American Hospital Conference
Report of aConference on Hospital Standardization
Held inChicago, April 21, 1919
1919
AMERICAN MEDICAL ASSOCIATION
FIVE HUNDRED AND THIRTY-FIVE NORTH DEARBORN STREET CHICAGO
Chicago, April 21, 1919
This conference was called in accordance with the resolution adopted at the Fifteenth Annual Conference of the Council on Medical Education on March 3, 1919. The resolution followed the reading and discussion of a paper presented by Dr. A. R. Warner, President of the American Hos pital Association, and Dr. Warner presented the resolution. It was as follows:
Resolved, That it is the consensus of opinion of the members of this Conference that the apparent agreement on the subject of hos1:»tal standardization, as expressed in this meeting, should be utilized to expedite progress on this problem. To that end it is the consensus of opinion of this Conference that the American Medical Association be asked to take the leadership in formulating a committee, representing all interested factors, which shall give this subject of hospital standardization such consideration and study as is possible, and that the American Medical Association, together with this committee, arrange to call a meeting of all those interested in 11nd affected by hospital standardization at some convenient poiftt and time within the next year.
The hospital conference was called to order at 10 a. m. by Dr. Arthur Dean Bevan, President of the American Medical Association, who said: The purpose of this conference is an attempt to elevate the standards of the hospitals of this country. The problem is too large to be handled by any single organization. It needs the co-operation of all organiza tions interested in hospital work. In order to develop ways and means to carry this on, that at the suggestion made by Dr. Warner, President of the American Hospital Association, at the last Conference on Medical Education, the American Medical Association has called this conference. More and more hospitals are becoming essential in every community as plants in which modern medical attention can best be obtained. lt seems as necessary for the state to make these hospitals safe and efficient as it is to have banks made safe and efficient.
A precedent that may be of service to us in undertaking this work, is the work accomplished in-the last fifteen years with the medical school problem. In that work it was necessary to obtain the cooperation of all factors vitally interested in the medical school problem. To secure this cooperation we called an annual conference, to which each association was asked to send a delegate. The improvement of medical schools which resulted has been one of the striking pieces of successful educa tional work. It required fifteen years to produce the results which are now of a great deal of value.
This hospital problem cannot be solved in a short time. We should now take steps to develop machinery that will be permanent. The dif ferent associations represented here must keep on with their own work. The American Hospital Association, the American Medical Association, and all of these different agencies must keep on with the work they are doing in their own particular lines. In the teamwork we are undertaking to establish the different associations should work in a broad spirit. No one association should feel that it is the most important factor in this cooperative scheme; there is work enough for all of us, and if we accomplish good results there is credit enough for every organization that is interested.
One concrete, definite suggestion is that, whatever plan we agree to carry out after this informal conference, we should plan for an annual conference to be atten<led by representatives of all the agencies interested in hospitals.
2
I would like first to call on each delegate to present his or her views in regard to the best plan of procedure. I would like to ask Dr. A. R. Warner, President of the American Hospital Association to present
his views. '
DR. A. R. WARNER: What is a hospital and what is it for anyway? There are afflictions of human life which are preventable and infirmities which may be delayed, but the need for medical care to the human family is unquestionably forever. Hospitals are institutions developed by society to meet this situation, to prevent or contribute to the prevention of the preventable, and to the delay of the delayable, and to make the inevitable as comfortable as possible. The fundamental aim of a hospital is, there fore, service to society. Hospitals may benefit and develop special groups of men and women as physicians, nurses, etc., but the fundamental aim will ever be service to society and all effort must justify itself in this light. Personal benefit to the individuals or groups is not to be consid ered, except as contributory.
One motive for the desire to standardize hospitals is an aim to reduce, to make logical and clear, the presen_t extreme variations in the types of existing institutions and their work; another is a desire to radically improve the hospitals as social institutions; and a third quite general motive is to bring about improvements in the particular depart
ments in which special groups are interested. But we are here today because every one wants something done about it.
Hospital standardization in this sense and degree seems to me to be made up of two distinct parts. The first is theoretical, individual, inspired. Some must see clearly and be able to make others see the details of the ideal hospital of today and tomorrow, rendering ideal service to society-service through training of men and women to per petuate itself and to carry on the work outside as well as inside its walls, training in all the various kinds of work necessary to make the institution ideal and doing effective work in all lines which can contribute to the fundamental purpose of the institution. These details must be seen clearly and then described clearly; they must be reduced to rules and the rules backed by common sense reasons which are so convincing as to command respect and general allegiance. This is the difficult part of hospital standardization. When we know what a hospital should be, it will be a simple matter to determine if a hospital is that or not and how much it lacks.
- The second part of hospital standardization is organization, mechan ical. Some one must determine how nearly the institutions approach these ideal standards and somewhere this information must be kept available to all those who would know it. This part of hospital standardi zation can and should be done by the American Hospital Association. This association can develop the necessary organization to measure the various institutions of the country by the rules determined. It can tabu late this information and classify the institutions. It can keep this information on file as well as any organization, and will have a more active incentive to keep it up to date. The American Hospital Associa tion is this year in a period of transition from an association of voluntary members to an association of institutions themselves as primary members, although personal membership is still permitted. This makes it possible to accomplish much which had heretofore been impossible. This associa tion more than any other will be interested in the developments of hos pitals to meet the higher standards and for obvious reasons will have the best o'pportunities for direct appeals to trustees. There is already before the association plans for the establishment of service bureaus to render free service to hospitals in matters of reorganization and
improve-ment. There seems to be nothing in the organization and mechanical part which the American Hospital Association cannot do better and easier than any other association now in existence.
