Report Resumes Ed 011 555 Vt 002 385 Technology and Manpower in the Health Service Industry, 1965...75

REPORT RESUMES ED 011 555 VT 002 385 TECHNOLOGY AND MANPOWER IN THE HEALTH SERVICE INDUSTRY, 1965...75. STURM, HERMAN M. OFFICE OF MANPOWER POLICY, EVALUATION AND RES.+DOL REPORT NUMBER MANPOWER - RES-BULL -14 PUB DATE MAY 67 EDRS PR/CE MF -$0.50 HC -$4.68 115P.

CESCRIPTORS OCCUPATIONAL SURVEYS, *HEALTH OCCUPATIONS, EMPLOYMENT STATISTICS, EMPLOYMENT PROJECTIONS, *TECHNOLOGICAL ADVANCEMENT, EMPLOYMENT OPPORTUNITIES, *EMPLOYMENT TRENDS, *HEALTH SERVICES, EXPENDITURES,

BASED UPON PUBLISHED SOURCES AND INTERVIEWS WITH EXPERTS, THE STUDY LOOKS TOWARD PROBABLE CHANGES IN THE SIZE AND JOB CONTENT OF KEY HEALTH OCCUPATIONS TO POINT OUT PROBLEMS AND OPPORTUNITIES IN DEVELOPING PROGRAMS AND POLICIES. SOME FACTORS AFFECTING HEALTH MANPOWER ARE (1) DEVELOPMENTS IN DIAGNOSIS AND PATIENT CARE, INCLUDING AUTOMATED CLINICAL LABORATORY EQUIPMENT, IMPROVED SURGICAL TECHNIQUES AND EQUIPMENT, AND THE USE OF THE ELECTRONIC COMPUTER IN DIAGNOSIS,(2) HOSPITAL INFORMATION HANDLING, ESPECIALLY THE APPLICATION OF THE ELECTRONIC COMPUTER, (3) IMPROVEMENT IN HOSPITAL SUPPLIES AND SERVICES, INCLUDING THE USE OF DISPOSABLE iTEMS AND IMPROVED MATERIALS HANDLING EQUIPMENT, AND (4) IMPROVEMENTS IN THE MANAGEMENT AND STRUCTURAL DESIGN OF HEALTH FACILITIES FOR BETTER UTILIZATION OF PERSONNEL, EQUIPMENT, AND SPACE. IN GENERAL, CHANGING TECHNOLOGY WILL AFFECT HEALTH MANPOWER GRADUALLY. LABORSAVING INNOVATIONS WILL PROBABLY NEITHER CAUSE WORKERS TO LOSE THEIR JOBS NOR ALLEVIATE HEALTH MANPOWER SHORTAGES. CONTENT OF HEALTH JOBS WILL CHANGE, AND NEW JOBS WILL APPEAR AS NEW EQUIPMENT AND TECHNIQUES ARE INTRCDUCED, BUT THE DEMANDS FOR WORKERS WITH NEW SKILLS WILL PROBABLY NOT OUTSTRIP THE CAPACITY FOR TRAINING THEM UNDER WIDELY RECOMMENDED LONG-RANGE PLANS. ANTICIPATED EMPLOYMENT GROWTH FROM 1965 TO 1975 IS 75 PERCENT FOR X -RAY TECHNICIANS, 60 PERCENT FOR MEDICAL LABORATORY PERSONNEL, 55 PERCENT FOR REHABILITATION AND OTHER TECHNICIANS, AND MORE THAN 40 PERCENT FOR NURSING PERSONNEL. RECOMMENDED ARE THE REMOVAL OF WAGE AND EMPLOYMENT CONDITION INEQUITIES TO ATTRACT ALREADY QUALIFIED PERSONS BACK TO EMPLOYMENT, THE EXPANSION Cf GOVERNMENT AND PRIVATE TRAINING PROGRAMS, AND BETTER COORDINATION BETWEEN GOVERNMENT AND PRIVATE AGENCIES IN DEALING WITH HEALTH MANPOWER SHORTAGES. THIS DOCUMENT IS AVAILABLE FROM U.S. DEPARTMENT OF LABOR, MANPOWER ADMINISTRATION, OFFICE OF MANPOWER POLICY, EVALUATION, AND RESEARCH, WASHINGTON, D.C. 20210. (JK) NUMBER 14 MAY 1967 ,0

;

Technology and Manpower InThe

U.S.,DEPARTMENTs!bF LABOR: W. Willard Wirtz, Secretary * ManpOwer Admintifratitm ,'J OTHER MANPOWER RESEARCH BULLETINS

Mobility and Worker Adaptation to Economic Change in the United States (No.1, Revised 1963)

Young Workers: Their Special Training Needs (No. 3, 1963)

Selected Manpower Indicators for States (No. 4, 1963)

Family Breadwinners: Their Special Training Needs (No. 5, 1964)

The Mentally Retarded: Their Special Training Needs (No. 6, 1964)

Training Foreign Nationals for Employment With U.S. Companies in Developing CountriesImplications for Domestic Programs (No. 7, 1965)

Training Needs in Correctional Institutions (No. 8, 1066)

Training in Service Occupations Under the Manpower Development and Training Act (No. 9, 1966)

Unused Manpower: The Nation's Loss (No. 10, 1966)

Manpower Policy and Programs in Five Western European Countries: France, Great Britain, the Netherlands, Sweden, and West Germany (No. 11, 1966)

Technology and Manpower in Design and Drafting 1965-75 (No. 12, 1966)

Technology and Manpower in the Telephone industry 1965-75 (No. 13, 1966)

00 I p 1/ Pt U.S. DEPARTMENT OF HEALTH, EDUCATION &WELFARE OFFICE OF EDUCATION

THIS DOCUMENT HASBEEN REPRODUCED EXACTLY AS RECEIVEDFROM THE PERSON OR ORGANIZATION ORIGINATING IT. POINTS OF VIEW OROPINIONS STATED r' NOT NECESSARILY REPRESENT OFFICIALOFFICE OF EDUCATION POSITION OR POLICY.

Technology and Manpower In The

HEALTH SERVICE INDUSTRY

1965-75

U.S. DEPARTMENT OF LABOR: W. Willard Wirtz, Secretary MANPOWER ADMINISTRATION Preface

Technological change has brought about vast changes in the social and economic structure of the United States.Of significant importance for more than a century, the influence of technology has been especially noticeable in the last two decades. Technological advances made during World War II established the foundation for many entirely new products and industries. More recently, Government military and space research expenditures, combined with greatly increased industrial spending for research and development, have produced an abundance of technological advancements which promise to have an even greater influence on our economy. Technological change has important effects on the labor force.Existing occupations are eliminated, others decline in importance; totally new occupations come into existence, job content changes, and new skills are required.Although a wide variety of mechanisms are available to facilitate manpower adjustment to technological change, planning lies at the core of each.The U.S. Department of Labor has for many years recognized in its research programs the need for advanced information on the potential impact of technology. Early in 1965, an experimental and demonstration project was launched within the Department of Labor as part of the Department's continuing efforts to refine and improve its research methods. The project was aimed at using interpretive analysis techniques, based on extensive industry interviews, to fill gaps in facts and judgments needed for planning manpower development efforts by industry, union, and school systems and for program and policy development within the Department of Labor.Three industries and functional areas in which technology is expected to have important manpower effects were selected and studied in depth.They are: The health service industry (covered in this report) ; the design/drafting process (see Technology and Manpawer in Design and Drafting, 1965-75) ; and the telephone communications industry (see Technology and Manpower in the Telephone Industry, 1965-75). This report was prepared by Herman M. Sturm under the supervision of Peter E. Haase, project director, and under the general direction of Curtis C. Al ler, director, Office of Manpower Policy, Evaluation, and Research.

Hi 4.111MFIMINIM,

Contents

Page

1 INTRODUCTION 3 OVERVIEW

3 The manpower background 3 and expectations Technological developments 4 The outlook for health manpower

7 1. MANPOWER INHEALTH FACILITIES

expenditures and facilities 7 Trends in health service 7 Health service expenditures 8 service facilities Hospitals and other health 11 establishments Employment in health service 11 of health facilities Organization and staffing 13 occupations Employment in health service 15 earnings Labor costs vs. employee 16 conditions Wages, hours, and working 18 Critical needs for health manpower 18 Seventeen key jobs 20 The nurse shortage 23 Medical laboratory personnel 1 llatA 'AT Ty't A /V T T_T1M A T f^I -T _ - -1 V V 1:41%. 11'1 Arat1.1., .11. FALAILITLE' Page MDTA programs for training health manpower 24

2. TECHNOLOGICAL DEVELOPMENTS AFFECTING MANPOWER 27

Effects of medical research and public health programs 28 Recent trends in causes of hospitalization 28 Medical research 30 Public health programs 31 Technological developments in patient care facilities 35 Developments in diagnosis and patient care 35 Hospital information handling 44 Developments affecting hospital supply and service 53 Improvements in the functioning and design of health facilities 60

3. OUTLOOK FOR HEALTH MANPOWER, 1965-75 69

Expected trends in demand and productivity affecting health jobs 70 Employment in health occupations, 1965 -75. 73 Expected differences among occupation groups 74 Limitations of projections 75 New and changing occupations 77 Developing and conserving the health manpower supply 79 Programs for training health manpower 80 Harnessing money incentives 82 Needs for information and research programs 83

APPENDIX

A. Definition of the health service industry 87 B. Statistical appendix 89 C. Appendix tables 95 D. Selected references 99 E. Interviews 107

TABLES AND CHARTS

Tables 1. Patterns of hospital utilization, 1964 9 2. Estimated employment inhealth serviceindustry establishments, by occupation, 1965 14 3. Employees of nongovernment hospitals earning less than $1.25 per hour, in selected occupations, 1963 16 4. Authorized trainees in health occupations funded under the MDTA, August 1962 December 1966 25 5. Causes of admissions to short-term general hospitals, study of 64 hospitals,1946, 1954, and 1961 29 vi TABLES AND CHARTSContinued

Tables Page 6. Short-term non-Federal hospitals purchase of selected disposable products, 1958, 1960, and 1962 57 7. Trends in utilization of selected hospital items and services: Ratiosper hospital admission, 1946, 1954, and 1961 72 8. Estimated employment in health service industry, by occupationgroup, 1965, 1970, and 1975.. 73 Charts 1. Growth in employment will vary widely among occupationgroups in next decade 5 2. Religious, charitable, and other voluntary groups lead as hospitalowners 10 3. Typical large general hospital organized into five divisions 12 4. Turnover of nurses dwarfs turnover of teachers 22 5. Total information system schematic, a State public health department 33 Y 6. Number of beds is rising faster in nursing homes than hospitals 71

vi' Introduction

In recent years the demand for medical and million persons arc active in health service and other health services has been increasing rapidly. related fields.The number of jobs available is Consumer expenditures for medical, dental,and growing rapidly in many communities.Admin- other health care and public budgets for com- istrators of health facilities throughout the Na- munity health programs and health research arc tion are constantly looking for workers because at peak levels.Coverage of families and indi- of heavy labor turnover-- as well as the growth in viduals under prepaid health insurance plans has demand for health services. become widespread.The establishment of the Needs for health manpower have been expand- Medicare programs has added to demand.In ing at a time when the number of new entrants many areas, demandsfor health care have out- to the labor force has also been rising.Thous- stripped the availability of physicians, nurses, ands of young people are preparing for the health and other trained health workers.Shortages of professions at schools and universities, and many hospital nurses are especially critical.Lack of others are learning and gaining experience in sufficient trained health personnel has become a health work on the job or in special training matter of national concern, notonly because of courses.Health occupations are in the lead domestic needs but also because of increased obli- among courses given in newtraining programs gations overseas for both military and civilian sponsored by Federal and State Governments. programs. They account for a large proportion of all pro- These trends have been developing against a jects and trainees in programs provided under background of stepped-up interest in opportuni- the Manpower Development and Training Act ties for employment in the health service industry, and related legislation. especially for individuals who have had difficulty Many problems need to be considered in plan- in getting work.Health service is one of the ning and developing programs to meet the need largest industries in the country.Well over 31/2 for manpower in the health service field.The

1 field is made up of numerous groups and institu- impacts on manpower in the next 10 years and tions that have a common goalcaring for sick examines what their effects may be. The third peoplebut also some basic differtnces : In train- analyzes the conined effect of expected trends ing and professional approach, in income pat- in the demand for health services and of key terns and wage structure, and in attitudes and technological developments on the structure of goals.The needs for adjusting manpower pro- health service employment.This analysisis grath: to take these factorsinto account is com- used as the basis for projections of growth in plicated by the fact that methods of detecting employment in the next 10 years and of structural illness and caring for patient; are constantly changes that will probably affect health jobs in changing. the future. Growing in significance are many recent tech- In view of the broad scope of the study, it was nological developments affecting various phases not possible to report in detail on all significant of the health service industry.Some technologi- developments related to health manpower and cal innovations offer promise of manpower sav- technology, nor to provide a detailed, systematic ings which may help offset shortages of health analysis of each of the many specific problems personnel and reduce the steadily mounting costs involved in programs for developing health man- of health care as well.Other innovations bring power. Many detailed studies are needed, espe- into being changes in job content and demands -4ally to deal with specific problems of shortages for training new kinds of specialists. .n particular health occupations.This report This report is particularly concerned v. ith the does provide a general perspective and some con- relationship between technological advances and clusions which may be useful in shaping broad other developments that will affect manpower programs and policies. in the health service industry during the next The study is based to a substantial extent on decade.It utilizes both readily available infor- published sources cited in the appendix.It has mation and expert judgments to develop projec- also relied heavily on interviews with experts in tions of future employment in major health occu- various fields who helped to provide judgment pation groups.The main purpose is to look and perspective on current problems and the ahead toward probable changes in the size and future outlook, as well as some estimates to fill job content of key health occupations, and to gaps in available data.Interviews of substan- point out problems and opportunities that will tial length were conducted with 51 individuals have to be considered in developing health man- whose names and affiliations are listed in the power programs and policies. appendix.Additional information was obtained The main body of the report consists of three from others not listed (including individuals pres- chapters. The first presents and analyzes trends ent at group meetings, persons who answered in the structure and characteristics of health serv- questions by telephone or mail, and staff of vari- ice employment and summarizes major current ous offices of the U.S. Departmentof Labor) . problems in meeting health manpower needs and Without the assistance of these individuals, it job requirements. The second chapter identifies would not 1 , been possible to achieve the pur- the technological developments likely to have poses of thistc.. Overview

The Manpower Background laboratory personnel, X-ray technologists, rehabilitative technicians and therapists, and phar- Demand for health services has been increas- macists. (Physicians and dentists are not in- ing rapidly in recent years, and has outstripped cluded among the manpower categories studied the supply of available trAined health manpower in this report.) in many areas and occupations. Shortages Public and private facilities are instructing among some skilled groups are becoming critical. students and trainees in various health occupa- Costs of health care have been rising, reflect- tions.The wide scope of training programs ing both higher labor costs in hospitals and im- sponsored through Manpower Development and proved standards of health care. But wage levels Training Act (MDTA) provisions has been and other conditions of employment in health particularly important in alleviating many health occupations continue to be substantially lower manpower shortages.Other important pro- than those of other pursuits; substantial numbers grams, provided by recent Federal legislation, are of health workers lack full protection of mini- helping to solve the long-range problem of im- mum wage requirements, social security, and proving the quality of nursing and other profes- other labor legislmion.These inequities are sional personnel. among the factors that account for difficulties in filling health jobs. Technological Developments Among health occupations, professional and and Expectations practical nurses are in particularly short supply. These two occupations, plus nursing auxiliaries, Substantial advances have been made in medi- account for roughly half of all health service cal research on disease prevention and cure, and jobs.Also scarce in many areas are clinical in environmental health protection.Further

