counties in the area of jurisdiction of the Regional Council. Orleans County is served by the Buffalo Center. Until the end of March 1954, there had been 187 admissions, 119 from Rochester and 68 transferred by ambulance from other areas. Facilities include accommodations for 20 premature infants as well as two incubators for transporting infants from other parts of the region. Transportation is arranged through a commercial ambulance concern, the Center sending a trained nurse on such calls.

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Staff of the Center includes a director, two residents, an intern shared with the Department of Pediatrics, a nursing supervisor, six full-time staff nurses and five part-time nurses, one nurse's aide, and a consultant ophthalmologist. Through affiliation with the Strong Memorial Hospital, a pediatrics resident is assigned to the Center for a one-month period of rotation. State aid was provided to assist the Center until January 1954. Since then patients have been billed full costs. All cases outside of Monroe County are eligible for State aid. Although the Premature Center operates independently of the Regional Council, the Council has cooperated with the Center in training personnel and in physician education in the care of premature infants. Several nonurban hospitals have referred premature babies to the Regional Premature Center, and, in general, find the service satisfactory. Educational and advisory services in this field, as well as the presence of the Center, have resulted in substantial improvement in standards of premature care at a number of member hospitals. Rheumatic Fever Diagnostic Clinic. In 1946, a Rheumatic Fever Diagnostic Clinic was established at the Rochester Municipal Hospital under the joint sponsorship of the Monroe County Medical Society and the Rochester Health fiureau. The service is purely diagnostic. The Council has cooperated with the clinic in publicizing its services among the physicians of the Region. COMMENT

Some of the most tangible results of the Council's activities are found in the field of hospital organization and administration. Though these results are no more important than those achieved by the educational program, they are more susceptible to objective evaluation, and in many respects these services are in themselves educational. As a central organization the Council is in a position to

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stimulate and initiate administrative programs on the basis of sound principles as well as to function as a clearing center through which administrative techniques found successful in one hospital can be transmitted to others. Furthermore, meetings of administrative and advisory bodies, institutes, and seminars provide forums for discussion of organizational and administrative problems by personnel of hospitals of various sizes. A good start has been made by the Council in establishing standards and recommendations for good organization. Although these have had a perceptible influence on many hospitals, it is obvious that they are not strictly applied in determining eligibility for membership. With the permission of hospitals concerned, rating schedules of some fourteen hospitals, based on inspections made by the American College of Surgeons and the Joint Commission on Accreditation of Hospitals between 1951 and 1953, were reviewed. Inspection of these reports indicates that certain surgical procedures, such as sterilization and Caesarean section, are often performed without adequate consultation. Consultation is often not sought for difficult medical and surgical cases. The findings of these accrediting bodies were, in general, substantiated by an inspection of hospital records made in the course of the study. A study of hospital staff appointments of physicians in the Region was conducted as part of the present study. The numbers of staff appointments for each physician listed in the New York State Medical Directory for 1946 and 1953 were recorded. In order to correct for deficiencies in the Directory information, these records were checked against listings of staff and courtesy appointments provided by hospitals in the Region. Because lists were not available from a few of the small proprietary hospitals in the Region, these corrections are not complete. The data accumulated suggest that, although the situation

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improved significantly between 1946 and 1953, a substantial number of physicians had no hospital privileges (staff or courtesy) in the latter year. This was true to a much greater extent of general practitioners (27.2 percent without hospital privileges) than of specialists (4.8 percent). In the metropolitan county of Monroe, where data are reasonably complete, 30.9 percent of the general practitioners were without hospital privileges in 1953. Although there was improvement between 1946 and 1953, these data suggest that hospitals in the Region have not yet applied fully the Council's recommendation (in "Suggested Qualifications for Medical Staff Membership and Hospital Privileges"), that staff privileges be extended to all physicians in accordance with their training. Comparison with experience in a control area reveals that improvement in this respect during the period under study was approximately the same in the two areas. This suggests that the program of the Council has had relatively little effect on this aspect of medical practice. Because time did not permit a more thorough exploration of this question, definite conclusions should not be drawn. Nevertheless, the data are strongly suggestive of continuing deficiencies in the distribution of hospital privileges among physicians in the Region. It is generally acknowledged that opportunity to participate in the activities of the hospital medical staff is an important factor in the continuing education of the physician. It would seem appropriate for the Council to conduct studies into the distribution of medical staff appointments, and to devise recommendations to rectify any inequities in opportunity that may persist. Although the recommendations of the Council with regard to medical staff organization have not been strictly adhered to in the past, the Medical Conference recently has expressed a direct interest in this matter. Consideration is being given to reestablishing the category of associate membership, adopting