But this part is the easiest part. The big problem is in the setting of the standards. It will require all the wisdom which can be secured to study, to comprehend, to analyze modern human physical life and to advise and determine the type of institution which can render maximum service. In this part of the work every viewpoint must be considered, every type of service weighed and evaluated not only for the present, but for the future. This seems to be work for more than one man. The problem is exceedingly complicated in comparison with that of medical education. The methods used in the case of medical colleges are not so serviceable in the case of hospitals. It would not suffice simply to study hospitals and make public their shortcomings. There is interest in hos pitals from so many active viewpoints that the defects of the institutions are now fairly well known to those directly interested. The public does not know them and it does not seem wise to attempt or permit the general education of the public in these matters. The results would be too serious. It mattered comparatively little to individuals if the med ical colleges did not give sufficient or effective education. Every one believed that their trusted family doctor had made up these defects in his years of practice and the matter was to them merely an academic one. This will not be the case, however, if the defects of hospitals are to be advertised. The interpretation throughout the country will be that their family and friends who are at the time in hospital care are receiving inadequate or incompetent care. It is difficult to conceive of the worry and heartaches such publicity would bring, especially to the poor to whom hospital service in case of illness is a necessity. Such publicity would also tend to decrease general contributions to hospitals. Hospital standardization cannot proceed along lines analogous to those used with medical colleges.
The object must be to reach and educate hospital trustees. Every trustee learning that his institution is classified D-5 instead of A-1 will ask why that institution in which he is so interested and to which he has given so much is not an A-1 hospital. The rules of standardization should be able to tell him the various points which his institution lacks. The result will be a spontaneous determination to get nearer the top by correcting defects. The American Hospital Association, through whom he should learn of the defects, should and will have service bureaus in charge of experts to plan with him the required changes. A limited public will get a certain amount of judicious education in the raising of necessary funds, but the heartaches will be eliminated. To me rapid progress in general betterment of every hospital in the country seems inevitable as soon as hospital standards are set and the institutions classified in accordance thereto.
The setting of the standard is, however, the jmportant and difficult task. In determining these standards every possible viewpoint should be carefully considered. There seems to be nothing to propose but a com mission or congress made up of representatives who can present the clearest and most accurate interpretation of every viewpoint and who have the interest and determination to carry this project through. This commission may well represent wider fields of interests than are repre sented by those present. In addition to the interests concerned with every type of work which now is or should be carried on in hospitals, which would include the trustees and other forms of management or control, various types of outside viewpoints should be selected for rep resentation.
THE CHAIRMAN: I will ask Miss Clara D. Noyes, President of the Ame_rican Nurses' Association, Washington, D. C., to continue the dis cuss10n.
Miss CLARA D. NOYES: I shall approach the question of hospital standardization from the viewpoint of the nurses' training school, which I am inclined to regard as a most essential part of the institution. The American Nurses' Association stands for a nursing education that develops and increases the efficiency of the nurse wherever she may be, whether as a pupil in the training school or outside. I have been both a hospital superintendent and a superintendent of a training school. I always felt, when I was the superintendent of a hospital. that if I made that training school as nearly perfect as I could, that the work would be reflected in the hospital.
I do not believe any one will disagree with me in the following points : First, the value of the nurses' training school to the hospital. With the training that the school provides we can have a more satisfactory nursing staff than can be gained in any other way. If I were given my choice of two nurses, I think I should take the pupil who is under expert super vision. I should feel that I could conduct a much better hospital under·
those conditions than if I had an entirely graduate staff. The advantages to the hospital obtained from having a training school are really greater to the hospital than to the pupils themselves. As a part of the hospital it must be subordinated in a measure to the interests of that institution. Very few training schools have separate endowments; therefore, they use hospital funds that exist for an express purpose, namely, taking care of patients, and in that hospital in a very great measure the nurses' training school must be subordinated to the interests of the institution.
Another point is that the graduate nurse has become a factor of vital importance to the welfare of society through the work in the various fields in which she is engaged. Inasmuch as that is the case, those who are interested in her preparation are morally responsible for the condi tions under which she is prepared.
Now, if the conditions in the school prevent women from entering or prevent their remaining after they have once entered, it becomes a matter for public concern. With the development of the medical profession; with the development of the public health field and the social service field, there is a call for greater and more highly prepared nurses. Hence, the character of the school that exists is a matter for public concern.
'vVe have not yet reached what we consider the ideal education for a nurse, but we have worked persistently, quietly, and carefully toward attaining an acceptable standard. First, it should be well balanced as far as theory and practice are concerned, and that implies the proper kind of hospital. It implies careful instructors and conditions which will permit instruction in theory and in practice along generally accepted lines.
In schools connected with hospitals which meet certain requirements, the education of the nurse should possibly be completed in that institu tion. If it happened to be a school connected with a· hospital that is more or less special in its nature, the education of the nurse should be com pleted in a group of hospitals, or it might go further afield than the hospital itself, and look to the public health organizations, the visiting nurses' associations, and so on, to complete the preparation of the nurse. The length of the course is a much mooted question. In New York State the law grants a minimum of two years; the majority of laws require three years, and it is left to the individual hospital what the length of the course should be. With the development in medicine, and in the public health field, we are gradually coming to believe that there
should be a third year, during which they shall have some general prep aration in public health work, social service work, and in other specialties than those which they will obtain in the ordinary three-year course. This supplem·ental work in the third year is a matter for careful study, but it can be obtained usually in public health lines, especially under the auspices of visiting nurses' associations, in social service departments, dispensaries, etc.
The requirement for admission is another question that has given cause for much discussion and is still subject to great variety. The American Nurses' Association favors a high school education as a pre liminary requirement. However, we have not yet reached that point, and it varies at the present time in varions states from one year in a high school to a complete high school education. But more and more, as we see the nurses at work, and as we depend on them to meet the require ments of the public, we see the necessity of a proper fundamental educa tion, and we would like to see not less than a high school requirement. With the rapid development of the field of public health, those of you who have been watching the Red Cross of late have noticed a public health program that it has launched, in which hundreds of carefully pre pared women will be required. When a community asks for a nurse they do not want a nurse that will be simply a bedside nurse; they want a woman who can take her place in the community, who can teach that community what they need in community nursing. They ask for the highest type of nurse. They say, "Do not send us such and such types; we want a woman who can speak at public meetings, one who can direct and guide our thoughts and educate us as we feel we should be educated toward the needs of the community." So more and more we are impelled to believe that we must stand for a higher education. Considering that the Army School of Nursing during the past year was able to secure some eight thousand applicants who met the high school graduation requirement and who were willing to go into these schools, we should be able to attract large numbers of properly prepared women.