3 de- scientific advancement, as well asexpanded pro- Advances in the functional and structural utili- grams for combatingenvironmental hazards, can sign of hospitals help toward more efficient These successes will save zationofpersonnel, equipment, and space. clearly be expected. in both many lives and protectthe health of millions, They involve continuing improvement but their net effect isnot expected to alter management and construction ofhealth facili- progressive greatly the kinds of health servicesneeded in hos- ties, putting into effect concepts of organizing pitals or other patient care facilitiesduring the patient care and other advances in next decade. health services. The innovations in health technologythat will These different innovations are beingadopted most affect health manpowerin the next 10 years rapidly in some instances, more slowlyin others. are most certainlythose now being designed or They vary both in regard to laborsavingeffects adopted for use in patient carefacilities.They and in affecting the nature of workdone by will involve various kinds of manpowerchanges, health service personnel. including changes in job content and emergence Automation in the laboratory is alreadywell of new jobs, as well as somelaborsavings. advanced, and will continue to affectboth the Significant changes in technology affecting volume of demand for medicallaboratory work- patient care facilities are of many differentkinds. ers and the contentof their jobs.The switch They may be grouped as follows: (a)Develop- to disposables is alreadywidespread and clearly ments in diagnosis andpatient care; (b) hospital results in laborsaving.In general, other changes information handling; (c) developmentsaffect- in patient care technology are proceeding more ing hospital supply and services; (d)improve- slowly; they will especially affect thejob content ments in the management and structuraldesign of nurses and some categoriesof technicians. of health facilities. Use of the computer inhospital information Improvements in patient care technology in- handling, and improvements in thefunctional clude such specific developments as automated organization, management, and design ofhospi- clinical laboratory equipment, artificialhuman tals and other health facilities arelikely to have organs, improved surgicaltechniques and equip- significant effects on the numbers ofworkers ment, and use of the electronic computerto help needed mainly by improvingproductivity, but it in diagnosis. will take time for the effectsof these improve- Advances in hospital information handling will ments to become widespread. come mainly fromapplications of the electronic computer.Computers are being used to handle The Outlook for HealthManpower patient billing and accounting, and inmedical research and diagnostic applications.They are Anticipated trends in the volume ofdemand also being developed to control theflow of infor patient care service and in thekinds of facili- formation in hospitals so that physicians can get ties and care needed are the primaryinfluences ready access to necessary data, and havetheir on future demandfor health manpower.Par- orders for treatment of patients quicklyand ac- ticularly important will be the Medicare pro- curately transmitted to all affected departments. gram, which willaccelerate needs for personnel and The computer can help nursing, technical, to staff hospital nursingunits, service, and out- other departments avoid errors and attain greater patient departments and for newnursing homes efficiency with less paperwork. and home care programs.The expanding de- Improvements in hospital supplies and serv- mand for laboratory tests and X-rayswill result ices include adoption of disposable items madeof for people such as in continued increases in the need plastic and other inexpensive materials, Technological devel- hypodermic needles, surgeon's gloves and sur- trained to do these jobs. of manpower geon's knives, adoption of improvedmaterials opments will affect the amount handling equipment, such as specialized carts, needed by the various health occupationsdiffer- conveyors, and pneumatictubes. ently.(See chart 1.) .4401CWWInewv....,....1140,e1010.1V1.01,MOVVVINM60..,10.11"Ipt,r,

# Chart3. Growth inemployment'will vary widely among occupation groupsin next decade. Percent of increase expected, 1965.75 No. of Occupation group 30 40 50 60 70 30 employees 0 10 20 I I 1965 I I I 1 I I I X-ray technicians 30,000

Medical laboratory 100,000 personnel Rehabilitative and other 120,000 other technicians Nursing personnel 1,200,000

All employees 2,700,000

Dietary employees 235,000

Laundry, housekeeping, 280,000 & maintenance personnel Medical records 35,000 personnel Administrative and 500,000 office personnel Pharmacists 11,000 All other employees 189,000

J/ Expressed in full time equivalents Source U S Department of Labor; Manpower Administration:Office of Manpower Policy. Evaluation, and Research

The total number of employees in the health are introduced in moreand more hospitals over service industry will increase rapidly over the the next 5 to 10 years, content of health jobswill next 10 years.The increase will vary among change and new jobs will appear.The pace health occupational groups; growth will be will accelerate as time goes on, but it is notlikely highest among X-ray and laboratory technicians, that demands for workers with altogether new lowest for office personnel, laundry workers, and skills will outstrip the capacity for trainingthem similar categories. under existing or widely recommended long- Many new jobs are appearing in the health range plans.Nor is it likely that the spread of service field.Examples of these are the inhala- laborsaving innovations will cause workers in any tion therapist and personnel needed to operate category to lose their jobs. and repair computer installations and other med- The laborsavingeffectsoftechnological ical electronic equipment.Entirely new cate- change in the health service industry will prob- gories of health personnel may emerge.Some ably do little to alleviate existing and continuing of thesesuch as the "assistant physician"are shortages of health manpower. Current and now mainly in the trial ordiscussion stage.In future shortages will have to be met by provisions long-established occupations, particularly those for expanding the supply of health workers, such in the nursing profession, constant needs for as: changes and adjustments in job content and ori- 1. Removing wage and related inequitiesand entation will result from adoption of new equip- providing other incentives to attract back to ment and techniques. employment the many inactive already qualified In general, the effects of changing technology nurses and other highlytrained persons and to on health manpowerwill be felt gradually. keep those presently employed in the healthin- Little by little, as new equipment and techniques dustry from leaving ; 5 2. Expansion of MDTA and other Govern- at all levels of government, and by private or- ment and private programs (including refresher ganizations, to coordinate policies on priorities courses) for training health professionals, sub- for dealing with shortages of health manpower, professionals, and auxiliariestofillexisting and to improve machinery for the collection and vacancies; and development of programs to pro- dissemination of statistical and other information vide upgra.lug and similar career development on the problems involved. training, and other programs to improve health Unless such steps are taken, existing shortages manpower utilization; of health manpower are likely to become greater 3. Expanded efforts among agencies concerned during the next few years.

6 1 Manpower In Health Facilities

The outlook for the amount of manpower and services of health facilities being used. Con- needed and requirements for jobs in the health tinued rise in general demand and change in the service industry depends on expectations regard- character of needs for patient care will have ing the expansion of demand for health serv- important effects on the number and kinds of ices and the emergence of new technological de- manpower required in health facilities. velopments, as these factors interact with the basic characteristics and problems of health service employment. Health Service Expenditures During recent years, the increase in the proportion of the gross national product spent on Trends in Health Service health and medical care has been rapid.In- Expenditures and Facilities cluding both consumer and public outlays, the proportion rose from 4.6 percent in 1950 to 5.9 The most basic trend in the outlook for health percent in 1964, an increase of more than 28 manpower isthe rise in general demand for percent.'This has reflected growth in activity health services.Rapid expansion in demand is (and jobs) in all types of health service facilities: evident from many indications.In particular, Hospitals, nursing homes, offices and clinics of '4.. has been shown by the growth in consumer private professional practitioners, medical and expenditures for health care, which has been even dental laboratories, and other public and private more rapid than the growth in capacity of facil- facilities. ities that care for patients.Significant changes in patterns of demand have occurred, as indi- 'Source: Social Security Administration.(See app. cated by shifts in importance among the types table C-1.)

7 Increased health care spending in the lastfew developed by the Federal Government and other years reflects not onlyincreased demand, but statistical authorities.Establishment/ included also the rising consumer costs of medical care. in the health service industry as here defined are Between1957-59and1964,the index of prices exclusively facilities that perform patient care for medical care increased 19 percentcompared functions. They include: Both private- and gov- with a rise in the index of all consumerprices of ernment-owned hospitals and nursing homes, the 10 percent.Price trends for individual medical offices and clinics of private medical and other item^ and services have varied: Costsof prescrip- individual practitioners and groups, and pri- tions and drugs'declined 2 percent,surgical fees vately-operated medical and dental laboratories. for tonsillectomies went up19 percent, but All employees in these establishments are in- charges for hospital rooms rose 45percent.2 cluded in employment figures used in this study, A major share of privateexpenditures for consequently, both employees in direct patient health care has channeled through variousforms care functions and in functions oroccupations of prepaid health insurance.The most wide- not directly concerned with patient care(laun- spread form of such coverage has beenhospital dry, etc.) are included as health manpower. expense protection aspurchased by individuals, The health service industry as referred to in employers, and organizations. By 1964, 79 per- this report is defined in detail in the appendix. cent of all individuals in theUnited States were It is wider in scope than SIC 80 Medical and covered by partial or complete hospitalization Other Health Services, which excludes the gov- insurance.Many of them were also protected ernment-owned hospitals and nursing homes by various forms of private medicalinsurance." included in this study.But the scope of the in- The Medicare programs, signed into law in dustry as defined here is narrower than some 1965,extend basic hospital and medical protec- interpretations of kinds of employment that uti- tions to persons65years old and over.Steadily lize health manpower.Several types of health- increasing numbers of aged persons will apply for related activity carried on by governmental units benefits under these programs in the next few (other than hospitals or nursing homes) such years.This will swell the demand for health as regulatory, informational,environmental, and services in every community.It has been esti- other public health programsoften considered mated by many authorities that these programs to be included in the health service industry, are will result in an average increase of about 5 per- not included in the definition used here. cent in demand for hospital bedsand other serv- This study is mainly concerned with employees The ices.In some communities, the increase will on payrolls in patient careestablishments. be higher, in others lower.Other new health employment statistics presented later do not in- care programs, such asFederal-State provisions clude self-employed professionals, proprietors for services to the medically indigent and ex- of health establishments, or students, volunteers, panded health protection under the heart dis- or other unpaid personnel. ease, cancer, and stroke. programwill further Health Facilities: Number and Use.Ap- spur the demand for healthservices. proximately 7,100 hospitals, with capacity for L7 million beds, are registered with the Ameri- Hospitals and Other Health Service Facilities can Hospital Association.' Newhospitals are Definition of Health Service Industry. In this 4 The source of data on hospitals in this section is study, health service activity is defined in terms the American Hospital Association (AHA). The data of the industry concept, as an adaptation of are summarized in app. tables C-2,C-3, and C-4.In addition to the 7,100 AHA-registered hospitals, there definitions set up by the Standard Industrial are well over 1,000 nonregisteredhospitals, infirmaries, Classification(SIC) a classificationsystem and similar units most of which are known to be smaller than most registertd. hospitals.Data on other health 2 Source:U.S. Department of Labor, Bureau of facilities are taken from the "County Business Pattdrns" Labor Statistics.(See app. table C-1.) Source: Health Insurance Council.(See app. table studies of the U.S. Department of Commerce and C-1.) studies on nursing homes by the Public Health Service.

8 constantly being built, but sinceolder hospitals TABLE 1. PATTERNS OFHOSPITAL UTILIZATION, 1964 are continuallybeing remodeled or abandoned, the number of hospitals andhospital beds rises [Percent] slowly.Between 1955 and 1964, the netincrease All All All in number of hospitals was only3 percent; the averagepatient out- increase in hospital beds, only6 percent. Type hospital daily admix-patient patient sions admis- Hospitals differ widely in regard tothe type census sions o; health care they providerFour out of five hospitals are short-term generalhospitals which 100 100 provide patients with care for acuteillnesses, All hospitals 100 needs of people births, and the other recurring Federal hospitals 11 6 25 for hospitalization.The remaining hospitals Non - Federal short term 38 92 72 chiefly serve long-term patients,especially those Non - Federal psychiatric .. 45 1 1 requiring treatment for mentalillnesses and tu- Non-Federal tuberculosis. 2 (I) 1 Non-Federal long term ... 4 1 1 berculosis.Over the past decade, the number of short-term general hospitalshas grown much more rapidlythan others.Differences in the 1 Less than 0.5. Association. pattern of utilization ofdifferent types of hospi- SOURCE: American Hospital in table 1, which tals are shown by the figures such visits was 70 percenthigher than in 1955. compare the percentagebreakdowns in 1964 of Outpatient visits in psychiatrichospitals that hospitals on an bed patients in the Nation's same year were upphenomenally, to a level 146 with average day(average daily patient census) percent higher than10 years earlier. data on patients admittedand on outpatients Number of beds in a hospitalis the commonly cared for. used indicator of hospitalsize.Hospital sizes hospitals on any Patients in short-term general range from fewerthan 25 beds to well over2,000. of slightly more than given day command the use The average number of bedsin all non-Federal a third ofall hospital beds.Nine out of ten hospitals in 1964 was 227. Typeof patient care general hos- hospital admissions are to short-term offered was a major factorinfluencing differences which pitals.It is the short-term hospitals to in average hospital size, asshown by the follow- they are in need of care, most people go when ing figures on non-Federalhospitals: usually for brief stays (average7.7 days). Also, Average these hospitals provide mostof the outpatient number Type of non-Federal hospital of beds care given bythe Nation's hospitals. 227 About half of all hospital bedsin the United Total States are usually occupiedby psychiatric pa- Short-term general and otherspecial hospitals__ 126 This percentage includes beds inFederal Psychiatrichospitals 1, 419 tients. 214 hospitals and psychiatric wardsin general hospi- Tuberculosis hospitals Long-term general and other specialhospitals 230 tals, as well as thoseenumerated in the total hospital patient census that are inpsychiatric hos- Thelargesthospitals,byfar,arethe Short-term general and pitals.(Sec table 1.) psychiatric institutions. The patterns of hospital usein 1964 reflect other special hospitals average notmuch more various changes from those of1955.Over the than 100 beds, but manylarge institutions are decade, the number ofadmissions to all hospitals included in this group.In 1964, 155 hospitals accounted for one-sixth rose 34 percent.However, admissions to tuber- with 500 or more beds culosis hospitals dropped 29 percent,and average of all beds in short-termgeneral hospitals. ownership and control, daily patient census and outpatientvisits in tuber- From the standpoint of the largest group of hospitals arethose owned culosis hospitals also declinedsharply.Another similar organiza- significant development wasthe general rise in by religious, charitable, and "voluntary"hospitals. outpatient visits.In 1964, the total numberof tions,and known as 9 244-295 0-67-2 These constitute 51 percent of all hospitals and dicate that in 1965 about 500,000 beds in homes provide 31 percent of all hospital beds. They are provided some amount of nursing care. mainly short-term general hospitals.Most other Most nursing homes are small.Median bed hospital beds are in State and local government capacity in 1961 was 25 beds.Nine out of ten hospitals, many of which are mental institutions. nursing and rest homes are owned and operated The remaining beds are in Federal Government by proprietors on a profit-risk basis; the rest are and proprietary hospitals, i.e., those owned by run by nonprofit organizations and by State and private individuals or groups.(See chart 2.) local governments. Available information on the number of nurs- Employment per hospital and nursing home ing homes and beds they provide is incomplete. varies according to type of service.Average According to a comprehensive study for 1961, employment per hospital was 265 in1964. about 10,000 homes with 350,000 beds had Average employment per Federal hospital was skilled nursing care available.Another 13,000 438;in short-term generalhospitals, which nursing homes, rest homes, and homes for the include more than three-fourths of all hospitals, aged, with 250,000 beds, provided mainly "per- the average number of employees was 233. The sonal care" ; only a small minority of these were largest hospitals in terms of average number of staffed to provide skilled nursing care.Since employees were the psychiatric hospitals, with 1961, the number and bed capacity of nursing 542 employees; the smallest were the long-term homes has been increasing rapidly and the general and tuberculosis hospitals with 223 and proportion of rest homes providing nursing care 160employees,respectively.Mostnursing is believed to be increasing. Preliminary in- homes have much smaller staffs than hospitals, formation from recently conducted studies in- but some homes, especiallythose providing

Chart 2.Religious, charitable, and other voluntary groups lead as hospitat owners. saa Percent of ownership 0 10 20 30 40 50 60 Ownership group Percent of hospitals Voluntary hospitals Percent of beds

State and local Percent of hospitals government hospitals Percent of beds

Federal Percent of hospitals Government hospitals Percent of beds

Percent of hospitals Proprietary hospitals Percent of beds a

SourceU SDepartment of Labor, Manpower Administration, Office of Manpower Policy, Evaluation, and Research, based on data for 1964 from the American Hospital Association