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ROCHESTER REGIONAL HOSPITAL COUNCIL

as a criterion for active membership adequacy of medical staff organization rather than type of control of the institution. Consideration of the "Standards for Admission and Maintenance of Membership" indicates that it would be difficult for the Council with its present personnel resources to apply these standards strictly. Furthermore, the standards are expressed in very general terms, and may be subject to wide latitude in interpretation. The Council has made little effort at routine inspection of hospitals to determine the degree of compliance with recommendations of the Council. In 1953, a questionnaire was circulated to all hospitals inquiring into certain aspects of organization, staffing, and facilities. Returns indicated that while a number of hospitals had revised their bylaws and rules and regulations since the inauguration of the Council program, at several hospitals statements of policies dated back as far as 30 to 40 years. Most hospitals indicated that they had reviewed the policies recommended by the Council and that the medical staff was organized into services, members being limited to fields of competence; and all but two hospitals stated that they had a medical records committee. Arrangements for laboratory and x-ray examinations at virtually all hospitals were reported satisfactory. At all but one hospital, facilities were available for all essential laboratory examinations, including chemistry, bacteriology, pathology, serology, and frozen sections. Most hospitals reported the availability of the services of a trained clinical pathologist and a radiologist. Most of the smaller hospitals use the facilities of county laboratories. It would appear that among those institutions aspiring to accreditation by the Joint Accreditation Commission, there is a stronger incentive to adopt acceptable practices than in other institutions. More frequent visits by members of the Council staff to review and consult on organization and standards at all nonurban hospitals would probably be desirable. Such visits

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should be long enough to make a reasonably good appraisal of the progress and deficiencies at the various institutions and to prepare recommendations. It is obvious that sufficient personnel time must be provided before undertaking such a program. In addition to staff visits to hospitals, a committee of the Medical Conference was appointed to visit hospitals and consult on special problems of medical staff organization. Although only a few requests of this sort were made, in several instances serious problems were resolved that the board of trustees and the medical staffs of the hospitals had been unable to meet with their own resources. The Medical Conference has manifested continuing interest in problems of medical staff organization. It is handicapped, however, in this work by the fact that there has not been sufficient professional medical staff. With the organization that has been established, it seems likely that more rapid progress would be possible in improvement of medical staff organization were more time of a properly qualified physician available. This fact is recognized by the Medical Conference and the possibility of employing a well-qualified physician has been discussed. The question of application of standards of eligibility for membership in the Council poses an important question of policy. Some regional programs, such as those at New York University and the University of Michigan, have established standards which hospitals must meet before they can become eligible to participate, and to which they must adhere. These programs limit their scope and objectives to the improvement of facilities for graduate and continuing education of the physician in selected institutions. Other programs, such as the Bingham Associate Program and the Rochester Regional Hospital Council, which are more broadly conceived, hold out affiliation to all hospitals that express an interest, on the prem-

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ROCHESTER REGIONAL HOSPITAL COUNCIL