The Council of National Defense made efforts to secure large numbers of pupils to enter civilian hospitals during the period of the war from a purely patriotic standpoint, and large numbers of pupils entered the training schools, but during the epidemic of influenza many of our stu dents dropped by the wayside.
Standing back of the question of nurse education is the question of good laws. Nursing is not a licensed profession like chiropody and a few other things. Standing back of good laws the American Nurses' Association places itself upon record, as it did a few years ago, as believing in two grades of workers, the trained attendant and the nurse. We have hesitated to do very much about the trained attendant or to push the measure until we could secure good laws to protect the trained attendant and thereby protect the community. The purpose of the trained attendant is to provide a type of nursing service for those who are chronically ill and they can act as assistants to the nurses. We are very anxious as regards the short course, which we feel is dangerous, and I think an attendant can be properly trained and properly licensed in the great majority of cases to do the work that is being done by graduate nurses.
THE CHAIRMAN : I will ask Dr. S. S. Goldwater, Director of Mt. Sinai Hospital, New York, to continue the discussion.
DR. S. S. GOLDWATER: I am not here as a delegate, so it is not my purpose to speak on behalf of any particular organization; I shall deal with the general situation as I see it. In order to accomplish what we
6
have in mind it will be necessary to agree upon standards. When we talk about agreeing on standards we ought to have in mind something more than the mere determination of the methods that are to be pursued in the conduct of hospitals. The American College of Surgeons, which has done splendid work, has, however, concerned itself with methods rather than with such essential matters as designating the type of hospital organization that is best fitted to do the work of the community. One of the first questions to consider is what type of hospital organization is best qualified to meet the needs of the community. Can we establish an organization which will adapt itself from month to month and from year to year to the advances in medical education and be always in a position effectively to apply the teachings of medical science? I think it is clear that in the present state of medicine the best type of hospital organiza tion is one in which the various specialties can combine their efforts for the good of the patient. I do not mean to say that a combination of specialists is necessary to the treatment of every case, but combinations are often necessary, and it is exceedingly difficult, if not impossible, to know in advance what particular combination will be required and it is essential that the various specialists be placed in a position to cooperate with each other at will-which is impossible when the various clinical branches are represented by independent institutions having no contact with each other. Now, one may ask, why has not the type of organiza tion that I am suggesting been more generally developed? It does not exist to any great extent even in large cities, where the population is pretty well concentrated, and where individual institutions, which are known by courtesy as general hospitals, are to be found in large numbers. The average general hospital is not a general hospital in the sense in which I have defined a general hospital. Why have we failed to develop real general hospitals? First of all, there has been a lack of definiteness of aim on the part of the people who have had to do with the development of hospitals. Most hospitals have been created without regard to the estimated needs of the community, taking the community as a whole; our hospitals have sprung up as the result of the special interests of individuals or of groups whose aim was less broad than the community's needs. There has been a lack of comprehensive, coordinated planning.
Another reason has been lack of means. Those who have been con cerned with the creation of hospitals have not had the resources necessary to carry on the work of large general hospitals. And there have been difficulties inherent in the character of rural communities where it will always be necessary to compromise and to accept something less than the ideal.
The question of the lack of trained personnel by means of which the work can be done, deserves consideration. Let me give an illustration:
The College of Surgeons has been insisting on case records as a means of improving hospital work. We know perfectly well that case records will not be kept by the visiting staff; they must, therefore, be kept by the intern. lf the number of medical men we are now graduating is insufficient to supply interns to the majority of the hospitals of the country, we will have no case records in these hospitals until one of two things is done: we must either increase the number of medical gradu ates or we must train a group of persons to take the place of interns in so far as the work of interns can be done by persons without medical degrees. Since it is clear that we have not a sufficient output of interns to supply the various hospitals, we should seek some means of bringing into the field the necessary substitutes. Perhaps three-fifths of the work of the intern can be done by nurses who are trained to do this work. A point demanding serious consideration in this connection is whether
it is fair to open a new occupation for graduate nurses when such large numbers are needed for nursing work. If, however, the development of such a program as Miss Noyes has suggested can be carried out, namely, to supplement the existing nursing forces by the training of bedside attendants under suitable conditions, it will be possible to assist a number of graduate nurses to the training necessary to enable them to take the places of interns and become clinical assistants in hospitals.
One of the fundamental difficulties is that hospitals are controlled by laymen who have no conception of the essential principles involved in hospital administration, and a question in my mind is whether a part of our study should not be directed to the possibility of modifying the character of the controlling organizations generally.
Machinery already exists which makes it possible to accomplish cer tain things. The American Hospital Association has clone extremely valuable educational work in the past few years. Dr. Warner and others have recently suggested means of changing the character of the member ship of the association, and it now seems possible to find funds with which to develop a broad program and to establish a service bureau in connection with the association:
The work of the American College of Surgeons has been most stimu lating and of great educational value. We have now reached a point where there is a general demand that we shift the burden of the manage ment of hospitals from undisciplined and untrained lay managers to persons professionally trained to do the work; such a change I believe will be welcomed by the medical profession. This was not possible before the American College of Surgeons began its work.