*10 skilled nursing care, have as many employeesas nates these activities with those of directors of the average long-term hospital. the medical care, nursing, and dietary depart- In 1962, physicians, osteopaths, dentists,opments. In most institutions, the medical director tometrists, and otherpractitioners provided is responsible to the administrator only in regard health service of various kinds in approximately to major administrative and financial questions, 150,000 offices and clinics, nearly all of which and on all other matters reports directly to the had fewer than four employees.There were governing board. approximately 2,000 privately owned medical The medical director coordinates the service laboratories, and 3,500 dental laboratories.In of staffs of physicians, surgeons, dentists, phar- these establishments, the size of staffswas larger, macists, technicians, therapists, and other pro- on the average, than in practitioners' offices.In, fessiorial personnel.Approximately 15 percent about a third of them therewere seven or more of the hospital's employees are under his super- employees. A few practitioners' offices, clinics, vision or that of his subordinates.Most of the and laboratories employ as many as 100 or more medical, surgical, and dental staffare independ- workers. ent practitioners, rather than employees of the hospital, and maintain offices outside the hospital. The director of nursing has assistant directors Employment in Health Service responsible for such functions as nursing educa- Establishments tion, evening shifts, and other generalor special services.In addition, there are many inter- A hospital combines some of the functions of mediate-level nursing supervisors.Altogether, a hotel, a group of physicians' offices, and a nursing personnel accounts for nearly half of all scientific research center.All of these functions, employees in the hospital.Included in it are and many others, are reflected in their organiza- professional nurses, practical nurses,nurse aides, tional patterns and the occupations of theirem- ward clerks, and orderlies. ployees, which range from highly skilledpro- The chief dietician is responsible for all food fessional positions to jobs unskilled beginners can preparation M the hospital, not only in kitchens fill. and dining rooms, but also in specialareas set Despite wide variations in occupations and aside for the preparation of infant formulas and training, most hospital employees and other special diet items.Over 10 percent of all em- health service workers face one group ofcommon ployees of a hospital are in the dietary depart- problemslow earnings and frequently unsatis- ment.Mostofthemaresemiskilledand factory working conditions. These problems unskilled workers. have contributed toward difficulties in recruiting The business management departments of the and holding workersinthehealthservice hospital employ many different kinds of white- industry. and blue-collar personnel, in skilled, semiskilled, and unskilled categories.About a fourth of Organization and Staffing of Health Facilities all hospital employees are employed in these The organization of a short-term general hos- departments. pital shown in chart 3 is a simplified representa- Most general hospitals differ insome respects tion of organization which may be typical of from the structure shown in chart 3.For ex- many institutions having about 500 beds and ample, social serviceis sometimes under the 1,000 employees. The management of the hos- medical director's jurisdiction.Central sterile pital is directed by a chief executive officer,usu- supply is sometimes attached either to nursing ally called the administrator, who is responsible services or to pharmacy; in some older hospitals it to a governing board. The administrator is is not set up as a separate unit.Instead, its aided by assistant administrators in charge of functions are divided among the nursing and departments concerned with business manage- other departments. ment and services.The administrator coordi- Specialized hospitals, such as maternity, chil-

11 Governing body Medical director Administrator Chief residentsof surgicalmedical staff Director of nursing Chief dietician Assistant adman strator, servicesAssistant ad mnistrator, Diagnostic and staff,Activetreatment residents, staff, courtesy interns Assistant directors: Therapeutic management Controller Special service X-ray,clinicalSurgicaldepartments, EEG, laboratories; operating physical, services facilities;EKG: andEvening nursing nursing service education, specialFormuladietician diets room, collectionAccounting, socialpublicPersonnel,volunteers, service:stations, occupational,other therapy inhalation,and services obstetrics,General,Nursing supervisorsmedical-surgical, operating room, Chef communicationReception and Engineering and Pharmacy departmentDental department psychiatric,orthopedic, pediatrics,tuberculosis butchers,Bakers,cooks, helpers Receptionistand swichboard water,Heat,maintenance securitypower, repairs, gas, Emergencydepartment and outpatient orderlies,HeadNursespractical nurses, and floor nurses, alliedstaff clerks nurses, staffnursing aides Countermen,supervisorFood service Purchasing andHousekeeping supply MedicalMedical records library department Admitting waitresses sterilelaundry,H ousekeeping,stores supply, central

we. dren's, psychiatric, and tuberculosis hospitals, aides, X-ray technicians, laboratory technicians, show characteristic differences from the general and physical therapists.Some groups also em- hospital in size, organization, and personnel. ployed social workers, dieticians, medical records Nursing homes are generally smaller and sim- personnel, opticians, and psychologists?' pler in organization than hospitals.The typical home that provides skilled nursing care has 30 Employment in Health Service Occupations to 35 beds and 15 employees. About half of the staff consists of nursing personnel.Usually one As a first step toward seeing the problems and or two of this group are registered or practical trends of health manpower in perspective, it is nurses; the rest are nurse aides andorderlies. useful to look at the different kinds of occupa- In some cases, the owner of the home is a nurse tions and establishments that provide patient who directs the care of patients in addition to care services and the number of jobs they repre- giving general supervision.More often, the sent.Table 2 shows estimated employment in owner acts as a general manager only.Aside 1965 (in terms of full-time equivalents for both from the nursing personnel, the staff consists of full- and part-time workers) in 27 important workers who do housekeeping, food preparation, jobs and groups of occupations in the main and food service. A very small number of homes branches of the health service industry.In- have physicians or physical therapists on the cluded are 18 occupations (or groups) desig- salaried staff, on either a full- or part-time basis. nated as "health occupations," (categories 1-6, More often, other arrangements are followed in table 2), which require skills primarily needed obtaining such professional services. in tile health service field, and 9 others (cate- Offices of physicians and dentists vary in size gories 7-10, table 2) that include many jobs in depending on whether these professionals are which the skills called for may also be utilized practicing in solo, partnership, or group practice in other industries. Lines cannot be drawn arrangements.In many instances, physicians sharply between the two groups of jobs.Both and dentists in solo practice have no regular em- are considered within the category of "health ployees, or at most a secretarial assistant and a manpower" for purposes of this study. dental or medical assistant or technician.In The total number of jobs in the health service some physicians' offices one person provides sec- industry, as it is defined in this study, is estimated retarial assistance and also performs some clini- at 2.7 million in 1965 in full-time equivalent cal laboratory tests and other technical tasks. terms (all full-time jobs plus half of the part-time Most offices of private physicians, dentists, and jobs). About three-fourths of this number-2 other practitioners working in partnership or millionwere in hospitals. Another 250,000 other shared arrangements are simple in organi- were in nursing homes.Offices and clinics of zation and do not employ more than three assist- physicians, dentists, and other practitioners, to- ants, such as secretary-receptionist, bookkeeper, gether with medical and dental laboratories and related establishments, accounted for 450,000. and technician (or hygienist). Group medical practice has attracted a stead- Over a million health jobs, nearly half of the ily rising number of doctors and has increased industry total, were held by nursing personnel, the needs for other health workers.According including nearly 500,000 professional nurses, to a 1959 survey, 1 in every 8 physicians in pri- 200,000 practical nurses, and over a half million vate practice is now in group practice.Most of nurse aides, orderlies, and attendants. The these are employed by health plan organizations. many other professional and technical occupa- Their offices and clinics vary greatly in size and tions account for only a small proportion of the organizational complexity.Many paramedical employment in the health service industry-- Other occupations that health workers are employed in these groups. less than 300,000 jobs. According to this same survey, the types of spe- S. D. Pomrinse and M. S. Goldstein, "The 1959 cialized personnel most often employed included : Survey of Group Practice," American Journal of Pub- Registered nurses, licensed practical nurses, nurse lic Health, May 1961. Table 2. ESTIMATED EMPLOYMENT IN HEALTH SERVICEINDUSTRY ESTABLISHMENTS, BY OCCUPATION, 1965

All health Private Occupation service Hospitals Nursing offices, establish- homes laboratories, ments clinics, etc.

Total employment 2,700,000 I2,000,000 250, 000 450,000 000 Nursing personnel 1,200,000 945,000 155,000 100, Professional nurses... 460,000 385,000 20, 000 55,000 000 Practical nurses 200,000 150,000 25, 000 25, Nurses aides, orderlies, etc 540,000 410,000 110, 000 20,000

Laboratory personnel (medical) 100,000 80,000 (2) 20,000 Medical technologists, technicians, scientists 60,000 55,000 (2) 5,000 Lab assistants (certified, semiskilled etc) 25,000 15,000 (2) 10,000 (2) Lab helpers, orderlies, etc 15,000 10,000 5,000

(2) 8,000 X-ray technologists 30,000 22,000

(2) 1,000 Pharmacists I 11,000 10,000 I

Rehabilitative and other technicians 120,000 61,500 4, 500 54,000 1,500 Physical therapists 11,000 8,500 1, 000 Occupational therapists 7,000 5,500 1, 000 500 (2) Speech and hearing technicians 3,000 1,000 2,000 Psychologists, social workers, counselors 32,000 23,000 1, 000 8,000 (2) Inhalation therapists 3,000 3,000 (2) (2) 000 Dental hygienists 10,000 2,000 8, (2) 12,000 Dental lab technicians 14,000 2,000 Optometrists, opticians (incl. mechanics) 15,000 (2) (2) 15,000 7,000 Other, misc 25,000 16,500 1, 500

2,500 Medical records personnel 35,000 32,000 500

(2) Dietary personnel 235,000 205,000 30, 000 20,000 18,000 2, 000 (2) Dieticians and nutritionists (2) Other dietary workers 215,000 187,000 28, 000

280,000 248,000 30, 000 2,000 Laundry, housekeeping and maintenance (2) Laundry workers 45,000 39,000 6, 000 Housekeeping and supply workers 140,000 122,000 18, 000 (2) 1,000 Building engineers and craftsmen 60,000 56,000 3, 000 1,000 Porters, elevator operators, etc 35,000 31,000 3, 000

Administrative and office workers 500,000 250,000 20, 000 230,000 Administrators and managers 45,000 12,000 14, 000 19,000 000 Bookkeeping, secretarial and misc 455,(X)0 238,000 6, 000 211,

189,000 146,500 10, 000 32,500 All other, raise ......

1 Excludes physicians, dentists, and persons not on 2 Few, if any, employees. payrolls.Allfiguresarefull-timeequivalent em- SOURCE: Estimates (see text and StatisticalAppendix). ployment.

14 account for large numbers of employeesinclude Labor Costs Vs. Employee Earnings the administrative and office category( about Employment in the health service industry has ,and workers in dietary, laundry, house- 500,000) decade, at a much keeping, and maintenance jobs (over 500,000) . grown rapidly during the past The figures in table 2 include only employment sharper rate than the rise in the patient load. on payrolls in the healthservice industry as it is According to the American Hospital Association, employment in hospitals rose 61 percent from defined inthis study, estimated in full-time In contrast, the number of pa- equivalent terms.If estimates were included of 1955 to 1964. the total number of persons in part-time jobsin tients cared for, as shown on the average daily only 4 percent. the health service industry, and if self-employed census of patients, increased persons, as well as all other personsin health- The employee/patient ratio computed for all related jobs in government or private industry hospitals went up from 0.95 in 1955 to 1.33 in establishments of all kinds were included, the 1964.Increases in this ratio occurred in all 2.4 in total count of persons in health jobs would prob- types of hospitals (by 1964 the ratio was ably approach 4 million.Physicians and den- short-term general hospitals but somewhat lower tists, the leaders of the health profession, were in other types) .7 omitted from the table mainly because mostof During the decade, wage rates of hospital em- This increase is re- them are self - employed; a relatively small num- ployees also rose rapidly. ber of residents and interns are actually on the flected in a rise of the payroll average per em- payrolls of hospitals, but are in a separate cate- ployee of nearly 54 percent.The proportion of total expenses in hospitalsalways high in view gory from hospital employees.In 1964, the total number of active physicians was about 275,000; of the fact that human effort is the chief input the total number of active dentists wasabout rose from 64 percent in 1955 to66.3 percent in 95,000." 1964. But although labor costs have risen sharply in Sources of estimates of employment in table 2 and hospitals as a result of increases in the size of their in the text are given in the Statistical Appendix.It work force and in their pay rates, the earnings should be emphasized that large numbers of workers received by health service workers generally have in some of the health occupations listed in table 2 are lagged behind those of other groups of workers. employed in establishments outside of the health serv- According to the U.S. Department of Commerce, Specifically, in addition ice industry as defined here. average earnings of health serviceworkers have to the 10,000 pharmacists and 15,000optometrists and opticians shown in table 2, about 100,000 pharmacists risen at the same rate (44 percent) as the aver- and 20,000 optometrists and opticians were activein age for all workers during the pastdecade, so the retail trade and manufacturing establishments.The traditional marked difference between levels of following figures show the number of other professional earnings of health service workers and workers or technical health workers activeoutside the health service industry as it is defined here (in addition to in all industries has not been changing. Average those indicated as employees of the health service in- yearly compensation of health service workers in dustry in table 2).Professional nurses(150,000), 1962 was $3,439, compared with an average for practical nurses (65,000), medical laboratory person- all employees of $5,449.4 The continuing gap in nel (27,000), X-ray technicians (40,000), dental labo- the earnings averages shown by these figures is dental ratory technicians (10,000), dieticians (10,000), accounted for only partly by the omission of some hygienists(3,000), speech and hearing technicians (12,000).Most of these health workers were em- highly paid categories ( physicians, dentists, etc.) ployed in schools, custodial institutions, and outpatient from the health service employee group.The health centers or government agencies, or were self- employed.Omitted entirely from table 2 are several total number may range from 100,000 to 400,000. For other occupations included in some studies of health fuller discussion of variations in estimates of total health service employment: Veterinarians, chiropractors, in- manpower, depending on definition, seeStatistical dustrialhygienists, and various categories of other Appendix note 1. workers in the fields of research and environmental See app. table C-4. health (such as chemists, sanitarians, etc.).Depend- Source :Publications of the Office of Business ing on which of these categories are included, their Economics, U.S. Department of Commerce. 15 Table 3. EMPLOYEES OF NONGOVERNMENTHOSPITALS EARNING LESS THAN $1.25 PER HOUR, IN SELECTED OCCUPATIONS, 1963

Percent of employees earning less than

Occupation $1.00 $1.25

United South United South States States

Nursing occupations: Practical nurses 1 3 11 31 Nurse aides 12 44 43 90

Office occupations: Payroll clerks 0 0 2 5 Switchboard operator-receptionists 3 11 21 37 Switchboard operators 1 4 13 45 Transcribing machine operators 1 3 6 11

Service and other: Chief housekeepers 0 0 2 10 Finishers, fiatwork, machine 21 60 54 96 Kitchen helpers 20 63 55 96 Maids and porters 17 61 48 96 Washers, machine 7 25 28 70 Dishwashers, machine 22 61 58 97

SOURCE: U.S. Department of Labor (see footnote 9).

main reason for the disparity is simply thefact $1.25 per hour.° As table 3 shows, the propor- of lower rates of pay for jobs requiring com- tion of hospital workers at low wage 1?vels is parable skill or training in health service thanin particularly high in the South. other industries or occupations. Most hospital employees work 40 hours weekly and are paid for overtime work either attheir Wages, Hours, and Working Conditions regular rate or are permitted equal time off from work. 4ospital workers, especially those who The low average earnings in the health service provide direct patient care, must often work industry reflect the presence of a very large Saturdays and Sundays.Many hospita) work- proportion of employees who receive subnormal ersabout a fifth of the profes?ional nurses, rates of pay. The prevalence oflow-paid work- smaller proportions of other groupsmust work ers, especially in voluntaryhospitals and other late shifts. Those who work on second andthird privately operated facilities, contributes toward shifts usually receive shift differentials of $5 to keeping the salary structure low throughoutthe $10 per week. health service industry. Some hospitals provide free meals, uniforms, Studies in nongovernment hospitals conducted and laundering of uniforms to certain employees, in 1963 by the Bureau of Labor Statistics and the Wage and Hour and Public Contracts Divisions " indusby Wage Survey; Hospitals, Mid-1963 (Wash- ington: U.S. Department of Labor, Bureau ofLabor sub- of the U.S. Department of Labor show that Statistics, June 1964), Bulletin 1409; and Nongovern- stantial proportions of the workers in several oc- ment Hospitals (Washington: U.S.Department of cupational groups, which account forlarge Labor, Wage and Hour and Public ContractsDivisions, proportions of total employment, earned less than January 1965).