ise that the organization is designed to assist all interested hospitals to improve themselves. In these programs it is visualized as the responsibility of regional organization to give whatever assistance may be required without regard to the status of the hospital at the initiation of affiliation. The answer to the question raised by this difference in approach cannot be made categorically. It depends in the last analysis on the philosophy and objectives of the organization. Should the Council decide to apply standards, however, it is obvious that its staff is at this time not adequate to administer such standards effectively. The other advisory services offered by the Council have proved to be valuable and well suited to the needs of the member hospitals. Periodic visits to the hospitals by the Medical Record Librarian, the accountant, and others have helped establish systems and procedures based on sound principles. Largely as a result of the Council's efforts, ten hospitals outside of Rochester now have good record systems set up which are fairly complete along the lines recommended in the "Medical Records Manual." In an additional seven hospitals the record system has been improved, but the complete system is not yet installed. The Medical Record Librarian was working intensively with some of these hospitals at the time of the study. Resistance still exists among medical staffs in some hospitals toward improvement in standards of medical records. They feel that records are of secondary importance and are reluctant to expend the time and effort needed to bring these records up to accepted standards. It seems evident that at many hospitals, there has not been as marked improvement in the content of medical records as there has been in the record system. The problem of improving the content of the record, as reflected in the quality of recorded histories and physical examinations and of operating-room, delivery-room, anes-

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thesia, and pathology reports, is essentially a problem of medical staff organization and physician responsibility. The advisory services in accounting have been of much greater value to the smaller hospitals than the larger ones, since the latter generally have trained accountants on their staffs. Efforts to install uniform accounting procedures have made some progress but still have far to go. Nevertheless, there has been definite improvement and the availability of the accountant for visiting and consultation has given the member hospitals an important source of special knowledge. The nursing advisory services have apparently not met the need for this type of service fully, primarily because of the inability of the part-time Nursing Associate to make sufficient field visits. Though the Nursing Associate is available for consultation, more frequent visits to member hospitals would be valuable, in view of the fact that a number of nursing problems are peculiar to the particular local hospital and could be more fully appreciated by means of direct observation. The employment of a full-time nurse assistant by the Council has been considered and there is a manifest need for one. Though this would involve increasing the budget, such an expenditure not only would fill a need, but it could materially enhance the present activities of the part-time Nursing Associate by providing a follow-up of her expert advice. It seems clear that the advisory services provided by the Council have filled a real need. More extensive controlled studies of operation in member hospitals and a similar group of hospitals outside of the Region would be necessary to measure the effects of Council operations more precisely. Should the necessary support become available, expansion of advisory services in the fields of medical staff organization and nursing would seem desirable. Of equal importance to the long-range improvement of hospital and health services of the Region would be the development of facilities for provision of advice

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in medical social service. Although most of the member hospitals are too small to employ qualified medical social workers, other methods of providing such service should be explored. Possibly groups of hospitals, by pooling their resources, could employ such personnel on an area basis, along the lines of an experiment that is being conducted by the Bingham Associates Fund and the Coastal Group of Maine hospitals. Working with public health nurses, hospital nurses, and social case workers, it might be possible to develop other methods for discharging many of the functions ordinarily carried out by the medical social worker. With increasing recognition of the importance of chronic illness and rehabilitation, and of continuity of care provided in the hospital, the home, and the physician's office or clinic, the need for adequate medical social service is brought into sharp relief. The central purchasing system should provide the hospitals, particularly the smaller ones, with the mass purchasing power of a large organization. Nevertheless, there have been marked variations in the extent of its use. Some hospitals have taken little advantage of it; others have saved enough to more than pay their Council dues. Efforts at adoption of standardized items of supply should be intensified. The adoption of a standard formulary by the Council would probably facilitate the joint purchase of drugs. The smaller hospitals have the problem of maintaining good public relations with local merchants. Nevertheless, purchasing service could effect sizable savings in hospital costs and it would be valuable for the Council to conduct studies of the various hospitals and of the reasons for their use, or failure to use this service. The analyses of professional activities give administrators an opportunity to review professional services with boards of trustees, and to explain the significance of various indices of professional activity. Although it is a useful educational device,