The American Nurses' Association has contributed materially to hos pital advancement. It has established a standard curriculum for the training of nurses, which is helpful, but which, I am satisfied, is not final. Miss Noyes spoke about the demand for public health nursing and of the need of corresponding modifications in the standard curricu lum. The American Medical Association through its Council on Medical Education, whose activities intimately affect hospitals, has accomplished a great deal for the improvement of hospitals by bringing into the hos pitals a better equipped class of medical graduates to carry on the work of the intern. The intern influences the character of the work done by the visiting staff quite as much as he is influenced by that work. It seems to me, that when such an organization as we are here considering is formed, it ought to work, in the first place, for ideal hospital organi zation, so far as that can be achieved. It can be clone in communities where there is a disposition on the part of all the elements to come together in an effort to meet the needs of the community as a whole. We should strive to bring about combinations of hospitals in many instances, and where combinations are impossible, we should work for a program of cooperation on the part of the existing individual units. We should present definite suggestions as to where the line of duty lies for each particular hospital and show how it should cooperate with other institutions in the same community. It is generally agreed that tll"e duty of a hospital is to care for the sick, to train nurses, and to furnish oppor tunities for medical research, and yet there are comparatively few hos pitals that are fully complying with all of these requirements; they are not trying seriously enough to do all these things; they cannot do these things until they have undergone radical changes. What we want today, first of all, is to devise a means of getting together. We need to agree on the ideal type of hospital organization. We need to set up a perma nent machinery which will stimulate hospitals to move toward the attain ment of our ideal.
8
THE CHAIRMAN: Will Col. Franklin H. Martin, the Secretary of the American College of Surgeons, Chicago, kindly address us?
COLONEL FRANKLIN H. MARTIN: The American College of Surgeons was induced to undertake the standardization of hospitals because of the lack of uniformity in the practice of surgery among the average of American surgeons, and the discovery that much of this lack of uniform ity was due to uneven facilities furnished by the average hospitals of the
. country.
As the American College of Surgeons desires to include in its fellow ship all surgeons and surgical specialists who aspire to do the surgery of the country and who can give satisfactory evidence of qualifying under the standards of the college, it soon became apparent that many otherwise acceptable surgeons were handicapped because of this unfor tunate situation confronting them in the hospitals in which they did their work.
Soon after the organization of the college its various committees on credentials suggested a remedy by pointing out the necessity for a mini mum requirement of efficiency in the hospitals in which the candidates for fellowship did their surgery, if the work of the committees was to be accomplished with reasonable uniformity.
The Fellows of the college accepted with great unanimity the sugges tion of its committees and the Board of Regents after ascertaining what had been accomplished by other organizations along the line of hospital standardization, formulated and put into effect under the direction of Mr. Bowman a plan that has been in operation for more than three years.
The program has for its immediate object the protection of the public against unskilled operating by furnishing surgeons uniform hospital accommodations in which they can do good surgery and in which their assistants, the future surgeons, may be trained in proper and safe environments.
The program has been worked out after careful consideration of the subject in conference with medical staffs, hospital superintendents, hos pital administrators, hospital trustees, house officers, civic health admin istrators, hospital associations, nursing superintendents, laboratory experts, hospital statisticians, military hospital administrators, medical societies, editors of medical and public press, the great foundations for economic betterment, and, of great importance, the people who are the patients in, and the principal support of the hospital.
The final analysis of the many problems brought out in the preliminary surveys enabled the college to base its program on a few fundamental requirements: First, an adequate system of case records; second, staff organization of qualified men; third, diagnostic laboratory facilities.
While insisting upon these essentials as a basis for adequate scientific conduct of the hospitals, the college in the progress of its survey takes cognizance of the hospital's physical equipment; its financial status, its nursir,g facilities, it;s dietetic requirements, its attitude to its interns, its heating, sterilizing, ventilating, cleaning, renovating, and laundry facili ties, all of which have their bearing on the ability of the hospital to care for its patients in a wholesome and satisfactory manner.
The methods adopted by the college in its investigation may be briefly summarized as follows : First, sending to all general hospitals of the country of twenty beds or over a questionnaire accompanied by literature stating what the college is attempting and asking the hospital to cooperate with it by filling out the questionnaire, and announcing that a representa tive of the college will visit the hospital within the near future.
Second, a representative of the college visits the hospital, and (a) with its superintendent or other official carefully inspects the plant with espe cial reference to its system of records, its laboratories, diagnostic facili ties, its operating rooms, and gains a knowledge of its staff organization.
(b) When it can be conveniently arranged the representative meets with the medical and surgical staff of the hospital, at which time a free interchange of views is indulged in, and the attitude of the college in its standardization po-licy carefully explained. (c) When possible, a conference is also held with the trustees or other managing body of the institution, at which the chief of staff, the superintendent, and the head of the training school is present, and a sympathetic-get-together discus sion is indulged in. ( cl) In communities where there are several hos pitals, the representative after these preliminary interviews with each and the conditions being favorable, calls a general public meeting when the hospital problems are discussed in a general way, that will enlighten the people and create a community interest in hospital support. (e) The visiting representative makes and files with the central office of the college on special forms, their reports of hospital visits and meetings, and these are made the basis of follow-up letters and further visits where necessary, and this data and all other reliable information that the college is able to obtain is tabulated and anlyzecl in the central office.
In this work of standardization of hospitals, the college has been obliged to proceed with care as it had no precedent to guide it and pro vide itself with the necessary personnel, office machinery and substantial financial support.
Under the supervision of a full-time director who has disinterestedly and enthusiastically devoted himself to the hospital problem for the last three years, the regents have succeeded in developing a corps of hospital visitors. During this time eight men and women selected for their peculiar qualifications have, under the director of the college, devoted part or whole time to the visiting of hospitals.
Questionnaires were sent to all general hospitals of over twenty beds, and of these hospitals 1,135 have made replies. The larger percentage of the replies were received from hospitals of thirty-five beds or more. The college has devoted special attention in its preliminary work to hos pitals of 100 beds or more doing general work. These hospitals number 612. Of this group of 100 bed hospitals, 503 replied to the questionnaire. The reports of those visited, which include most of the states, show that only 15 per cent. meet our minimum requirements; 65 per cent. additional hospitals in this group have pledged to cooperate with the college· and to meet its requirements at the earliest possible elate.