16 especially to kitchen helpers, but very few provide Collective Bargaining. No satisfactory esti- free uniforms to nurses.Most hospital workers mate is available of the number of hospital work- are entitled to some sick leave, and to hospitaliza- ers covered by collective bargaining agreements, tion and medical benefits.Some form of retire- but it may be in the range of 100,000 to 300,000. ment pension plan is also available to most hos- The file of collective bargaining agreements pital employees." maintained at the Bureau of Labor Statistics, Wages of employees in nursing homes, practi- collected on a voluntary basis, included 21 col- tioners' offices, and laboratories tend to be more lective bargaining agreements covering hospital or less the same as those of nongovernment hos- and nursing homes workers in 1955.The total pital workers in comparable occupations and number of workers covered by these 21 agree- localities. ments was approximately 16,000. included were various types of agreements.Some were con- Minimum Wage Coverage.Because of statu- tracts covering professional nurses only, nego- tory exemptions, employees of nongovernment tiated between hospital employers and affiliates hospitals and nursing homes did not become sub- of the American Nurses' Association in several ject to the Federal Fair Labor Standards Act States; others were agreements covering groups until February 1967. A small proportion of hos- of nonprofessional employees in Arizona, Cali- pital workers have been covered by the State fornia, Minnesota, Missouri, and New York who minimum wage laws in 24 jurisdictions( 22 were represented by one of the following unions: States and the District of Columbia and Puerto BuildingService Employees'International Rico), but the protection is limited in various Uni m (BSEIU) ; Retail, Wholesale and Depart- ways in many of these States.Only in nine ment Store Union; Hotel & Restaurant Em- States is the minimum $1.25 or more. ployees and Bartenders International Union; In- The Fair Labor Standards Act was amended ternational Union of Operating Engineers. A in 1966 to become effective February 1, 1967 to union spokesman for the BSEIU stated in 1962 that that the total number of hospitalem- cover hospital workers.The amendments pro- ployees represented by the union was 75,000. vided for a minimum hourly wage for hospital Substantial numbers of hospital employeesare and nursing home workers and provided for represented by unions of government workers, overtime rates of pay after 44 hours per week such as the American Federation of Government with certain exceptions.The amendments pro- Employees and the American Federation of vide for a minimum. wage of $1,00 hourly for State, County and Municipal Employees.Un- these newly covered workers effective in967, affiliated local. of the AFLCIO are also believed rising gradually, in four additional steps, to $1.60 to represent hospital workers in some cities. in 1971.In its present form, provisions of the Hospital workers are not covered by the Na- legislation will have only moderate effects in the tional Labor Relations Act and therefore lack short run on existing pay differentials between the collective bargaining protections provided employment in hospitals and nursing homes and under this law. A few States, such as Minne- other industries, for undee the same new law, sota, Michigan, Wisconsin, and New York, have minimum wage levels for workers already cov- laws providing some forms of collective bar- ered became $1.40 on February 1, 1967, and will gaining protection which cover workers in hospitals along with workers in other fields.Among step up to $1.60 on February 1, 1968.Substan- the few other States that provide collective bar- tial differences between the earnings of health gaining protection, certain classifications of hos- service workers and workers in nonhealth jobs pital workers are excluded in some States; in will continue for a long while. others, all hospital workers are excluded. Legislative proposals to amend the Federal " IndustryWage Survey;Hospitals,Mid-1963 (Washington: U.S. Department of Labor, Bureau of labor relations law so as to remove the exemp- Labor Statistics, June 1964), Bulletin 1409. tion of employment in hospitals have been intro-

17 duced in Congress, but thus farhave not been shortage by subtracting from that total the num- Another enacted. ber of workers currently employed. approach, which is more realistic, is to estimate Social Security Programs.Socialsecurity the number of vacant jobs employers are actu- coverage under theFederal old age and survivors ally trying to fill.Efforts are currently being program is voluntaryfor hospitals owned by non- made to develop job vacancy statistics which may profit organizations or governmentunits. Many eventually result in satisfactory estimates of the such hospitals have elected coverage.Sixty per- national shortage of health workers. Meanwhile cent of all employeesin State and local govern- partial information from offices of public employment hospitals andabout 95 percent in nonprofit ment services, privateemployment agencies, em- hospitals are covered. ployers, and other authorities leaves nodoubt In only a few States are employeesof nonprofit that the number of health job vacanciescontinues hospitals covered by unemploymentinsurance to be very large. programs.In less than half of the Statesdo Reasons for the shortages of health manpower employees of State and local governmentsreceive vary to some extent amongoccupations. A gen- such protection.President Johnson has urged erally potent reason is the lack of attractiveness the adoption of legislation whichwould remove of pay and working conditions in health occupa- the exemption of employmentin nonprofit hos- tions by comparison with other jobs ( see page pitals from tax provisions of theSocial Security 16) Many occupations in the health service in- Act that relate to unemploymentinsurance and dustry require comparatively long periodsof thereby help extend coverage ofthis program to training.Incentives to attract recruits and fa- employees of such hospitals. cilities for training health workers have been Not more than half of the Statesrequire cover- insufficient to meet the need.During the last age of hospitalworkers under workmen's com- few years the Federal Government hasbegun to pensation laws and there appears tobe little take steps toward overcoming shortagesin health effort to extend this protection tothem. service occupations by enacting legislation such as the ManpowerDevelopment and Training Act of 1962, the Vocational Education Actof Critical Needs for Health 1963, and the Nurse Training Act of 1964 and to Manpower provide new and expanded programs a-id facilities for training health workers, but much A critical need for health manpowerexists in remains to be done. many communities.In some occupations, such nurse, licensedpractical nurse, asregistered Seventeen Key Jobs medical technologist, and a fewothers, the short- be age is nationwideand is generally believed to The U.S. Employment Servicerecently pro- worsening. vided a list of occupations incritical demand, Authoritative estimates of the sizeof the total the Career Guide For DemandOccupations, nationwide l'ir!alth manpowershortage are lack- which includes 17 health serviceoccupations. ing.According to some statements, as many as The list is based on nationwideinformation de- industry jobs 500,000 to 1 million health service veloped by the Bureaus ofApprenticeship and these figures are probably much are vacant, but Training, Employment Security,and Labor Sta- too high, consideringthat the total number of tistics, and by the Women'sBureau, all of the is less than 3 jobs in the health service industry Department of Labor."The 17 health service million. occupations included on the list areshown in yardstick should Opinions differ as tb what exhibit 1. be used to determin: theshortage.In many studies, the approach used is toestimate total " Career Guide for DemandOccupations (Wash- manpower requirementsin terms of a standard ington: U.S. Department of Labor,Manpower Admin- of desirable health care, and todetermine the istration, Bureau of EmploymentSecurity, 1965).

18 EXHIBIT 1-HEALTH MANPOWER IN CRITICAL DEMAND, 1965 12

Occupation Basic Educational Requirement Physician 7 to 8 years college and medical school plus 1 to 2 years internship.

Dentist 2 year predental plus 4 years dental college.

Clinical psychologist 5 years college plus 1 year experience or Ph. D.

Physical therapist 4 years college plus 1 year special clinical training.

Occupational therapist 4 years college plus 1 year clinical experience.

Dietician 4 years college plus 1 year internship.

Pharmacist 4 to 5 years college (at least).

Parasitologist 4 years college (at least).

Chemist 4 years college (at least).

Bacteriologist 4 years college (at least).

Medical technologist 4 years college (including 1 year technical training in accredited school).

Registered nurse High School diploma plus 2 to 4 years nurse training.

X-ray technician High school diploma plus 2 years in approved X-ray technology course.

Dental hygienist High school diploma plus 2 years special course.

Dental technician High school diploma plus 1 to 2 years dental laboratory school or on-the-job training.

Practical nurse, licensed 2 years high school, plus 1 year school '-raining, practical nurse course.

Ward attendant. High school graduate preferred, 6 to 12 months on-the-job training.

A striking fact about training requirements in women, but men dominate some categories, such these occupations in critical demand' is that they as physician and dentist, and women others, such range from that of the physician, which requires as nurse and dietician.A broad range of health 8 to 10 years of training beyond high school, to occupations attract substantial numbers of both ward attendant, which requires only on-the-job men and women. training of several months.Most of these oc- To cope with problems of shortages in specific cupations call for moderate periods of training, occupations in particular communities and in the ranging from high school equivalentor less (in Nation, it is necessary to study the special cir- the case of the practical nurse) to 4 to 5years at cumstances in specific situations.It is not pos- the college level.All arc open to both men and sible in this study to analyze problems affecting the many different health occupations and proposals for dealing with them.It seems best to 12 SOURCE:U.S. Department of Labor, Manpower- Administration, Bureau of Employment Security, U.S. focus on the shortages in a few particularly sig- Employment Service. nificant occupation groups.The sections that

19 follow examine the problems of shortages among courses are referredtoas:"Baccalaureate" nursing personnel, a majority of allworkers in course (4 years college),"diploma" course (3 health occupations, and medicallaboratory per- years hospitalschool), or "associate degree" sonnel.The latter are in some ways generally course (2 years junior college) . representative of the health technician group, Licensed practical nurses must be graduates though most individual occupations in this group of State-approved schools of practical nursing present special problems oftheir own. and must pass a State examination.Practical nurse training generally lasts 1 yearand may be The Nurse Shortage obtainedinpublicvocationalschools, high schools, or adult education programs. Approval "A severe shortage of nurses exists inthe of such training is given by State boards of nurs- United States today.It is both quantitative and ing.In most States, completion of 2 years of qualitative.Quantitatively, the shortage makes high school or equivalent is required, and six it impossible to supply hospitals and other health States require a high school diploma. facilities and organizations with sufficient num- Nurse aides and similar auxiliary personnel bers of adequately prepared nurses.Qualita- are not licensed, and are usuallytrained on the tively,it impairs the effectiveness of nursing job or in brief vocational training courriv; care."This statement is taken from a report Differences in job content between r on the problems ofthe nurse shortage and nurses, licensed practical nurses, and ,y4les providing recommendations for meeting them. are substantial, reflectingdifferences i.Pdt.c - It was issued in December 1962 by the Surgeon tion, skill, and responsibilities.The scope of General's Consultant Group on Nursing. The each job is also determined partly by legal re- data, analyses, and recommendations in this requirements and partly by custom in hospitals and port, entitled Toward Quality in Nursing: Needs other patient care facilities, which vary somewhat and Goals,13 constitute a major contribution according to local circumstance and interpreta- toward an understanding of the general man- tion.Laws in many States restrict certain duties service industry, as power situation in the health to registered professional nurses. well as problems specifically related to the nurse Standards maintained by professional nursing shortage. bodies, as well as widely used job definitions, dis- One of the first facts to note about the nurse tinguish among the levels of nurses and auxiliary shortage is that there aft three distinct groups personnel along these lines : Professional nursing of nursing personnel :(1)Registered nurses practice refers to performance for pay of patient (R.N.s'), also called professional nurses and care and related duties, including the o(minis- graduate nurses; (2) Licensed Practical Nurses tration of medication and treatments as pre- vocational (L.P.N.'s),alsocalled"licensed scribed by physiciansordentists,based on nurses;" and (3) Aides, attendants and orderlies, substantialspecializedskillandknowledge. which include "nurse aids," "psychiatric aides," Practice of practical nursing means the perform- and others in auxiliary nursing capacities. ance for pay of selected acts ofpatient care, R.N.'s must pass State licensing examinations under the direction of a professional nurse, physi- to be accepted for registration.Eligibility to take cian, or dentist, not requiring substantial skill and these examinations is limited to graduates of knowledge.Auxiliary workers such as nurse schools of nursing approved by State boards of aides can carry out certain essential time-con- nursing. suming duties effectively and safely, under the Registered nurses may be graduates of either directionofprofessionalnursesorlicensed of three different kinds of schools requiring 4, 3, practical nurses, but their activities are not con- or 2 years of study beyond high school.These sidered to constitute the practice of nursing."

"Toward Quality in Nursing: Needs and Goals 'I Statement on Auxuliary Personnel in Nursing Serv- (Washington:The SurgeonGeneral'sConsultant ice (New York; American Nurses' Association, April Group on Nursing, 1963). 1962).

20 Discussing the extent and effects of the nurse ministrative methods and staffing patterns in shortage, the report of the Surgeon General's health facilities, and ways of making better use Consultant Group quoted reports that in hospi- of nurses' time.The report discusses the need tals located in many areas as many as 20 to 30 for incentives to bring inactive nurses back to the percent of positions for professional nurses were profession and to reduce turnover among nurses. vacant, and vacancies for practical nurses were It points out that an estimated half million also widespread.According to the report, "be- women trained as professional nurses, many of cause the need for professional and practical them married women with young children, are nurses is increasing so much faster than the sup- not now practicing.The report suggests re- ply, hospitals have employed ever larger numbers fresher courses and flexible arrangements of work of nursing aides, many of whom are inadequately hours to attract these women back to nursing. trained.This pragmatic solution to the prob- Data are presented in the report showing that lem of shortages has produced an alarming dilu- turnover rates among nursing personnel, ap- tion of the quality of service.In some hospitals proximately 60 percent per year, compare with the use of auxiliary workers has reached such a rate of 18 percent for female teachers in public extreme proportions that nursing aides give as schools.(See chart 4.)In discussing this con- much as 80 percent of thedirect nursing trast, the report draws attention to the difference services." to the median salaries of the two groups: $5,500 In the judgment of the Consultant Group, an yearly for teachers, compared with $3,900 for adequate level of nursing care for the patient re- staff nurses.Also discussed is the omission of quires a ratio of 50 percent of patient care pro- nurses from the coverage of social security laws, vided by professional nurses, 30 percent by collective bargaining protection, and other labor practical nurses, and 20 percent by nursing aides. legislationThe report points out the need for This standard is used in the report, in conjunc- improving the economic status of nurses in order tion with other factors, to develop goals for to attract recruits and hold them. expanding and improving the quality and supply The recommendationsoftheConsultant of nursing personnel.The report examines ma- Group may be summarized as follows: jor problems involved in achieving these goals, 1. A study should be made of the present sys- including the outlook for the supply-demand re- tem of nursing education in relation to the relationship in 1970, educational requirements for sponsibilities and skill levels required for high nurses, problems in utilizing nurse manpower quality patient care, using funds from private effectively, and in recruiting nurses and students. and government sources. The report emphasizes the need for expanding 2. The Public Health Service should expand the recruitment and training of professional its recruiting of nursing personnel, and should nurse candidates.Its analysis of number of aid State and other agencies in their recruitment graduates expected to he produced by nursing programs.Federal funds should he made avail- schools indicates that a de=sirable goal of 850,000 able for student loans and scholarships. professional nurses in practice in 1970 is unlikely 3. Federal funds should be provided to help to be met. A "feasible" goal of 680,000 is ac- build schools of nursing and extend the develop- cepted as a compromise, with an implication that ment of new nursing education programs. continued heavy reliance on practical nurses and 4. Programs in support of traineeships for bac- nursing aides will be needed. calaureate and advanced degree candidates Among other aspects of the nursing profession should be extended, using Federal funds. examined was the quality of nurse training now 5. Federal aid should be made available for being offered.The report concluded that "the demonstration projects and training to improve present educational structure for the training of theutilizationof nursing personnel and to nurses lacks system, order, and coherence." strengthen in-service education and on-the-Job Measures suggested to make the best use of training.Public Health Service programs which the present supply of nurses include improved ad- provide consultation and other services to healw

21 C art 4.Turnover ofnurses dwarfs turnover of teachers.

Rate of annual Ir turnover (percent) 80 80 Teachers Nursing personnel

60 60

40 40

20 20

0 0 Teachers All nursing Administrative, Practical Staff nursesAides, attendants, (public school) personnel supervisory nurses (R.N.) orderlies

U S Department pl Leo, Manpower Aiiministrat,on. OM, r Itlinpower ,,Ivaluatiun. and Research based (in hatsinToward Quality in Nursing Care.- Report ofConsultant Group to the Surgeon General

facilities, to improve patient care throughim- qualified R.N.'s, and toward improvement in the proved personnel utilization and othermethods, quality of nursing instruction.But the act is should be expanded. not likely to have more than a superficial effect 6. Programs providing Federal aid to research on the nurse shortage for many yearsahead. in nursing should be expanded. In a recently published analysis of the Nurse Training Act of 1964 and its probable effects, The Nurse Training Act of 1964 translated Prof. Donald E. Yett of the University of Cali- into action several of the recommendations of fornia concluded that "this legislation will not be the Consultant Group.It provided for: Grants adequate to accomplish even its 'feasible goal' of for construction of schools of professional nurs- preventing a further increase in the percentage ing; loans to students in associate, diploma,bac- of unfilled positions for professional nurses."In calaureate, or higher programs: payments to his view, the nursing shortage will persist as long diploma schools of nursing to encourage ex- as the salaries of nurses remain low incomparison pansion of their facilities; grants for projects to with salaries in competitive careen for women improve nursing instruction ; and for extension (such as teaching and even secretarial jobs) . of the professional nurse traineeship program Meanwhile, he recommends strengthening of the providingtuition and other allowances for act by the development of a large nursingschool limited periodstonursesinqualified bac- scholarship program.15 calaureate and advanced training programs. 'Donald E. Yet, "The Nursing Shortage and the These provisions of the act will contribute to- Nurse Training Act of 1964," Industrial and Labor ward an eventual increase in the number of Relations Review,January 1966, pp. 190-200.