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it has thus far proved inadequate for making comparisons of performance among the several member hospitals. There have been differences in interpretation of various indices, such as obstetrical complications. There have also been differences in definition of minimum preoperative study, and of the distinction between major and minor surgery. As a result, large, wellregulated hospitals often show a higher rate of complications than do other institutions, a circumstance that may not accurately reflect actual experience. Examination of reports of the first five years, from 1949 to 1953, indicates wide variation in indices in individual institutions from year to year. More consistency was found in records of numbers of diagnostic procedures which apparently are more easily recorded and in which problems of definition do not arise. The Committee on Medical Staff Organization and Activities of the Medical Conference and the Medical Records Committee of the Administrators' Conference have been concerned with deficiencies in the system, and from time to time they recommend improvements. Although the analyses of professional activities have thus far proved to be of only limited value, the principal is a good one. The intensive study of methods of measuring quality of hospital care being conducted by the Southwest Michigan Hospital Council in cooperation with the Michigan School of Public Health was stimulated in part by the work initiated in the Rochester area. It would seem appropriate for the Rochester Regional Hospital Council to continue its efforts to develop a practical system for measuring the quality of medical care in its member hospitals, since this would provide a key to identification of many problems in organization and administration as well as hospital financing. It seems obvious that, in order to pursue this objective, a greater amount of staff time and more adequate medical supervision will be necessary. A visit by a representative of the Council to the Southwest Michigan Hospital Council to observe the oper-

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ations of the study on quality of hospital care would probably be worth while. It is obvious that one agency cannot assume responsibility for initiating or administering the full range of health services necessary to an area. Possibly the principal value of a regional program is the development of a pattern of cooperation, and effective channels of communication within the area served. Once a cohesive region has been developed, the matrix thus formed may be adapted to serve a number of specialized needs. This fact has been demonstrated by the adoption of the region as an area of service by the Blood Bank, the Premature Center, and the Rheumatic Fever Diagnostic Clinic. The Council has developed effective working relations with the agencies responsible for these services, giving assistance as needed. Future progress in the Region may well be measured by the degree to which other related agencies develop specialized services on a regional basis in cooperation with the Council. An inventory and program summary of the various health and related agencies and services in the Region would be useful in projecting further cooperative relations. It could be used by the Council in planning its program, and by hospitals, physicians, and public health and social agencies in recommending specialized services. Such a study has been made in the City of Rochester, under the sponsorship of the Community Chest. This could be supplemented by a study of the agencies in the remainder of the Region, conducted by the Council and other interested agencies. Such a study would provide a basis for comparison of the adequacy of specialized services in the rural areas with those in the metropolitan center.

Chapter

T h e Council an and Healtk R

esources

To a large extent, health programs influence the availability and quality of medical care by improving facilities and resources necessary for the provision of care. Of primary importance are human resources — the various types of professional and auxiliary personnel essential to the full range of health and related services. Of increasing importance are hospitals and other facilities necessary to the provision of the various diagnostic and therapeutic services.

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The program of the Council was designed to improve resources in a number of ways: by means of hospital planning and capital grants, by means of recruiting, and by means of training and advisory services. Some of these influences are direct, others indirect. In this study, it has been possible to attempt to measure only a few facets of the complex of health resources. Certain data were accumulated to measure changes in the distribution of hospital facilities. A study of the distribution of physicians in the Region in 1946 and 1953 was made in order to measure trends and compare them with trends in a control area. Furthermore, information concerning hospital staffing in 1946 and 1953 was obtained. These data are presented in this chapter. HOSPITAL PLANNING AND CONSTRUCTION

When the Region was established, the Commonwealth Fund agreed to provide support for hospital construction. According to the terms of the agreement between the Fund and the Council, $200,000 a year would be allocated by the Fund for improvement of hospital facilities for a period of five years. The Council would make grants-in-aid to participating institutions to defray part of the costs of new buildings, building alterations and additions, and equipment, under terms and conditions satisfactory to the Fund. With the passage of the Federal Hospital Survey and Construction Act soon after the Council was organized the agreement was modified to make it possible for member hospitals to receive support from both sources. The efforts of the Council toward improvement of hospital facilities in the Region complement those of other agencies, official and voluntary. The New York State Joint Hospital Survey and Planning Commission was established by law in 1947. In addition to being responsible for the administration of the Federal Hospital Construction Act in New York, the Commis-