Mr. Bowman and his corps of assistants have made over four hundred personal visits to these hospitals of 100 beds or more.
Through the cooperation of the members of the college in various cities and communities more than twenty large public meetings have been arranged, which meetings have been addressed by the director and his associates. These meetings have averaged an attendance of from one hundred to five hundred individuals and are the outcome of a thorough canvass of the hospitals of the city in which they are held. These meetings represent the alliance of the staffs, the trustees, and the lay supporters of all hospitals of the city.
A few illustrations may be cited which show the methods pursued by our hospital visitors, the influence of our method of examination of junior cancliclates for fellowship and the practical support of our program by
the Fellows of the college.
-The following is one of many reports filed with us by Mr. F. E. Chapman on one of the hospitals he visited:
Equipment: X�ray equipment is very complete with an exceptionally bright and intelligent technician on duty at a11 times. Volume of work 1s not large but the character is very good. Do not believe it is being used as much as 1t should be. They have technician in charge of the laboratory. They are not equipped to do Wassermanns and from the conversation I had with the technician, I do not think she is equipped to do anything else. In fact, my diagnosis would be they are merely going through the motions. There is no such thing as routine. laboratory work. They do very little pathology and that only when they make special charges. Remarks: The deplorable thing about the hospital is the general atmosphere of the place. It is a business proposition from start to finish: Pupil nurses are permitted to do special duty work even in the first year of their training for which the hospita1 charges and col1ects the fee. This institution is operated in conjunction with two other hospitals of the state, all of which are on a par.
Another report in regard to case reports is as follows :
Current: Personal history; physical findings; laboratory findings; operation and nurse's notes; summary card.
Filed: Laboratory findings; operation or treatment; final diagnosis; summary card.
Laboratory: All on main floor; X-ray man and interns; additional laboratory for each ward.
Division of fees: No evidence. Action of hospital: Very favorable.
Remarks: The present personnel of the hospital is excellent. The hospital has the right ideals and determination and seems to have sufficient backing to put through the ideals. All the elements of a good hospital are present. The super intendent has the proper ideals and determination and force of character. A social service department has been recently installed and certainly is in very capable hands. On account of the stage which the hospital organization has reached, the social service takes upon itself to cover more ground than belongs to it, but it is well that it does this at present, e. g., securing personal and medical history from the patient. It is well done, but not by medical people. There is a good follow-up system. .
The interns are chosen by appointment; they are well cared for and the service is a rotary one. They receive $12.50 per month compensation, in addition to their maintenance.
The entrance requirement for nln-ses is two years of high school at present; next year, however, the law will require four years. Instruction to nurses is given by physicians, but not necessarily members of the staff. They Jive in a dormitory.
Urinalysis is the only routine laboratory work. All other laboratory work is done on indication and order from the physician. The patient is charged according to his means (social service report). The work is progressive and everywhere eYidence of reconstruction is found.
One of the most practical means the college had of illustrating its efficient methods is through more than 800 separate sets of hospital records that have been filed by its candidates for fellowship. These must conform to our minimum hospital requirements in history writing. The hospital in which such a candidate does his work that is not in accord with the standard of the college is usually induced to conform to its plans.
Among many examples of partial reorganization of hospitals along the line suggested by us and as a direct result of our propaganda is that of one of the oldest and best known institutions in one of our largest cities. For two years they have carried out the following program.
Dr. George Gray Ward, Jr., Chief Surgeon of the Woman's Hospital
New York City, states : '
In 1913 the Regents of the American College of Surgeons first announced its purpose of taking measures to bring about hospital standardization in order to improve existing conditions, and in October, 1917, the first Conference of the Inter national and State Committees on Standards was held in Chicago.
It was the writer's privilege to attend this meeting as a member of the New York �ommittee. The enlightenment as to the actu_al facts and the great need for nnf:'rovement �s presented to the . Conference, with_ the enthusiasm and inspiration which were kindled to take part 1n such constructive work, made the journey and the time spent well worth while.
The chief points brought out were, that the proper care of the patient was held �s the test _of efficiency in the standardization program; that the hospital is primarily for the patient, for his convalescence and complete recovery from illness; that there was a great need of closer cooperation betwen hospital staffs and hospital trustees
and that it was necessary to establish a strong administrative authority in order t� accomplish results.
t
.
I
This then in briefest form is an outline of the work we are striving to do. We are endeavoring by suggestions, by sympathetic conference, by the combined effort of our four thousand Fellows to create a public opinion in the profession and the laity that will enable the hospitals that are anxious to maintain a commendable standard to do so, and that will induce those that are satisfied to a higher level to see to it that it is to their interests to ally themselves with a progressive program.
This comprehensive survey undertaken by the American College of Surgeons has required for its successful execution the expenditure of a considerable sum of money, an average of more than $20,000 a year, and as the work develops the expenditures will increase. More than $30,000 will be required for this work during the present twelve months. The Fellows of the college have provided liberally for this and similar work in their dues, in the interest on the endowment of $500,000 that was contributed by the founders-a group of Fellows-and a thirty thousand contribution to this special work by one of the great foundations.
The rank and file of the Fellows of the college and its Board of Regents are keenly alive to the responsibility that they have assumed in undertaking this work that they· have so carefully planned and that in assuming such important proposition in personal service and financial outlay and the college can be depended on to cooperate with all inter ested in the subject and to continue the direction of this important work.
THE CHAIRMAN: The police power of controlling public health and hospitals, as provided hy the Constitution of this Government, rests with the state, and if the police power is to be called into this work it must be done through the State Licensing Boards.
I should like to ask Dr. Bierring, Secretary of the Federation of State Medical Boards of the United States, to continue the discussion.