22 The expansion of hospital programs for train- tical nurses in vocational schools, would bere- ing practical nurses and nurse aides because of placed by courses in senior and junior colleges Federal and State Government assistance has that would utilize hospital facilities as labora- helped to alleviate the effects of the continuing tories.The nonprofessional "assistants" would nurse shortage. Many nursing duties can be also get some introductory practical training in shifted to such.workers, freeing the R.N., for work hospitals after completing their courses invoca- at a more professional level.Differences of tional schools and entering upon employment. opinion exist regarding the most desirable staffing ratios of R.N.'s to less fully trained personnel. Medical Laboratory Personnel But under prevailing conditions, the flow of traineesfromprojectsprovided under the Modern medicine depends heavily on tests MDTA and related legislation administered by performed in medical laboratories. The special- the Department of Labor and the Department ist physician who directs the laboratory's proce- of Health, Education, and Welfare has made a dures in a hospital and interprets findings is the very important contribution toward providing pathologist. adequate patient care.It has kept in satisfactory The main work of the laboratory is done by operation some hospital wards that might other- the medical technologist, trained in scientific wise have had to close altogether. fundamentals andinlaboratorytechniques. Leaders of the nursing profession continue to With assistance from subordinates, the medical stress long-range goals in the programs they urge technologist carries on tests for a wide range of for the training of nurses.In a publication diseases, from noninfectious disorders, such as called "A Position PaperEducational Prepara- diabetes and leukemia ( diseases whose presence tion for Nurse Practitioners and Assistants to can be positively identified only by laboratory Nurses" (1965),issued by the American Nurses' tests) to contagious diseases, such as tuberculo- Committee on Education, a program is pre- sis and syphilis.They conduct tests for preg- sented which, if adopted, probably would have nancy, make culture smears of body fluids, and far-reaching effects, not only on the nursing edu- analyze samples of blood and urine for a wide cation system, but also on the status of the great range of conditions. The tests involve chemical, majority of nurses now in practice. bacteriological,physical, and otherscientific The program calls for a shift in nurse training principles. Laboratorypersonnelsometimes away from a system relying substantially on hos- work under conditions of great pressure (for pital-based diploma programs toward one rely- example, while surgery is proceeding on a pa- ing on college-level institutions of learning within tient),sometimes at the pace of ordinary routine. the general system of education, and for major But at all times, their work is potentially of vast changes in the structure of nursing personnel. significance to the life, health, and general wel- Currently, over 70 percent of nurse graduates are provided by the 3-year diploma programs. fare of the patient. The proposed approach involves a concept of There are various types and levels of medical two levels of nurse practitioners:(1)Profes- laboratory jobs.It is important to emphasize sional nurses, educated in courses leading to the certain distinctions among them, to avoid termi- baccalaureate degree in nursing (4 years) ;(2) nological confusion that has plagued discussion technical nurses, educated in courses leading to of these occupations for a long time.The fol- the associate degree in nursing (2 years). The lowing are the four basic distinct job titles, and new system would also provide for training of the requirements that have been established by "assistants in the health service occupation," the American Medical Association (AMA) , the such as nurse aides, through short, intensive pre- AmericanSocietyofClinicalPathologists service programs in vocational education insti- (ASCP),and the schools, registration boards, tutions.Existing diploma programs for training and professional organizations of laboratory pet - R.N.'s in hospital schools, and for training prac- sonnel associated with these medical groups :

23 Title Education or training and for checking progress in their treatment. Medical technologist, 4 years college, including 1 The supply of ASCP-registered medical tech- MT (ASCP). year specialized training nologists and cytologists, certified laboratory as- Cytotechnologist, CT 3 years college, including 1 sistants and histological technicians has not kept (ASCP). year specialized training pace with the expanded demand for their skills. Because of the shortage, commercial schools of- Certified Laboratory as-High school diploma plus fering inadequate training course, are supplying sistant, CLA. 12 months training in an personnel to many commercial laboratories, doc- approved school tors' offices, and even some hospitals.Most of Histological technician, High school diploma plus these schools train students in shortcut courses HT (ASCP). 12 months training in an lasting 1 year or less, for fees ranging from $600 approved laboratory to $1,400. Most urban hospitals avoid accepting grad- All of these titles, which indicate fully accept, uates of these courses and other job applicants able professional or subprofessional status, re- who are registered by unrecognized, self-con- quire that graduates of training pass examina- stituted authorities.In some cases, hospitals tions to show they are qualified for registry or have been able to use biologists and chemists certification.Passing the exam enables them to with B.A. degrees to substitute for medical tech- use the professional initials after their names." nologists.But lacking fully trained people, hos- In addition to these titles, there are several other pitals generally prefer to make use of certified recognized medical technologist specialist cate- laboratory assistants who are at least trained gories which require at least a year of additional properly to do less complicated tests, or even to advanced training. train unschooled laboratory helpers to do simple Terminological confusionusuallydevelops tests, rather than hire graduates of commercial from one of two sources.One is the fact that laboratory schools.Some hospitals have reacted there are several self-constituted registries for to personnel shortages by reducing or eliminating medical laboratory personnel which lack recog- laboratory services requested by physicians for nition by organized medical groups but offer ex- their office patients.This has forced some doc- aminations and grant registration and privileges tors to rely on their own less adequate testing for use of certain initials after registrants' names. facilities or on commercial laboratories having These groups commonly have standards distinctly uncertain quality standards.''As a result, the lower than those of the ASCP, and in some cases level of health care received by their patients has register as "medical technologists" persons with suffered. brief, inadequate training in commercial laboratories.Another source of confusion is the continuing use of the term "medical technician" as MD TA Programs for Training a generic designation for persons who perform Health Manpower medical laboratory tests of any kind.In many doctors' offices, nurses or even secretarial assist- The supply of trained health manpower is pro- ants who have had little or no schooling in sci- duced by a variety of training facilities, including ence or laboratory techniques learn on the job universities, junior colleges, public high schools, how to do some tests, and sometimes become and vocational schools, gaining programs con- known as "medical technicians." ducted by Federal, State, and lc.^,al authorities, During recent years, there has been a very big private business schools and schools for training increase in the use of laboratory tests of all kinds, in technical specialties, and on-the-job training in conjunction with the examination of patients on a formal or informal basis.The education

1° Careers in the Medical Laboratory (Muncie, Ind.: " "Medical Lab Tests: Mistakes That Are Endan- Registry of Medical Technologists, 1965), Fact Sheet. gering Your Life," McCalls, May 1965. 24 and training of health service personnel, espe- Table 4. AUTHORIZED TRAINEES IN HEALTH OC- cially of those who require advanced education CUPATIONS FUNDED UNDER THE MDTA, AU- is a vast subject which cannot be examined in GUST 1962DECEMBER 1966 detail here.For purposes of the present study, the programs for training health personnel under Occupation Number the MDTA and related provisions are a particular focus of interest. Total 63,036 Since 1962, MDTA training has become a significant factor in supplying health manpower, Professional nurses (refresher training) 4,723 not only in projects training workers for semiskilled or subprofessional jobs, but also in re- Licensed practical nurses 20,695 'fresher training projects for professional health Nurse aides/orderly and related occupations. 30,028 workers. MDTA training projects approved Nurse aides/orderlies 27,220 between August 1962 and December 1966 pro- Clinical assistants 120 vided training for a total of 63,000 men and Home attendants 448 Occupa- Housekeepers (medical service) 1,654 women in health service occupations. Ward maids 378 tions such as licensed practical nurse and nurse Other attendants 208 aide ranked among the largest categories of all fields in which MDTA training was conducted. Specialized technical aides 7,123 Approximately one-fourth of all the women Dental technicians 491 Dentists' assistants 765 trained on MDTA projects were in courses for Medical laboratory assistants. 544 training licensed practical nurses or nurse aides. Medical records aides 151 As table 4 indicates, thousands of other men and Medical technicians 147 women were trained in other healthoccupations, Occupational therapy aides 145 such as psychiatric aide, dental assistant, labora- Psychiatric aides 2,978 Special diet workers 440 tory aide, surgical technician, home health at- Surgical technicians 925 tendant and in other specialties. X-ray technicians 132 Most of the MDTA health occupation train- Others 405 ees have been enrolled in "institutional" projects 'Health clerical 467 which provide formal classroom instruction at Ward clerks 320 health facilities and in .schools. A growing num- Secretaries and other 147 ber are being trained in on-the-job projects conducted at hospitals.Of particular interest is a SOURCE: U.S. Department of Labor; Manpower contract for on-the-job training of roughly 4,000 Administration; Office of Manpower Policy, Evalua- tion, and Research. hospital aides in various classifications being conducted in up to hundreds of hospitals, under the general direction of an affiliate of the American One of the most significant developments in Hospital Association.Thi; project is expected the evolution of MDTA programs for developing to provide guidelines for important advances in health manpower has been the growth of proj- on-the-job training techniques. Many other ects providing refresher training for professional contracts have been concluded with other spe- staff nurses.Already several thousand profes- cially qualified agencies concerned with relieving sional nurses have been helped toward returning shortages of health manpower and making better to active status through these MDTA refresher use of available human resources.Typical of courses.Data on nurse licensure indicate that these is a project for training physically handi- roughly 300,000 of the fully trained professional capped and other disadvantaged persons as cer- nurses who are currentlyeither not working as tified laboratory assistants.Other experimental nurses or not working at all stillhave their R.N. projects are constantly being undertaken. licenses.Many of them, mothers who left the

244-265 0-67-3 25 nursing field to raise their families, would prob- attracted back to work with the help of refresher ably return to their profession if they could get courses. According to Mrs. Dallas Johnson, convenient refresher training. MDTA programs executivesecretary,National Committee for for refresher training for nurses are therefore Careers in Medical Technology, other persons expected to expand. These programs can make with baccalaureate degrees in the sciences (such a substantial contribution toward relieving the as chemistry, biology, physics) probably could be nurse shortage. retrained as medical technologists within 12 to It seems likely that refresher and retraining 18 months. courses for other groups of professional health These are only a few examples of ways in workers could also contribute to relieving short- which the MDTA programs now help or could ages.For example, according to one estimate, help alleviate shortages of health manpower. 7,000 trained and registered medical technolo- However, it must be kept in mind that these pro- gists, men and women, have left the laboratory grams represent only one phase of many efforts in recent years. Many of these women, now by both government and private agencies to deal homemakers whose children are grown, could be with needs for trained health manpower.

26 2

Technological DevelopmentsAffecting Manpower

What effects will technological developments Technological changes and related develop- have on the outlook for health manpower re- ments may have various effects,such as reducing capi- quirements?Can automation or other labor- costs, lowering requirements for manpower, saving technological advances help close the gap tal equipment, or materials, providing con- between supply and demand for health person- venience, comfort, and greater output or dur- In this study, nel?Whatever its possibilities may be for re- ability of goods and services. lieving manpower shortages, technologicalad- attention is focused on those technological de- in vances result in newkinds of jobs, and require velopments likely to affect health manpower changes in the content of existingjobs.These the. next decadewithout regard to lifesaving, effects of technological change are..tt ticularly costsavine, la other effects. how.er impottant important in planning training projects anti re- these may be in themselves.Manpower effects lated manpower progr at us. will take the form of reducing (or increasing) Technological change in general has been de- total man-hour requirements, changingthe na- scribed as any changi, in the method of produc- ture of skills required to carry outhealth service ing or distributing goods or servicesresulting functions, or both. from the direct application of scientific orengi- Technological developments in the field of neering principles. All kinds of innovations, health service include not only those innovations such as new methods of materialshandling, the that have originated in medicine andother use of new andsubstitute products, and more branches of the health sciences, but also some efficient information handling andmanagerial that were first developed in industriessuch as control, as well as changes in productiontech- manufacturing and trade. Some of the medical niques and resources, may be included among discoveries that have altered health technology laboratories of rnedi- technological developments. were developed in research 27 cal centers; others have evolved in the course of especially involve expected trends in the growth daily patient care activity.These developments of public health programs. may affect health manpowerrequirements in It is useful to start by looking at the kinds of various ways. patient care that have been required, and are One way is by affecting the demand for use likely to be required in the future, in patient care of health facilities.For example, a new drug, a facilities.This requires consideration of data on new instrument, or a change inmethods of pa- illnesses and other conditions that give rise to tient care, may reduce the number of hospital patients' use of the facilities of the health service admissions or the length of hospital stay needed industry, especially the facilities of its mainstay to treat a particular disorder.But in other in- the hospital. stances, new discoveries may bring into hospitals patients who were previously considered untreat- able. Developments which prevent illness or Effects of Medical Research and disability, however, generally result in reducing Public Health Programs requirements for health manpower. Some developments affect health manpower needs by The tremendous advances made in medical re- altering the number of man-hours required pet. search and programs for protecting public health unit for performing specific activities in health have lengthened the human lifespan greatly over facilitiesfor example, by reducing the man- the past few decades, but somehow they have not hours needed to carryout a given number of iden- brought about significant changes in the pattern tical laboratory tests, or to prepare and serve a of illnesses or related causes of patient admissions given number of patient meals. to hospitals.Available evidence gives no rea- Estimating the effects of innovations on man- son to expect that medical research and public hour requirements for patient care during the programs for preventing illness during the next next decade calls for a forecast of the pace at decade will greatly reduce the volume or change which they will spreadhow long it will take the character of demand for patient care in from the time of their invention or discovery un- health service establishments. til they are adopted on a wide scale.Since the pace of spread varies widely among different Recent Trends in Causes of Hospitalization kinds of technological advances, it is necessary to examine each category separately. The total number of hospital admissions and Among the basic questions involved in deter- outpatient visits has increased steadily during mining the manpower effects of technological recent years, mainly as a result of social and changes in health service are those relating to economic trends.The pattern of reasons for the expected effects of medical research and de- hospitalization of patients in short- term general velopment and its application.What important hospitals has changed very little, howeer, at legit discoveries are on the way? How long will it in terms of the ranking of major groups of dis- 4 take for them to be widely diffused in practice? eases or conditions.Data from a study spon- Apart from new discoveries, how long will it take sored by the American Medical Ascociation, for already developed techniques to be applied which was based on a representative sample of to the full?These questions relate both to re- short-term general hospitals, shows remarkable search results and the spread of new technology stability in the pattern of causes of hospital ad- in protective or preventive medicine, and to in- mission, as shown over the 15-year period 1946- novations involving the care of patients already 61.1 These findings are summarized in table 5. in need of health services.Sooner or later, medi- Throughout the 15 years, childbirth and re- cal advance and its spread through public and lated conditions accounted for about one-fifth private programs of preventive medicine will Report of the Commission on the Cost of Medical affect the extent to which patient care facilities Care, vol. I (Chicago: American Medical Association. are used.The protective or preventive aspects 1964), p. 146.