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sion was also charged with developing a coordinated hospital plan within the State to ensure economical and efficient use of facilities and services. By early 1948, the Commission completed an inventory of existing hospitals in the State, ascertained the geographical areas in need of additional facilities, and established a priority list of counties indicating the relative urgency of such needs. To assist in planning the distribution of hospital construction funds, the Joint Hospital Survey and Planning Commission appointed Regional Hospital Planning Councils in each of the seven regions into which the State had been divided. The Executive Director of the Rochester Regional Hospital Council has served as secretary of the Rochester Regional Hospital Planning Council of the State, and many of the members of the Planning Council are also members of the Board of Directors of the Rochester Regional Hospital Council. Although consideration has been given to appointing the Regional Hospital Council as the responsible planning agency for the Region, this has not yet been done. State Aid for County-Owned Hospitals. The New York State Public Health Law gives the State Commissioner of Health authority to grant 50-percent State aid to counties for various public health purposes to be decided by him. The State Commissioner of Health has authorized such State aid for the construction of county homes, and of general hospitals in counties under 50,000 population. In the Rochester Region at the time the Regional construction program was inaugurated, six counties — Allegany, Livingston, Orleans, Schuyler, Seneca, and Yates — had a population of under 50,000 and were therefore eligible for State aid for construction of county hospitals. In addition to providing funds for construction, the State Public Health Law provides 50-percent State aid for operating deficits of county hospitals thus supported. To be eligible, the county must establish a county health depart-

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ment. This provision has kept several of the counties from participating in State aid for hospital construction and operation. Although Seneca and Allegany Counties made a real effort to organize county hospitals eligible for State aid, no county in the Region has as yet been able to take advantage of this State provision. Among the obstacles encountered have been difficulties in achieving agreement as to where the hospitals should be located and a disinclination on the part of residents to support a county health department. Rochester Hospital Fund. In 1946, six general hospitals in Rochester organized the Rochester Hospital Fund to conduct a campaign for $7,000,000 for the support of necessary construction. It was planned that approximately 500 beds would be supplied for the acutely ill, including replacement of some 135 beds located in obsolete units. Although the Rochester Regional Hospital Council did not make funds available for construction of facilities in the City of Rochester, the work of the Council was closely coordinated with that of the Rochester Hospital Fund, the Executive Director of the Council being secretary of the Fund. Council Grants for Hospital Construction. In 1947, the Rochester Regional Hospital Council appointed a Committee on Capital Grants, responsible to the Board of Directors, to supervise surveys of need and plan the distribution of capital grants. At its first meeting, in October 1947, principles to govern the distribution of capital grants were formulated and these were adopted by the Board of Directors in November 1947. The salient points among these principles were: (a) All nonprofit general hospitals that were members of the Council would be eligible for grants, except those located in the cities of Rochester and Elmira. Proprietary and government hospitals were not eligible. (b) Grants would be made only after the need for facilities had been substantiated by surveys by the Council staff.

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( c ) Contracts for construction would be given on the basis of competitive bidding, the terms of the contract subject to the approval of the Council. (d) Applicants were required to contribute from their own resources a substantial part of the cost of the project. In the event that a Federal grant was also made for the same project, at least one-third of the cost of the project must be borne by the applicant. ( e ) The community must provide adequate evidence of ability to finance operations. ( / ) Regulations of the Federal Hospital Council under the provisions of public law 725 would govern standards of construction. (g) No project designed purely for the replacement of facilities or equipment would be eligible for support. (h) Assurance must be given that specialized equipment would be operated under the supervision of properly qualified personnel. (i) Evidence must be given of compliance or ability to comply with the Council's standards for maintenance of membership. (/') Grants would be made on a basis of the Council's estimate of the relative needs for the project as well as financial needs of the hospital and the community. Grants were made by the Council subject to the approval of the Commonwealth Fund. The Commonwealth Fund indicated that it would not approve grants under the following circumstances: (a) Where the community is within 20 miles or less of a substantially larger community having, or likely to have, adequate general hospital facilities. ( b ) Where the hospital would serve an area with a population of less than 20,000.