DR. WALTER L. BIERRIKG: Only a few boards in this country are intimately connected with the training of nurses, yet a ,number of them are so constituted that they have a nurses' department which is largely in charge of one or more representatives of the state nursing association. It is hoped that in those states where there are organizations of medical examiners and nursing boards of examiners, they may in some way be combined in the future for the purpose of regulating the education of the registered nurses. Wherever it is possible for a state board to have some control over the nurses' training, those hospitals which wish to have a nurses' training school can be brought up to a certain standard. That has worked out very well in the various places in which that is carried on; so that by a definite course of study and an annual or more frequent inspection such as is now in vogue in Illinois and Iowa and a number of other states, it is possible to so standardize hospitals that they will comport with the requirements for training of nurses.
In about nine states the state boards have requirements for an addi tional intern year of hospital service as a requirement either for gradua tion from a medical school or for admission to the examination fop licensure. It can be readily seen that where this arrangement exists, the state licensing board has a definite control over those hospitals which desire or are able to give the paper intern service. If I were to suggest any plan for standardization or classification of hospitals, I would suggest that there be a definite plan or standard which will apply to hospitals that are able and wish to have a training school in connection with the hospital, but those hospitals that are of proper size and equipment to give the necessary intern service, should be placed in a different class from the special hospitals.
12
The question of an ideal hospital has been mentioned; namely, the general hospital, as being of greater service to the community, because they combine the specialties and have the facilities for a complete exam ination in the one hospital. The transfer of patients from one service to the other will adapt itself equally to the charity hospital as well as the hospital that depends on pay patients. A campaign of education should be instituted by the publication of definite standards, wherein the standards should be placed in this so-called general hospital. This may not be under the control of state boards, but possibly through the means of standardizing the nurses' training institutions and the intern institu tions it will be possible also for state boards indirectly to influence the standardization of the so-called general hospital. Along those lines it seems to me, this general committee may at least institute its work.
THE CHAIRMAN: One of the newer developments in hospital work is that of the social service, and I am going to ask Miss Edna G. Henry, President of the American Association of Hospital Social Workers, Indianapolis, Ind., to continue the discussion.
Miss EDNA G. HENRY: The social work of the American Association of Hospital Social Workers is so very new and it has been subjected to so many trials and variations, that it has hardly a right to speak at this time. The work in any form whatever is little more than a dozen years old, and the association has not yet had its first annual meeting. It is made up today of individuals who, through want of experience or of training, have failed to adapt themselves to the problem in hand, and yet a great deal has been accomplished by the social service departments in our hospital dispensaries. I say that positively, although I know that the majority of the three hundred social service departments are not true social service departments. There is often among the social workers a very vague idea of what constitutes a true medical social service. The very name is a misnomer. We call it hospital social service, and yet some of the best work that is done in our out-patient departments,-dis pensaries,-should be called medical social service. It was not called medical social service because it was clear among the members that if we called it medical social service the people might think it was general public health work; whereas the very place for a medical social service department is within a medical institution or hospital. It is that which distinguishes it from all other forms of social service. The social service must be a part of the medical institution, existing within it, and cooper ating with all other elements.
Our biggest problem is the training of the medical social service worker. The first essential of the social service worker is that she should be a teacher. You can fix up a milk formula, but it takes a teacher to get the women to learn how to do it and to teach it to the neighbors.
One of the dangers which I see is that hospitals have found the medical social service department of such value that they feel it is becoming a part of the organization and a part of the therapeutic work. If the social service department is to be what it should be, it must grow and take care of patients in the dispensaries, obtain information regarding the family history and ga.ther outside evidence which the doctor needs for diagnosis and for the treatment of the patient or the proper discharge of him.
There are no two medical social service departments exactly alike.
Some are taking care of bed.s in hospitals; some are doing case work; some are acting as clearing houses to the community for patients to pass through the hospital and dispensary; some are teaching medical students;
some are teaching nurses; some are teaching social service to students, and still others are doing nothing but talking.
THE CHAIRMAN: Dr. Fred C. Zapffe, Secretary of the Association of American Medical Colleges, will speak for the medical educational institutions.
DR. FRED C. ZAPFFE: The Association of American Medical Colleges is naturally tremendously interested in the question of hospital standardi zation, representing, as it does, the purely educational institutions of whose product there is required or demanded by some states, as well as by some schools, one year of hospital service before graduation. The Association has always favored the project of hospital standardization and the intern year requirement for graduation, although the constitution of the Association has not yet been amended to include the intern year as a requirement for graduation, mainly because this whole matter is still in the formative stage. The first question to be answered is: Of what shall the instruction during this hospital year consist? Second, if the colleges are to require a year of internship for graduation, they naturally want to know in what hospital this internship can be served to meet the requirements of the state and the college. The college also wants to know whether it is necessary, either directly or indirectly, to give recognition to these men on the staff of the hospital who will be concerned largely in the education of the intern, or will it simply resolve itself into a recognition of the hospital per se and not so much its per sonnel? Or, can the clinical faculty be made the hospital staff? Of course, this does not apply to the hospital which is owned or controlled by the college. In such an institution the teaching conditions are almost ideal.
The Association of American Medical Colleges some years ago adopted a curriculum in which it provided for certain hours of clinical instruction. The Council on Medical Education of the American Medical Association also adopted a curriculum providing for such hours of instruction. The propaganda made by the Council did much to elevate the clinical instruc tion in medical curricula. The American College of Surgeons, by its work of hospital visitation, will be able to point out many weaknesses in the hospitals of this country. The Association of American Medical Colleges will gladly avail itself of the assistance which these and other organizations can give in arriving at a solution of this problem. The solution, of course, is hospital standardization. The College Association is very anxious to cooperate in this work. vVhere shall it send its students for the intern year? How shall it give credit for the work that is done? In what hospital can this work be done? Must it be done in a general hospital or may tlie students be allowed to elect? Can they go to a special hospital and do special work and receive proper credit for a year of intern service, or must they engage in general work? For instance, a student may want to qualify in ophthalmology or gynecology; can he go to a sp�cial hospital where this work is done, if not wholly, at least, in large part, to the exclusion of other work and get his credit for the intern year? Will the college give credit for it; will the state recognize it; will the hospital standardization agencies accept it? These are some of the questions that must be answered. Colleges will naturally
be interested to know who shall be the accrediting agency.