28 Table 5. CAUSES OF ADMISSIONS TOSHORT- public health programs, is one reason to support TERM GENERAL HOSPITALS, STUDY OF64 the belief that general patterns of hospitaladmis- HOSPITALS, 1946, 1954, AND 1961 sion will not be greatly affected bycommunity decade. (Percent] healthprogramsduringthenext Whether other leading causes of hospitalization, digestive Cause of admission 1946 1954 1961 such as diseases of the respiratory and systems, will alter in importanceremains to be seen.Some shifting will probably occur, per- 100. 0 100. 0 Total, all causes 100. 0 haps relative declines in injuries, offset by rel- Deliveries and complications of ative increase in admissions among aged per- pregnancy, childbirth, and sons, but big changes areprobably not in prospect puerperium 22. 521. 0 18. 1 between now and 1975.Slight changes probably 15. 7 Diseases of the respiratory system.16. 2 15. 9 will occur in some instances, as suggested by the Diseases of the digestive system. .12. 6 13. 8 14. 0 Injuries and adverse effects of fact that there were gains between 1946 and 1961 chemicals and other causes. ... 9. 5 9. 7 10. 2 in the importance of diseases of the circulatory, Diseases of the genito-urinary nervous, and other systems, anddeclines in the system 8. 1 7. 9 8. 7 importance of conditions such as infective and Diseases of the circulatory sys- parasiticdiseases. Innovations in preventive tem 5. 5 7.4 7. 8 Neoplasms (tumors, cancers, health technology may in the future produce etc.) 5.8 5.9 6.1 some change in patterns of causesfor hospitali- Diseases of the nervous system zation, but these changes in patterns will prob- 4. 0 and sense organs 2. 9 3. 5 ably be slight. Diseases of bones and organs of The AMA-sponsored study we have been dis- movement 1. 9 2. 7 3. 1 Allergenic, endocrine system, cussing also has provided information on trends metabolic and nutritional dis- in length of stays in general hospitals, which is an eases 2.0 2.4 2.6 important element affecting the demand for 1. 6 Infective and parasitic diseases 2. 5 1. 7 patient care in health care establishments and Mental, psychoneurotic and personality disorders 1. 3 1. 0 1. 3 their requirements for manpower. It was found Diagnosis not ascertained 3. 0 .9 .1 that the average stay in surgical cases declined All others 6. 2 6. 2 6. 7 from 17.9 days in 1946 to 12.7 days in 1961, and of the cases that got medical treatment the stay SOURCE :Report of the Commission on the Cost of Medical fell from 12.8 in 1946 to 9.5 in 1961. The de- Care, vol. I (Chicago: American MedicalAssociation, cline appeared to be due partly to increased ap- 1964), p. 146. plication by physicians of the concept of early ambulation during patient recovery, partly to growing reliance on outpatient care and other diseases of the of the general hospital admissions; forms of gradation in methods of patient care. respiratory, digestive, and genitourinary systems, It appears likely that in the future the average another together with injuries, accounted for length of hospital stay will continue to decline, Conditions such as diseases of the two-fifths. perhaps at a slower rate than in the recent past. etc.), circulatory system (heart disease, stroke, In view of the stability of the pattern of causes of death and cancer, which are leading causes of hospitalization and length of hospital stays in subject of gen- and therefore quite naturally the recent years, and the prospect of only minorde- eral concern, rank relatively low among causes clines, can major changes be expected in de- of hospitalization by comparison withother mands for patient care as a result of the advance conditions. of medical research and public health programs? The continued importance of factors such as the birth rate and injuries (mostly from automo- A brief review of the progress of medical care bile, industrial, home accidents, and disasters) , and public health programs helps to throwlight not strongly responsive to medicalresearch or on this question. 29 Besides these funds for grants, other workin Medical Research many areas is being supportedby programs budg- Health The accomplishments ofmedical research in eted separately within the Institutes of Health this century have been littleshort of miraculous. and other branches of the U.S. Public Advances of the past few yearshave included Service.Many more projects in medical re- Federal antibiotics, tranquilizers, vaccinesfor polio and search are being carried on outside the measles, new advances in surgery,and new Government by State and local governmentsand of means of birthcontrol.Many new medications by private groups, using their own sources of all kinds have beendeveloped; 3 out of 4 financing. being medical prescriptions being writtentoday were Despite the fact that so much research is of unheard of 25 years ago. conducted in so many fields, there is no way knowing where important results can be expected Health research activity has beenexpanding in develop- the United States at a phenomenal rateduring in the near future in the form of specific orcuringdisease. the last decade, largely as a resultof financial mentsforpreventing In 1954, Specialists in particular fields tend to be reluctant support by the Federal government. especially of medical to be quoted on forecasts of progress, total public and private expenditures results. research were estimated at about a quarterof a how long it may take to achieve successful other One can only guess at forthcoming accomplish- billion dollars; about 17.000 medical and using informed con- scientists were employed full or parttime.By ments in medical research, jectural comments by medical specialists and oc- 1960, only 6 years later, expenditures were Of course, roughly three-quarters of a billion, and40,000 re- casional items in the popular press. all such conjectures are of limited valueand are search workers were employed.It is expected likely to be contradicted by unexpectedstand- that by 1970, national medical researchexpendi- tures may reach $3 billion aridnearly 80,000 stills, or by breakthroughs, in research. In cancer research, particular attentionis be- professional workers will be needed.2 ing focused on research concerningrelationships There seemsto be no reallysatisfactory between viruses and malignancy.It is now be- method of summarizing the direction or pattern lieved many separate and combined factors con- that health researchistaking.The dollar tribute toward the many different forms cancer amounts made available to outsidescientific in- takes; -research is proceeding along severallines. vestigators in fiscal year 1964 by the National Hope is expressed for finding a cure forleukemia Institutes of Health, give only a suggestion of within the next decade, and for meansof the breadth and intensity of campaigns covering preventing and curing some other forms of can- a broad front: " cer, but few informedobservers believe that progress toward cure orprevention will be sufficient Health field Amount (millions) by 1975 to reduce the cancer tollsubstantially. Mental health $135.4 Cardiovascular disorders are another areaof General medical science.. .. . 99. 2 Heart 95 3 research on which much attention is centered. . . 85. 4 It is considered likely that by 1975there will be Arthritis and metabolic . .. Cancer 66 8 much greater knowledge oftheeffectsof Neurological diseases and blindness . . . 64. 2 cholesterol, sugar, and other dietary factors on Allergy and infectious diseases 46. 0 heart disease, and that gains will be made inbet- . 27. 0 Child health and human development hypertension.There are Dental 13 8 ter understanding of general expectations that progress willcontinue these condi- 'Manpower For Medical Research Requirements in the development of drugs to treat and Resources, 1965-70 (Washington: Department tions.Progress in the improvement of surgical of Health, Education, and Welfare, Public Health Serv- techniques for treating various forms ofheart ice, 1963), p. 14. disease is likely to continue. Someobservers ex- 1964 Annual Report (Washington: U.S. Depart- will also bring further ment of Health, Education, and Welfare,1964), p. 231. pect that the near future

30 gains in knowledge of how to preventstrokes, on Public Health Programs which some progress has already been made. Only to a limited extent are hospitals or other The research in several other areas appears to patient care health service facilities (as defined Study of drugs for use in offer great promise. for purposes of this study) engaged in the pre- mental disorders is considered likely to continue vention of illness. A major share of the preven- of treat- to produce new and improved means tive and related efforts toward protecting the Progress is ing the mentally ill and retarded. health of the population at large is made by gov- few expected in the prevention and cure of the ernmental and other community agencies that major infectious disorders which are still serious carry out regulatory, information, diseasedetec- medical research specialists causes of disability; tion,and relatedhealthfosteringactivities. for prevent- appear to be confident that measures Among these,the well-established programs avail. ing German measles will soon be generally Protecting the public against contam- hepatitis may be include : able and that protection against inated foods, poisonous drugs, and other harm- However, it is found in the next few years. ful materials; controlling the spread of communi- be- widely believed that it may take many years cable diseases; fluoridation of water supplies for fore effective means of preventing the common protection against dental caries; occupational research cold is found, despite the fact that much disease and accident prevention programs; pro- on this problemis going on. moting infant health; examining children and Progress is expected in the development of the population in general to detect visual defi- drugs to aid in the treatment of arthritis, enzyme ciencies, tuberculosis, diabetes, veneral disease, There is general ex- deficiencies, and obesity. and other disorders; vaccinating schoolchildren field pectation that gains will also be made in the and others against smallpox, diphtheria, polio, implanting of of tissue transplants and in the influenza, measles, and other diseases; promoting artificial internal organs and parts, as well asin the health of the population generally through improving artificial limbs. the the issuing of information on personal hygiene. The foregoing observations scarcely touch Expansion of such programs depends partly on surface of the enormous scope of medical re- the results of continuing research toward finding search, and merely suggest some general expecta- solutions to health problems, but perhaps even tions, What do these expectations imply in more on the availability of funds tospread the regard to demands for patient care, assuming a application of known techniques. moderately optimistic outcome for ongoing research efforts during the next 10 years?It is Environmental Protections.Leaders in the obvious that even moderate success in these re- field of community health increasingly emphasize search activities would eventually lengthen lives, the threat to health of many physical and social diminish pain, and increase the happiness of mil- factors in our environment.Dr. George Jame, lions of people.But at the same time, it seems former Commissioner of Health of the City of reasonable to expect that progress in preventive New York, has said : health technology will not be sufficiently rapid to alter greatly the kinds of healthservices Our society is now creating our most demanded in patient care facilities in the next significanthealthdifficulties.As a decade.Much will depend, of course, on the matter of fact most of the major health specific nature of the new discoveries or other problems awaiting our attention appear developments that will occur.But considering to be man made.As man has con- the time needed for diffusion of the use of new quered infectious disease, perhaps more techniques, equipment, or medications, moderate through an improvement in his stand- success in research willprobably not greatly ard of living than specific therapy, he reduce the volume or change the pattern of must pay the price for thisstandard demand for manpower in health service estab- ofliving.The background ofthe lishments during the next 10 years. health problems of our current and

31 -fqc11.11(

individuals, al- made up of storage ofmedical records of future age is increasingly retrieval of patient data cigarette-smoking habit- lowing for access and our growing doctors in the area.'Some alcohol-centered socializa- by all hospitals and uations, our plans feature massphysical examinationsin tions, our high-fathigh-calorie routine which, as a preliminary tophysical examination diet, our swift anddangerous motor- and health counselingby a physician, there cars, oursmoke-belching factories, our patient a battery of pesti- would be administered to a heavily polluted waterways, our in a period of agriculture and our at least 20laboratory health tests cide-dependent 2 hours using automatedtechniques.The re- steadily increasing exposureto ionizing sults would he analyzedby a computer and a radiation:1 report printedfor the physician,indicating ab- Some of these problemshave become the tar- normal test values andabnormal symptom com- get of newpublic health measuresduring the plexes that require specialattention. The mass last 5 years, including programsfor control of routine procedure would cost anestimated $25 the pollution of air andwater, warnings tothe to $30 andreplace procedures nowcosting $100 public of the dangersof cigarettes andhigh- to $200 andrequiring 1 to 2 days.° calorie diets, control inthe use of pesticides. Continuation and strengtheningof these environ- Informational Uses of ElectronicComputers. mental programs anddevelopment of new ac- Success in communityhealth depends partly on community systems for col- tivities for protection ofthe public health are the effectiveness of health data of the widest certainly to be expected. lecting and analyzing variety, such as dataresulting from the operation Diagnostic Programs.Along with broadening of public health agenciesand data from special of public health programsand increasing stress studies. Systems are now beingdevised to on providinghealth care to individualshas come harness the electronic computer tothe collection a shift inemphasis among manyleaders of the and analysis needs ofstatewide and nationwide health professiontoward a patient-centered, public health administrationagencies. Con- rather than a disease-centeredapproach to the siderable attention has beengiven to a system problems of public health.This would involve of this kind that isbeing developed for states.7 going beyond theailments that bringpeople to (See chart 5.) a publichealth facility, to look attheir total Use of the computer incarrying out public health needs.One implication ofthis concept health programs will parallelthe already expand- is that there is need for a greatexpansion in pro- ing reliance on the computerin statistical and grams fordiagnostic examinations, to coverthe medical research programsrelated to public entire population, goingwell beyond what are health.Statistical data on health trends among now themodest screening programscurrently the population that result as abyproduct of pub- in effect in some cities. lic health programs canfurnish a valuable re- Modern technology has animportant role to sourcenot only forresearch, but also for pro- physicians as they treat play as this trend develops,by providing new in- viding immediate help to struments andincreased convenience and re- illness or try to prevent its spread. patients and keeping duced costs of examining Statement and memorandumby Dr. James W. Dow studying patient records.Health planners are and other staff of theNational Institute., ofHealth, possibilitiesof regional and localprograms July 16, 1965. for large scale diagnosticscreening of the whole ° Letter by Dr. RichardA. Prindle, U.S. Public Health Service, to the NationalCommission on Tech- population,utilizingcomputer-based,^entral nology, Automation, andEconomic Progress, June 7, Commissioner of 1965. Address u; Dr. George James, Proposal to Design A PublicHealth Information Health, New York City, tothe Eastern States Health Lockheed Missiles & Space Medicine, April 20, System (Sunnyvale, Calif.: Conference, New York Academy of Co., November 13, 1964) . 1964.

32 a 4011.61S Chart`5. Total. information systemA State punt:schematic health department Regulation and licensing State public health department Standardized information Radiation LabXrayNursingHospitalsLaboratories personnel equipment homes InformationResearchRecord inputs inquiries requests VitalEnvironmentalRegistriesResearchReports statistics requirements data chartsdistribution WaterAir pollution quality EpidemiologicalStatewideAnimal disease information data surveys inputs Environmental input data Countyinterchangedepartment health ReseachMachineLandPopulationVector usage needscontrol readable movement changes surveys DirectoriesResearchRegistriesSpecialinquiries reports Vital statistics GovernorStateWelfareFinance agencies CommunicableVitalU.S.Water statisticsPublic and Healthair disease data Service data and Census Bureau Agriculture RadiologicalCensusSpecialInquiriesReports requestsdata data =cur:e 5, 'ks AC' Another use of the computer for furtherance 1. An increase in life expectancy of both medical research and patient care, some- from 70 to 75 years. health sta- 2. Reductionofinfantmortality what related to its use in processing from 25 to 15 per thousand. tistics,is the establishment of computer-based 3. Virtual elimination of tubercu- networks of information on significantdevelop- losis, measles, and whooping cough, as ments in biomedical science.In 1963, the Na- well as polio, diphtheria, and typhoid tional Library of Medicine activated the Medical fever. 4. Reduction of one-fifth in the in- LiteratureAnalysisandRetrievalSystem cidence of heart disease, cancer, and (MEDLARS),producing a monthly list of 14,- stroke, which now account for 70 per- 000 articles from the world's biomedical litera- cent of all the deaths in the United ture, the "Index Medicus," using the computer. States. It has been estimated that this is five times as Apart from the programs for dealing with the large an index system as had previously been scourges indicated by the President, thereis available (in a project antedating the computer evident a general determination to broaden the operated by the American Medical Association) . protection of the public from hazards in the air Work is now proceeding on an International we breathe, the water we drink, the food we cat, Nursing Index.It is planned to extend such and other environmental hazards.It is reason- programs to include publicationof specialized able to expect that substantial progress will be bibliographies, translation, abstracts, and similar made eventually in reducing many of these pre- services related to the needs of health sciences. sent dangers to health, both from research pro- Computer systems are being developed link- grams and from the extension of publichealth ing the medical libraries of major universities by activities.But it is difficult to venture a guess teletype wires to provide literature searches of on the pace of the expected progress and itseffect all the libraries' materials instantaneously, on de- on the volume and pattern of demand forservices mand.It is expected that eventually interna- from hospitals and other patient care facilities. tional networks of information using computers For the present, therefore, it seems necessary will be established to give instantaneous service to omit a forecast of the effects of researchand to specialists performing medical research,public public health programs on the demand for health health and patient care activities, furnishing in- manpower during the next 10 years.In any formation not only from medical literature, but case, available evidence suggests that progress also statistics on current and past trends among will be slow. the population in relation to specific health sub- Among the many difficulties that would be in- jects.Substantial assistance toward community volved in such a forecast is the fact that some a health goals, in this country and in the world applications of medical research and public may be expected from suchdevelopments. health protection programs reduce demands for patient care of certain kinds, but other applica- Outlook for the Effects of Research and Pre- tions may bring about increased demands for ventive Programs. Many of the most dramatic patient care services.To illustrate, develop- of the expanding programs for community health ments in preventive medicine such as thedis- care are being aimed at major threats tolife. covery and distribution of poliovaccine have President Johnson has outlined in many public greatly shrunk demands for hospital bed occu- statements his intentions to increase allocations pancy ; however, developmentssuch as the suc- of money and manpower to a number of critical cess of tuberculosis detectioncampaigns have been bringing to hospital wards patients who programs.He has stated the following as some might never have gotten there otherwise.For of the goals of his administration : the present, perhaps it is reasonable to assume, as suggested by the datain table 5, that in any Remarks of the President at the signing of the of disability among Community Health Services Extension Act, August 5, case the extent and causes 1965. the population will not change sufficiently in the