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(c) Where the project would provide for a bed-to-population ratio greater than that specified in Public Law 725. Between 1946 and 1948, the staff of the Council conducted an intensive survey of the needs of the Region for improvement of hospital facilities. The division of the Region into natural hospital service areas was accomplished by making a study of the residence of persons admitted during the first six months of 1946 to some 45 hospitals in and around the Region, with an aggregate of about 4000 beds. On the basis of distribution of admissions to the several hospitals in and bordering the Region, townships were grouped about the various hospital centers into hospital service areas. The population of each of these areas was computed from census data and estimates were made of facilities required in each area. Existing hospital service areas were mapped, and it was found that all parts of the Region except the village of Geneseo were within 15 miles of a general hospital of some size or description. Natural barriers and roads were studied. Also taken into consideration was the distribution of physicians practicing in the Region in 1947. From all of these factors, fifteen proposed hospital service areas were developed, as shown in Fig. 1 (facing p. 14). In estimating the facilities required in each of the areas, the bed-to-death ratio used by the State Hospital Survey and Planning Commission, the standards adopted by the Public Health Service in administration of the Federal Hospital Survey and Construction Act, and current actual usage and longterm trends were taken into account. The last two were considered to be important because of the evident decrease in average length of stay. Each of the hospital service areas, except for Rochester, Elmira, and Clifton Springs, was subjected to intensive survey and, if requested by the local hospital, a detailed report, including findings and recommendations, was prepared. These reports were reviewed with boards of trustees and other in-

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terested groups to create a greater understanding of the various considerations in planning hospital facilities. Preliminary estimates of the cost were made, and a formula was devised for distribution of grant funds. Particular attention was given to small hospital service areas, which because of their character and location were considered suitable for the location of some sort of facility but inadequate in size to support general hospital services. In such instances, small medical service centers were recommended to be affiliated with larger institutions in the vicinity. In a number of instances, an effort was made to convince adjoining communities supporting individual hospitals to pool their needs and support the construction of a single larger facility. In the description of the over-all plan presented in a detailed report in December 1948, general information concerning hospital facilities and needs in the Rochester, Clifton Springs, and Elmira areas was included in order to complete the picture of distribution and needs in the Region. The Council's approach to planning of facilities on the basis of hospital service areas rather than on a county basis is fundamentally sound. Such an approach, however, is possible only where sufficient staff is available to do the necessary studies and planning. The records of distribution of townships and localities among the hospital service areas which were compiled in 1946 were no longer available at the time of the current study. It was, therefore, not possible to compile data on the current distribution of population and hospital facilities on a similar basis. Recause most data available from State agencies with regard to hospital planning are based on counties, quantitative data used in this report relate to the county and district rather than to the hospital service areas. On recommendation of the Committee on Capital Grants, the policy was adopted of providing differential support for those hospitals which were eligible for Federal grants and

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those which were not. Hospitals eligible for Federal grants were allowed support from the Council up to one-half of the amount of the Federal grant or a maximum of 16.7 percent of the cost of construction. Hospitals not receiving Federal grants were eligible for a grant from the Council up to a maximum of 38.6 percent of construction costs. In addition, applications from small hospitals for purchase of equipment would be considered, the Council providing 50 percent of the cost of such equipment to a maximum of $10,000. The Council maintained $100,000 of its grant fund unallocated to be used for contingencies. On the basis of these policies, and the criteria established by the Commonwealth Fund, eight projects were approved and received a total of $923,624 from the Council. Among this same group of projects, with an aggregate cost of $4,006,778, four received Federal support in the amount of $1,033,975. The grants from the Council accounted for 23 percent of the expenditure, ranging from 16.2 percent to 50 percent. Three of the grants exceeded the maximum percentage of support planned by the Council, as supplementary grants were made from the contingency fund to assure completion of these projects. Total costs of all the projects, sources of support, and numbers of beds added are shown in Table 11. In each instance where a grant was made, an agreement between the Council and the recipient hospital was signed in which the various principles and policies of the Council and the Commonwealth Fund governing distribution of capital grants was set forth. The maximum commitment of the Council was stipulated in this agreement. Applications for support from several hospitals were disapproved on the basis of criteria set forth for approval by the Commonwealth Fund. It will be noted that in two projects no beds were added. A small grant was made to the Bath Memorial Hospital to assist in enlarging and remodeling the dietary department. At

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