THE CHAIRMAN: The discussion will be continued by Dr. B. F.
McGrath, Secretary-Treasurer of the Catholic Hospital Association of the United States and Canada.
DR. B. F. McGRATH: The principle of the Catholic Hospital Associa tion in the problem of so-termed hospital standardization is as follows:
14
Once the hospital assumes the responsibility of the patient's care, the patient has the right to the most scientific and skillful service that is available. On this principle the Catholic Hospital Association was founded, by it we have been constantly guided, and on it we must ever firmly stand.
Adequate service to the patient is an obligation of every hospital. To meet this obligation requires an organization which provides for the successful diagnosis and treatment of the patient in accordance with progress in the medical sciences. This requires, first, diagnostic and therapeutic departments that are ample in number and completely equipped; second, staffs whose personnel is ethical, scientifu: and skillful, all harmoniously cooperating for the best interests of the patient, the hospital itself, the community, and for medical work in general.
For the attainment of this end we are constantly emphasizing the following: (1) A thoroughly organized department of records. Without this an efficient and progressive hospital is not possible. For the depart ment of records to be able to render fullest service there must be fixed periodic meetings of the staff, with attendance compulsory, at which records and conditions are frankly discussed, and means for betterment suggested. A follow-up system is an essential part of the department.
(2) Postmortem examinations. Such examinations, together with the follow-up system of records, are necessary both for learning the truth with regard to results and for adequate progress in the hospital's work and in medical practice in general.
In the work of standardizing hospitals we firmly believe in the prin ciple of construction before classification. That is, viewed in the light of conditions, we hold that the present work should consist of educating, encouraging, and aiding hospitals. The reason for this principle is that many hospitals, particularly hospitals conducted by Sisters, have been and are for the most part now laboring at a disadvantage. Together with narrowly limited finances, Sisters' hospitals have commonly lacked the advantage of proper guidance and cooperation on the part of their staffs. In many instances they have been the victims of incompetent staffs, whose dominating factors have been selfishness, jealousy, and individual endeavors for control. Doctors have thought more of their own profes sional advancement and financial emolument than of the hospital's inter ests. Under such conditions correct organization with resultant suitable standards have not been possible.
To educate, encourage and aid; to eradicate such defects and evils, is the purpose of our organization, a purpose in which we are firmly resolved to persist.
As a practical contribution to hospital organization we have begun the development of summer schools for laboratory technicians, in order that Sisters and other women may be available to help supply the demand in this regard.
To briefly summarize, all the work of the Catholic Hospital Associa tion is done in the light of the best interests of the patient. We hold that this is the logical foundation on which to build, and on which the adequate betterment of every phase of the hospital's function should be developed. We believe that, as a matter of justice, hospitals should be first shown the way and given ample time to meet requirements before they are publicly classified. As far as Sisters' hospitals are concerned, this belief is based upon the common knowledge of the disadvantages under which many Sisters' hospitals have been and are still laboring. al�upon investigations and correspondence by which we are assured that the hospital Sisters are most eager to cooperate and to do all within
their power to attain the scientific standard that is desired. With any organization that meets these principles we shall unite most heartily and do all in our power to help in the solution of this most important problem.
DR. JOHN M. DoosoN, Acting Chairman of the Council on Medical Education, Chicago: I do not like the term "hospital standardization." I wish we might get another term. Standardization sounds a bit drastic. It seems like an effort to bring the hospitals up to line by rigid measures. There are many more phases than the medical connected with the situation so that we must proceed with great care. After all, what we are after is not so much the exclusion of hospitals that do not come up to certain standards, as it is the elevation and the improvement of all hospitals. I like better the term hospital elevation or hospital improvement.
I cannot quite agree with Dr. Warner that there is great danger in informing the public as to the results of such investigation. I have great faith in the beneficent influence of publicity. Of course, we should pro ceed with such an organization as this with great care, and in making public the results of any investigations, they should be set forth in such a manner as not to disturb the public unduly. I believe that publicity of this sort is safe and will bring that most effective of all pressure-public opinion-to bear upon the hospital to compel it to improve its standards. I should, therefore, not think this was an unsafe thing to do.
In the discussion of Dr. Warner's paper at the conference in March, Mr. Shepardson of our Department of Registration and Education said that the department needs some classification of hospitals in order to carry out the legal duties imposed on it. The regulations stipulate that a fifth or intern year will be required for licensure in medicine in Illinois after 1922. That concerns students now in residence in medical schools, and yet so far it has not made a single step to determine what hospitals are to be approved. The same difficulty faces it in reference to the nurses. If the state is to license nurses it must know something about the hospitals where they get their training. As Mr. Shepardson also stated, under the Workmen's Compensation Act, industrial establishments are vitally concerned in the standardization of hospitals.
There was organized in Detroit in June, 1915, a new association called the American Association of Industrial Physicians and Surgeons, which is a most important and promising organization made up principally of medical men. They are engaged in preventive medicine work, which points the way in which the rest of the profession have got to go.