34 next decade to have mucheffect on the volume Diagnostic, Testing, and Monitoring Equip- and kinds of manpower required toprovide ment.In the clinical laboratory the develop- patient care. ment and spread of automaticequipment for chemical and other tests of body fluids and tissues has proceeded rapidly.So much of the Technological Developments in work previously done by manual methods is now handled routinely by mechanical devices and Patient Care Facilities instruments that "automation of the laboratory" The effects on manpower re'luirementsof the is widely considered to be well-advanced. technological developments being adopted for Exhibit 2 lists automatic and other advanced use in facilities providingdirect patient care are electronic devices currently to be found in re- somewhat easier to evaluate than those aft/ib- search and clinical laboratories.Most of these utable to advances in preventive medicine.The have been developed in the last 10 to 15 years; important technological developments in health in fact some are not yet widely in use in hospitals service facilities include both clinical and non- orotherclinicallaboratories,being limited It will not be possible clinicalinnovations. They assume various mainly to research labs. forms, and can be grouped intocategories in here todiscuss more than a few of these more than one way.Popular discussions devote instruments. much attention to highly technicalinnovations in The development of the automatic chemical the field of "medical electronics," aswell as to analyzer represents the greatest single contribu- more homelydevelopments such as the use of tion, thus far, toward automation of the labora- disposable supplies made of paper and plastic tory.Most of the work in a typical clinical lab- materials to replace items that have to becleaned oratory consists of repeated performanceof a and sterilized.From the standpoint of apprais- small number of routine tests, many of which ing manpower implications it seems mostuseful can now be done on afew automated devices. to consider the variouskinds of technological Two analyses (for glucose and urea nitrogen) and related developments taking placein health account for somewhere between'25 and 35 per- in terms of these four broad func- cent of all tests in the average lab;10 types of care facilities of the tional categories : tests can account for 70 to 80 percent entire workload. 1. Developments in diagnosis and pa- In many small hospitals automatic devices are tient care, generally absent, but in most medium-size or 2. Supplies and services in health large hospitals, it has been estimated that in 1965 facilities, perhaps 25 to 50 percent of the laboratory work- 3. Hospital information processing, load had been turned over to automatic instru- and 4. Organization and design of health ment and that in 10 years this figurewill climb facilities. to 75 percent. The spread of the automatic chemical analyzer Developments in Diagnosis and Patient Care is largely responsible for the spread of automation in the laboratory.In 1963, nearly 5,000 auto- Technological developments in the fields of matic chemical analyzers were in clinicallabs. diagnosis of illness and care of patients cover a Most U.S. hospitals with over 200 beds have one very )road range.They may be summarized or more of theseinstruments. in three groups :(1) Diagnostic, testing, and The device consists basically of seven com- monitoring equipmentlaboratory instruments, ponents: A sample turntable, aproportioning X-ray and related equipment, computers, and pump, a mixing coil, adialyzer, a heating bath, equipmmt for patient monitoring; (2) surgical a colorimeter, and arecorder.The operations equipment and procedures;(3)therapeutic it performs may be summarized as follows:The techniques and materials. sample turntable is loaded with a largenumber 35 EXHIBIT 2- -APPLICATIONS OFELECTRONIC INSTRUMENTS IN MEDICAL LABORATORIES('

Analysis of biochemical constituents Paramagnetic oxygen analyzers Ionization detectors Colorimeters, automatic chemical analyzers Oxygen electrodes, blood-gas analyzers Spectrophotometers forvisibleultraviolet,infrared spectroscopy and fluorescence Analysis of physical properties Emission spectrometers, famephotometer, emission Densitometers spectrograph Light amplifiers Chromatographs (paper, gel, starch) Electron microscopes Gas chromatography, amino acidanalyzers dioxide, nitrogen, Ultraviolet microscopes Gas analyzers for oxygen, carbon Electronic micrometry carbon monoxide, helium and radioactive rare gases Electronic scanners, cell counting, cytology (krypton, agron) Isotope detectors, scalers, counters, integrators,plotters Analysis of physical and chemical properties Miscellaneous laboratory apparatus pH meters Electrophoretic apparatus Fraction collectors Nuclear magnetic resonance detector Deionization apparatus Electric conductivity meters Centrifuges, ultracentrifuges Viscosimeters Titration apparatus Ultrasonic cleaning equipment Osmom eters Automatic equipment for staining of pathologicspeci- Mass spectrometer Thermal conductivity meters mens

the of specimens, which are pumped into the system different chemical components at once on of analysis provided by the other componentsand same specimen.In an 8-hour day it can run of what an subjected to specific analytical operations,sample 960 individual tests, the equivalent expected to do in 3 weeks. by sample.Individual samples are separated by average technician is air bubbles.The final results of tests are entered (See drawing.) develop- on a strip chart shownby the recorder. Many other significant laborsaving Procedures have been worked out fordeter- ments in automatedlaboratory equipment have mining at least 18 different componentsin blood been introduced.These include the blood-gas the and urine on the automatic chemicalanalyzer. analyzer, the automatic chloride titrator, Other fluids can also be tested on theinstru- atomic absorption spectrophotometer,the Coul- counter, automatic ment, and some laboratorytechnologists have ter automatic bloodcell extended its versatility over a wide rangeof pipettes, cytoanalyzers, and variousothers. Each tests in additional clinical tests.For most tests, accu- of these makes it possible to carry out racy of the automaticchemical analyzer is at a fraction of thetime required by manual meth- least equivalent to that of manualmethods. ods, without loss of accuracy(and sometimes The early automatic chemical analyzer per- with gains in accuracy) . mitted substantial reductions in timeand costs Among the valuable features of theseinstru- to carry out tests (cost of aglucose test was re- ments is the fact that manyof them produce a duced from a range of 50 to 75 cents bymanual graphic or tabular permanent recordof test re- methods to 20 to 30 cents on the autoanalyzer) . sults which saves labor, reducesopportunities Even further savings result from useof an im- for error, and otherwise increasestheir clinical chemical ana- proved model of the automatic value.Moreover, many new instruments are This instrument has lyzer announced in 1963. adaptable for use with digital electronic com- eight eight channels, allowing for tests measuring puters to carry outcalculations that otherwise technicians using Post- have to be done by laboratory " Source: "Impact of Electronics on Medicine," The physicians who graduate Medicine, October 1964. conventional methods.

36 order examinations need test results in quantita- ofautomatedequipmenthaveoffsetonly tive terms that are not derived automatically in partially the continuing shortage of medical tech- standard laboratory procedures.In the absence nologists. One team of experts has said : "Auto- of computers, this often requires calculations mation can handle the repetitive 'routine' tests which would take up much of the time of which account for 90 percent of laboratory load technicians. and free our technical staff for new and impor- Clinical laboratory specialists expect that in tant tests and more difficult patient problems." 11 the future it will be possible to extend greatly It is for this reason, and the greatly increased the mechanization of laboratory tests.Appara- capacity for testing provided by automation in tus is being developed, for example, to carry out the laboratory, that the new equipment is gen- continuous monitoring of the blood and other erally welcomed.Since the demand for labora- body fluids of patients during surgery or post- tory services will continue to rise, the need for surgical recovery periods.Indwelling catheters highly trained technologists will not be reduced. or detectors connected to the patient's body Important advances are being made in X-ray would monitor the patient's body chemistry con- and fluoroscopic equipment.In most hospitals tinuously and set off alarms to warn the medical and offices of physicians and dentists, X-ray and staff instantly if dangerous trends develop." fluoroscopic equipment represents a substantial It is generally believed by informed observers investment and is constantly in use as a basic tool that recent sharp growth in demands for clinical in the diagnostic process.Fundamentally, the laboratory tests will continue, and perhaps ac- same type of X-ray equipment has been used for celerate.Consequently, the laborsaving effects diagnosis by radiologists and other physicians over many years, but developments now under- " The discussion of clinical laboratory equipment in this section was based mainly on "Instruments for Philip H. Geisler and George E. Williams, "Auto- Clinical Chemistry Labs," Chemical and Engineering mation in the Clinical Laboratory," Hospital Topics, News, December 9 and 16, 1963. February 1963.

This automatic chemical analyzer includes six components.They are, from left to right: Recorder, dual beam flow colorimeter, heating bath, dialyzer inconstant temperature bath, pump, sample turntable.

37 spot into a numerical code;. .It then con- verts the numbers back into light intensities on a display screen, therelv sharpening contrast and p4. t- 0 11.1116111MINWIL.M revealing details that might otherwise be lost completely." 13 Other extensions of X-ray techniques include various adaptations of television, c.nd production of three dimensional images. Modes of visualization based on principles other than X-ray are being adopted in the radiology department of some large hospitals. One of these modes is ultrasono-

40 graphy, which avoids risk of radiation damage, provides visualization of soft tissue not shown by

4\111111. X-rays, and has other advantages,' Use of radioisotopes for diagnosis of disease ciai.es back at least a decade; new developments * make; possible photoscanning of tissues attacked by disease and the production of an image on The patient's blood pressure can be checkedby special paper which helps towards diagnosis. Ac- stethoscope at the central nursing station. cording to results of a survey conducted by a trademagazine,radioisotopescannersand way are likely-) result in adoptionof a much monitors have been acquired by a substantial broader range of advanced equipment. number of hospitals.15 According tc one specialist, recent technical Still other related techniques are under de- innovations may make standard fluoroscopy velopment, and some are already in clinical use. equipment obsolete. New electronic devices now One, called "Theovision," involves the ap- being installed in hospitals magnify verysmall plicat::,..of,elevision techniques to medical radiations and achieve brighter images without thennography, allowing doctors to get an im- increasing radiation risk to the patient or fluo- mediate look at heat patterns in the body. The roscopist.Some types of presently available new new process, developed in Sweden,helps doctors equipment routinely record fluoroscopy on mov- observe disease activity in rheumatoid arthritis, ing picture film; the cineX-rays can thenbe local infections, and other conditions and can viewed by physicians in slow motion, or a frame speed diagnosis.'" at a time.Such images can be transmitter over These arid related developments are likely to wires, and make it possible for rural or other result in some laborsavings in the radiology de the advantage of inter- remote hospitals to have partments of hoTitals and in physicians'and pretation by expert roentgenologists located in dentists' offices, and to have other manpower distant cities.12 implications, apart from their enormous value Feasibility of other advances in using basic X- They ray equipment has beendemonstrated at several in improving the quality of patient care. medical research centers. One innovation makes possible optical scanning of X-ray films and con- " John E. Pfeiffer, "How Technology Advances the Art of Medicine," Think, July-August, 1964. version of images into a digital form which a " William E. Bushor, "Medical Electronics," Elec- computer can then store and process. The pro- tronics (5-part article, January 20, 1961 throughJan- cedure provides the physician with a valuable aid uary 19,1962) . to diagnosis."The device measures the image 'Survey Shows Widespread Acceptance of Elec- density of the film, spot by spot, translating each tronic Instruments in U.S. Hospitals," Modern Hospi- tal, November 1961. 1' Mark S.Blumberg, "Electronics Can Expand 10 Robert Skole, "Thermovision: Heat Pictures on an X-ray Capability," Modern Hospital, 1964. Oscilloscope Screen," Electronics, July 26, 1965. will enable technicians to work, more quicklyand functions, such as theelectroencephelograph surely and help physicians to arrive at better (EEG), electromyograph (EMG), andothe' diagnoses more rapidly.The result is likely to instruments. led to the be a demand for more highly trainedtechnicians Further extension of these principles into in the X-ray department than have beenneeded incorporationofelectronicinstruments mounted in up to now. "total monitoring systems" (often New testing and patient monitoring instru- consoles for use in operating rooms or atthL bed- and ments based on the electrocardiographprinciple side of patients) for observing, recording, func- are being developed andadopted. Many new signaling measurements of numerous body instruments being applied to the diagnosis ofill- tions. In addition to providing continuous ness, and to testing andmonitoring the patient's recording of heart activity, these bedside systems condition, are extensions of the principle repre- may currently gage temperature,blood pressure, sented by the electrocardiograph (EKG or respiration rate, and other measurements. ECG) invented in 1903.Perfected in 1935 in Acceptance of the value of these multipurpose the form of a portable device, the EKGinstru- instruments during surgery is general. Opinions ment is available in practically everyhospital are divided, however, onwhether "total monitor- and physician's office to measure contractionand ing systems" are useful in patient care units. relaxation of the heart muscle and record these Much has been written about the potentiality events on paper.Since 1935, similar devices for use of these systems as a way ofsaving have been developed to measure other bodily on the need forprofessional nursing timein

Electronic body function recorders are attached to thepatient. 39 make a to promise of the ventricles),for instance, doctors some quartersthey are considered 24 percent of thetime.The alleviating the nursingshort- correct diagnosis substantial aid in machine scores 94 percent.Doctors can detect conservative view isthat these age.17The more evidence of an old heartattack 7 of 10 times. of them, will someday pro- systems, or elements The VA computerhasn't missed yet." 2° adjunct in manypatient care situ- vide a useful Physicians using computers arestudying variations, but will not saveonrequirements for faulty heart specialists o4 the U.S. ous heartconditions, including nurseman-hours. Heart blood vessels, andother con- of a cardiac valves, misplaced Public Health Ser/ice urge the use be repaired surgically. continuous EKG genital defects which can monitor(whichprovides Salt Lake Cityhospital intensive care units A group of doctors at a measurements) in specialized method of computerdiagnosis nursing have developed a for coronary patients,but call for the statistical application take of these defects based on a staff, rather thanelectronic monitoring, to probability of causes.It such as of Bayes' Theorem on measurements ofother body functions of the computerdiagnosis pulse.18 A staffmember at is reported that results blood pressure and of heart conditions weredetermined to be highly of the NationalInstitutes of the Clinical Center accurate bycomparison with theperformance of Health says that forpatients not underanesthesia and better than therecord monitoring is rarelyneeded on a con- skilled cardiologists, even EKG made byphysicians who werenotheart tinuous basis, andthat equipment forbedside bodily functions is not specialists.21 monitoring of general In another applicationof the computer, atthe trustworthy and otherwise notyet well enough Texas Institute forRehabilitation and Research, designed to be feasiblefor use.He says that statistical correlationtechniques were used to "Monitoring systems willbe used in the future. length of time a cast limited. determine the optimum Their use, however, willbe selective and for straighten- They will save nothingin should be worn following surgery They are expensive. At Kalamazoo'sBorgess Hos- in fact, personnel costwill ing the spine.22 nursing time and, pital a computer isbeing used to help prevent probably rise as a resultof using various ofthese embolisms after surgery. monitoring devices." 1° developments in the is making possible These and many similar The electronic computer to aid indiagnosis have con- in clinical medicine.Dr. use of computers i,;? portant advances tributed toward somespeculation on whether the VeteransAdministra- Herbert Pipberger of these machines will someday completely rou- Public tion (VA), Dr. CesarCaceres, of the U.S. function.There islittle using a tinize the diagnosis Health Service, andother physicians are doubt that right nowthe computer canbring a stored in a mass oinformation on heart disease vast amountof information tobear quickly on diagnosis computer as a basisfor aiding in the diagnostic problems, can"read" EKG reports in patients for whomelec- of cardiac conditions and X-rays withspecial acuity, and canrapidly transmittedover trocardiograms have been carry outvarious other tasks tohelp in diagnosis. ordinary telephone wires.It is reported that the However, the intuitionand judgment of the at- and more computer reads theEKG more quickly tending physician willcontinue to make his par- "In cases of thoroughly than a physician can. ticipation indispensable.As physicianslearn thickening of the wall biventricular hypertrophy ( to use the computerin widening applications,its potential toward raisingthe quality of care " Conversion Prospectsof the Defense Electronics saving the timerequired N.Y.:HofstraUniversity, patients receive, and Industry(Hempstead, other personnel willbecome 1965), pp. 320-332. of physicians and "Coronary Care Units(Washington: U.S. Depart- better understood, but sowill its limitations. ment of Health,Education, and Welfare, PublicHealth Service, 1964), p. 30. 'Newsweek, January 25,1965, p. 75. i" Robert M. Farrier,"Problems of Electronic Moni- 28, 1963. of the American Hospital 2' New York Times, May toring," Hospitals, Journal "New York Times, July21, 1963. Association, April 1, 1963.