I think we all feel that the work which the American College of Surgeons has already done is of enormous value. I had not realized how much it was, although I knew it was very large. The cooperation of that organization in this movement which simply takes up the work from several additional points of view, will be extremely helpful. I think the medical schools that are requiring a fifth year are going to have information that cannot be obtained from any other source. We at Rush Medical College have been confronted with the concrete question as to what hospital the intern can enter and get the work we are willing to stand for with our degree. We have not laid down any rigid or drastic rules because we do not yet know just what standards to lay down. We are much in the position, as are the hospital social workers we are trying to find out just exactly what is the best method of pro� cedure, but this much we have learned: You can get from the interns themselves, after they have been in a hospital for a few months, a kind of information you can get nowhere else, and particularly is that true as to the character and attitude of the personnel of the hospital staff which, after all, in my judgment is 60 per cent. of the whole matter. A
16
hospital needs good equipment; it needs a good nursing school; it needs a pathologist, and all that, but over and above everything else it must have an efficient. capable, honest medical staff, or it is not a fit hospital for anybody to go into. No medical man who has no knowledge of a hospital would he able to give offhand what he thinks of the staff; nor could he be very definite as to the kind of work they are doing, and especially what they are doing in their relation to the interns. The interns do get this information. To be sure that kind of evidence has to be sifted with some care. Personal prejudice may enter into it, but if, year after year, we get from different interns uniform criticism of a certain hospital along certain lines you may be pretty sure it is true. If you get commendation of a hospital, on the other hand, by these men, you can be reasonably sure that it is a good hospital, and with the type of men that are now being graduated from the better schools in this country, most of them college-bred men, averaging at least 27 years of age, and many of them older, their judgment is extremely worth while. This conference should arrive at something concrete out of these informal talks, but it is a question whether the best way is to approach, that is from the several individual points of view. No contribution to this discussion so far has been so illuminating to me as Dr. Warner's paper read at the Conference in March. Many interests are involved in the modern hospital. Medical men cannot .et up a standard of hospitals from the nursing point of view that will be satisfactory to the nurses, neither would physicians be satisfied with the point of view as to the staff which the nurses would set up. It might be well for each group represented here to indicate what they regard ·as the standard of a hos pital from their point of view, and then we can bring these different views together. It might be well to have some of the 'leading hospitals investi gated from the various points of view. They have been efficiently and splendidly investigated from the point of view of the surgeon by the American College of Surgeons. I think they have paved the way for us in certain communities very effectively indeed and they have got the people to thinking about this thing who have never thought about it
before.
The suggestion I would like to make for discussion is that we decide whether an investigation of hospitals should be made from all view points by a single committee, or whether we should approach the matter primarily from the point of view of the several interests and then bring the results of these different investigations together.
Mrss M. H. McMILLAN, Principal of the School for Nurses, Presby terian Hospital, Chicago: Miss Noyes has represented the nurse's point of view quite fully, and in speaking in behalf of the nurses of the country I can only add that they are ready to do everything in their power to help develop the hospitals of the country along right lines. The hos pitals are the nurses' homes, and they are just as anxious to improve these homes as housekeepers are to maintain good conditions in private homes.
Naturally, when nurses speak of hospitals, they think first of nurses' contribution to the hospitals and of the specific work of nursing, but as graduate nurses occupy other positions outside of the nursing school itself, their interests are not confined to nursing only. Nurses feel that the women who nurse in a hospital have a great deal to do with the atmosphere of the institution simply because they are the largest in num ber and their whole lives for the time being are spent in the institution, so that the kind of woman in the nursing school is bound to reflect itself upon the general institution. For that reason, if women of high
char-acter, in whom may be instilled high ideals, can be persuaded to enter nurses' schools, it is felt that the right kind of service to the sick and to the institution may be secured.
Nurses feel that the salvation of nursing is to hold on to its tradition of service, and only women with ideals can truly serve. In the early days religious men and women gave their lives to the care of the poor and sick, and while with 50,000 young women in the Nursing Schools, training to be nurses, it can hardly be expected that the religious point of view will be maintained, still much can be done to inspire these student nurses, if they have good home training and other necessary background. If, on the other hand, the nurses' schools are filled with women of low calibre, it is almost impossible to secure the right kind of nursing care for the sick.
Nurses believe that the best thing for the hospitals is to secure the interest and support of the public so that these institutions may be prop erly aided to become better places for the care of the sick. At present many fathers and mothers are unwilling to allow their daughters to enter nurses' schools on account of the length of hours of duty, of the living conditions and the general lack of interest in the student nurses' welfare. If the public is informed that the general hospital situation is to be studied by a group of representatives such as this, it will tend to strengthen their faith in the hospitals and to bring to these hospitals the. interest and support without which it is difficult for them to be main tained. This seems a happier result than an uninformed, disinterested public, necessitating the hospitals to struggle for existence, ready to adopt any means of livelihood and willing to accept for nurses any woman, whether qualified or not.
Reference has been made to examining boards and inspection of nurses' schools. For many years a large number of states have had their own nurse examining committees or boards. In New York the committee. is under the Board of Regents; here in Illinois it is under the Depart ment of Registration and Education. The Illinois nursing law and the nursing laws in many other states provide for state inspection, so that for a number of years these schools have been inspected. By this inspec tion of nurses' schools it has been found that many of the nursing schools- are schools in name only and give little training. Nurses have tried to regulate these schools in a mild way, but have been unable to do so. Any time any special effort is made to standardize them, the opposi tion becomes intense, antagonistic and bitter, especially at legislative periods.
I merely wish to add that as one of the nurses of Illinois, and today with Miss Noyes representing the nurses of the country, we are ready in every way possible to help to bring the hospitals of the country into a better condition.
THE CHAIRMAN: I will ask Dr. Colwell, Secretary of the. Council on Medical Education, to take part in this discussion.
DR. N. P. CoLWELL: I will endeavor to present in a brief way what the American Medical Association has been doing in connection with hospitals, and it is chiefly limited to work along the line of medical edu cation and the hospital intern year. The Association, at its headquarters, has been collecting information in regard to hospitals since 1904, or even before that, since which time we have obtained every year a report of some kind from every hospital the existence of which had been reported to us. This at first was for publication in the American Medical Direc tory. The reports at first gave merely the name of the hospital, the name of the superintendent, the number of beds and the character of the