40 machines are Procedures. Many Meanwhile, artificial kidney Surgical Equipment and kidney failure, but these in surgery during the used in treating chronic advances have been made few kidney requiring many newkinds of machines are available only at a past few years, dialysis centers, and help but asmall number of equipment and humanskills.An achievement the many thousands of personssuffering from which has helped toward enormousprogress in incurable kidney disease. cardiac surgery has beenthe development of the The machines are used to cleansethe blood heart-lung machine.This artificial heartand of afflicted patients, who reportfor care once or lung is both a pump and ablood aerator; it adds 'twice weekly. The patient's bloodsupply moves oxygen to theblood and removes carbondioxide blood flow between his body and the machinethrough two from it.It permits the patient's attached to his during surgery to bypasshis own heart and small plastic tubes permanently be operated on to forearm.This treatment has saved many lives lungs so that the latter can kidney disease vic- repair defects or malformations.Using it, sur- and has even enabled some In many cases, how- geons such asDr. Michael De Bakeyof Baylor tims to continue working. represented only partial University and Dr. AlbertStarr of the Uni- ever, the results have the patient's capacity for versity of Oregon havedeveloped procedures for success in restoring reaming clogged arteries,repairing damaged functioning. According to the National Kidney Founda- hearts, and installingartificial valves and other machines plastic body parts. tion, about 400 hospitals have these in Synthetic body parts are nowbeing implanted but most of them use them only for relief in many organs of thebody, providing relief acute kidney cases.23It has been estimated that victims of chronic kidney dis- against desperate illnesses,and lengthening the every year 3,600 be saved by the ma- lives of thousands of people.Even the brain is ease die whose lives could amenable to such surgeryand implantation of chines.Currently fewer than 60 hospitals in the artificial devices.Only 10 years ago, achild United States provide kidney dialysis care to born with the condition known ashydrocephalus chronic sufferers.In many of them capacity is (water on the brain) wasdoomed to mental limited, and patients must be selected among retardation or early death.Today, more than many applicants for treatment. used 80,000 youngsters with thiscondition have been One reason the equipment is not generally helped by an implantedsilastictube.23Dr. for chronic cases is that kidney diseasespecialists But in the De Bakey is confidentthat within a few years a differ regarding itseffectiveness. complete mechanism will bedeveloped and suc- opinion of some specialists it is the shortage of cessfully implanted in humans,replacing defec- personnel qualified to give the treatment, aswell that holds back tive hearts.21In 1966, both he and Dr.Adrian as the high cost of the treatment, Kantrowitz, of MaimonidesHospital, Brooklyn, its spread.The cost of care per patient at a di- succeeded in installing artificialheart pumps alysiscenterisestimated at $10,000 yearly. which took over part of the heart'sload. Enough centers to take care of mostchronic kid- could ultimately re- Limited advances have alsobeen made in ney sufferers in the country thousands of transplantation of organs, such asbones, skin, quire billions of dollars, as well as health workers, because of the cumulativeeffects. Experimentation and the cornea of the eye. full-time human kidneys To care for 30 patients at one center, a toward replacement of defective staff of 1 doctor and perhaps 7technicians and donors or bodies with transplanted organs from 10 nurses would be needed. of deceased persons hashad success in a few Many specialists are urging widespreadestab- cases, and somespecialists hope that transplants lishment of such centers, saying thatwithholding will soon be done well enough tobecome the of a beneficial medicaldiscovery from general preferred method of treating kidney&eases. 25 "Does Your Hospital Belong inU.S. Network of Modern Hospital, January ' Time Magazine, January 1, 1965. Kidney Dialysis Centers?" " Parade, May 16, 1965. 1965. 41 244-295 0-67-- in a repeated surgical availability is unprecedented?'Others believe out and must be replaced It is expected that ultimatelymeth- that the artificial kidneymachine has not yet procedure. brought sufficient help topatients to justify ex- ods will be found of utilizing electricity generated within the body, or perhapsatomic fuel, to pense of theoperation of dialysis centers.They inclined to rely on hope thattechniques power the implantedpacemakers. are more used in sur- for transplants of humankidneys will improve. Other electronic devices are being Meanwhile, research work isproceeding aimed gery in variousother waysto restore hearing, speaking after sur- at developinghome dialysis machineswhich to make possible new ways of gical removal of the larynx, toenable artificial would substantially reducethe cost of treatment. function usefully.It is re- If existing models of suchmachines are improved arms or hands to have developed and adopted on a wide scale,the efforts of many ported that Russian physicians physicians, nurses, and technicians athospitals an artificial armwith an electronic hand that reversing action almost instan- and medical centers would beneeded to prepare, opens and closes, patients using them. taneously, capable of a maximumforce of 33 instruct, and otherwise treat fastened to Development of artificial aids tobody func- pounds, and activated by electrodes Progress along these same lines tion has achieved successin various other body muscles.27 has also been reported frommedical centers in directions.One of the most significantis the tiny battery- the United States. surgically implanted pacemaker, a of the operated device which is installedunder the skin Among the more spectacular aspects electronics in surgery have been theappli- in the abdominal area, withelectrodes embedded use of cation of extreme heat, in theform of laser intheheart muscle.This unit paces the heartbeat of victims of heartblock, a condi- beams, and extreme cold, usingcryoprobes. in eye sur- tion in which the heartbeats too slowly or Lasers have been used successfully Present models of implanted gery.Cyrosurgery has made possible substantial undependably. Parkinson's disease pacemakers have inadequaciesthat many spe- advances in the treatment of cialists believe will be overcomein time. A and other disorders. that the batteries run major shortcoming is 27 William E. Bushor,"Medical Electronics," Elec- Wall Street Journal, August 22,1963. tronics, January 19, 1962.

411111".+4:

silastic Artificial parts for the body arebringing a new era to medicine.Here are a -zumber made of including chins, ea;s, noses, andheart valves.

42 Another development in modern surgerythat equipped specifically for handling heart attack has attracted wide attention isthe use of hyper- victims.The equipment usually includes the baric oxygen chambers for performingsurgical electrocardiograph, oxygen units, electrical beds, and other procedures.These chambers are con- andintercoms.Externalcontinuous EKG structed to withstand pressure much above nor- monitoring equipment, and electronic devices mal, holding an atmosphere consisting of up to such as defibrillators and external pat makers, 100 percent oxygen.During the past few years, which help to restore normal heartbeat in case these chambers have been added to hospitals in of cardiac arrest or other malfunction oftil^ various parts of the country. A typical chamber heart, are standard equipment in these units. is 12 f-et long and 8 feet in diameter,large New techniques are being t sed widely in the enough to hold equipment, the patient, two treatment of cancer by various typo of radiation nurses, two surgeons,and one anesthesiologist. devices, providing X-rays and gamma rays; The staff are all equipped with special air- equipment utilizing high-speed electrons is used breathing apparatus.The special atmosphere in treating certain skin lesions.Hodgkin's dis- makes it possible for some heart patients, especi- ease, a type of cancer, is being treatedwith energy allyinfants,tosustain surgery which their from linear accelerators. condition might otherwise not tolerate.." Hyper - In the field of dentistry, steady progress is baric chambers are also used for intensive pa- being made in the development of materials for tient care in several other conditions which do filling cavities.One type of material, still being not require surgery, but do require treatment tested, would require less drilling and would with elevated amounts of oxygen in the blood. retain effectiveness much longer than materials Considering these and all of the many other now used.Another material being developed new developments thathave been taking place is an adhesive coating intended to prevent decay in surgery, involving new equipment, materials, from forming in crevices of the teeth.Already and techniques, it is evident that during the next in use are many improved drugs for treatment of 10 years many professional and other health gum troubles and other mouthdiseases, and workers will be needed and will have to be trained high-speed air turbine drills which allow dentists in new specialties, and that many changes in job to prepare tooth cavities for filling morequickly content will be taking place affecting traditional and less painfully than with standard equipment. jobs. One of the most significant developments in the field of medicine has been the development Other Therapeutic Techniques and Mate- of drugs which help in the treatment and care rials.Outside of surgery, many important new of mental patients.These drugs, along with developments have occurrred, just a few of improved methods of psychotherapy, have aided which can be referred to here. many patients previously viewed ashopeless, and In the treatment of coronary heart disease, have greatly shortened average hospital stays of which accounts for over a half million deaths mental patients.They have also brought about yearly and ranks as the greatest single health substantial changes in the design, operation, and problem in the United States, a significant ad- staffing of hospitals and other facilitiesfor vance in dealing with acuteheart attacks has psychiatric care.Security is much less a prob- been the establishment of specialized intensive lem, so the need for custodial manpower is re- Substantial rehabilitation is much more care units in many hospitals.These coronary duced. of a realistic possibility with many patients, so close observa- care units provide for continuous the need for personnel trained in psychiatric tion of patients; they are staffed with personnel techniques has risen. specially trained to deal with myocardial infarc- In the treatment of chronic respiratorydis- They are lodged in areas designed and tion. eases, such as tuberculosis,drugs have been so John C. Adams, "Hyperbaric Oxygen Therapy," effective that needs for hospital beds and staff American Journal of Nursing, June 1964. previously reserved for care of their victims have

43 fallen off.Many other successes in the discovery plications have involved functions for which no and use of drugs in treating infectious and many parallel exists in business and related fields; func- other conditions have been achieved, and others tions of aiding doctors, nurses, and technicians are on the way. The range the drugs cover is so in actual patient care.Some of these are readily wide that a summary discussion cannot hope to put on the computer; others offer problems that deal adequately with their effects nn the man- must he analyzed in detail and tested at length power needed to cart for patients. before satisfactory handling by the computercan be achieved.Thew more difficult problems are Hospital Information Handling being faced by a few hospitals that are working toward fulfilling the concept of a total hospital One of the most far-reaching developments information system, in which the computer will affecting hospital technology is the use of the be utilized to the full in patientcare, business, computer to handle the mass of information and other functions.Total systems will be in- generated by hospital operating routine, in addi- stalled eventually in many hospitals, and will tion to its use in diagnosing and treating illness. have substantial effects on the number of health Few businesses or other activities have needs workers needed and their occupations. equal to those of the hospital for speed and accuracy in the communicatien, recording, pro- Present Status of Information Handling in Hospitals. An effort to show the many possi1A- cessing,andanalysisofvitalinformation. Much of this information is either the source or ities and needs for the use of computers in hos- the result of physicians' written and verbal pitals on a detailed basis would take up more orders for treating patients, which must be space than can be allowed here.Some idea of carried out quickly and accurately.The re- the status of information handling in key hospi- sults of observations of patients, of tests and treat- tal departments is provided by the tabulation in ments, are constantly being catered on patients' exhibit 3.Separate columns summarize some of records.There is a continuous flow to the ac- the main types of information used or prepared counting department of charges to patients for in key departments, the actions they relate to, For medication,specialequipment,orservices. and shortcomings in the existing systems. Patient and staff needs, and other requirements most of the departments shown, the activities and in the operation of a hospital, require many records referred to represent only a portion of ether recordsfor food preparation,house- the total scope of the department. Some activi- keeping, maintenance, and other functions. ties, such as handling the vast amounts of in- Since information handling requirements in formation that need to be read, written or other- hospitals are so massive and highly diversified, it wise communicatedin activities such as medi- is no wonder that the possibilities of using the cal study, consultation, research, and teaching computer have excited great interest.The com- are not shown at all. puter's ability to communicate, record, process, Serious inadequacies exist in present systems of control, and analyze different kinds of informa- information handling in key hospital depart- tion, at unprecedented levels of speed, detail, ments.During the past few years many studies and precision, provides an unusual tool for the have revealed serious shortcomings in the data use of the hospitals. handling procedures used in hospitals.They Like many types of business firms, hospitals show that a large proportion of the time of scarce began using computers for operations such as professional workers must be devoted to routine billing, payrolls, inventory, and related business paperwork and that existing record systems per- applications.More recently, as capabilities of mit errors on a large scale and fail to record vital computer equipment advanced to permit almost information. instantaneous communication and manipulation Evidence from only a few studies will be cited of data, applications related to the special needs here ;they deal with nursing service.Direct of hospitals have been put into effect.These ap- patient care by nurses is the most basic of all

44 EXHIBIT 3-SOME ASPECTS OF INFORMATION HANDLING INKEY HOSPITAL DEPARTMENTS

Department or Uses or prepares information on Main actions taken Shortcomings of the existing service system

Admitting. (1) Doctor's orders for (1) Sets up appointments. (1) Scheduling problems immediate care, tests. causing patient waiting, failure to use (2) Bed availability. (2) Assigns room. (2) Tardy or inaccurate information. Nursing service, (1) Doctor's orders for (1) Receives, transcribes, (1) Orders are sometimes in- medication. transmits orders; gives accurate due to incomplete- medications. ness or illegibility. (2) Changes in doctor's (2) Changes treatment as (2) Data on changes or orders. needed or directed. cessation of orders often received late. (3) Maintenance of patient, (3) Regularly enters data on (3) Paperwork excessive, yet medication, other records. patient chart, various other needed records are often records. incomplete, and not organized in most effective form.

Pharmacy, labora- (1) Item or procedure (1) Provides item or com- (1) Orders sometimes not tory, X-ray, requested. pletes procedure. given accurately or too soon, physio-therapy. or too late. (2) Charge for item to (2) Sends charge to (2) Patient charges often patient. accounting. erroneously omitted or sent out late. (3) Maintaining stock in- (3) Maintains inventory (3) Difficult to maintain ventory. record. satisfactory inventory records, present method. (4) Individual and summary (4) Prepares records for each (4) Difficult to prepare patient reports. patient. satisfactory summary records for each patient.

Dietary. (1) Arrival, location transfer, (1) Starts, reroutes, or stops (1) Frequent mistakes, in- discharge of patients. meals. convenience, waste. (2) Special diets or diet holds (2) Changes or holds meals as(2) Frequent mistakes; delays for patients about to take directed. in test or surgery. tests or enter surgery. (3) Maintaining food (3) Maintains records. (3) Hard to keep adequate inventory and purchase records with present system. records.

Medical records. (1) Full records of each (1) Obtains reports. (1) Limited capability for patient's history and assembles folders. auditing or research use of treatment. data in present form. (2) Preparation of abstract in (2) Codes data to card (2) Mistakes, heavy convenient form. records. workloads.

Accounting. (1) Patient third party (1) Obtains information on (1) Complex problems due to coverage or credit standing. admission. multiplicity of plans. (2) Patient charges for (2) Record charges prepare (2) Some charges often invoicing. invoice. omitted or received late. (3) Payroll and accounts (3) Prepare payroll, other (3) Usually few problems, payable payments. payments but heavy workloads. (4) Various accounting (4) Maintain accounts, (4) Not much useful detail system records. other records. derived under present system.

45 services provided by hospitals.As previously Adoption of the computer would not eliminate noted, nursing personnel representroughly half the need for materials or equipment convention- of the staff of most hospitals;it is several times as ally used in handling medical records and other large as any other group.The shortage of information.Index cards, handwritten forms, trained professional nursesmakes it extremely and other records would still be needed, and as- important to use their time at themaximum level sembled and stored in individual file folders, Use of microfilming of their skill.According to a careful study in a for each patient or subject. fairly representative hospital, about40 percent of is spreading very slowly in hospitals.Spreading the nurses' time was spent inactivities other than more rapidly are improvements in thephysical direct patient care, mainlypaperwork activities. handling of index cards and file folders, such as This study showed that under currentpractice 1 equipment designed with automatically con- physician's order could generate as many as15 trolled rotating file trays and folder racks, oper- forms." ated by pushbutton.Equipment such as this, Other stuAies have shownconditions such as now being installed in many hospitals andclinics, the following:" saves space and reduces clerical timeand effort at one universityhospital, one-sixth of all in filing and retrieving information. medication d uses given by registered nurses were Although not many hospitals have installed in error. advanced equipment for mass data processing, at a representative groupof hospitals in the this picture is changing rapidly. San Francisco Bay area, the formsused to record A 1963 survey of all registered hospitals of the physicians' orders for medication wererudimen- American Hospital Association (more than 7,000 tary, and did not clearlyrequire information es- hospitals),showed that the proportion of hos- sential for protLetion of the patient.As a result pitals with any kind of automatic data processing some suchinformation was frequently omitted installation was very small.Only 7 percent of (resulting in guesswork or neglect onthe part of the reporting hospitals (less than 400 hospitals) the nurse) ; other information wasfrequently ab- had either electric punch-card equipment or elec- breviated or otherwise provided in a mannerthat tronic computers.Only 39 hospitals were using was unclear. computers. The chief uses of data processing Equipment presently used in mosthospitals equipment are for payroll, billing patients, and for handling information haslimited capabilities. inventory control.Applications such as medical In most hospitals (including manylarge hos- records and research were reported only in a small fraction of the hospitals involved.3' pitals),the office equipment used todayin nursing units, medical records departments, account- By 1965, however, the number of hospitals that ing departments, and other unitsis about the had either installed or ordered computers was same as the equipmentused in offices of single believed (by computer industry sources) to ex- active medical practitioners for many years: ceed 200.Most of these were large hospitals. Typewriters, file cabinets, kardex files,calcu- It is evident from many indications that use of lators, and bookkeeping machines.Only a computers in hospitals will spread in the years small number of hospitals haveinstalled elec- that lie ahead. electronic com- tric punched-card equipment, The Promise of the Computer. The relatively specialized equip- puters, microfilming, or other small proportion of hospitals using computers in business ment for handling medical records or 1963 reflected the fact that, as they were thenbe- data. ing used, they offered relatively few advantages in comparison with carriage bookkeeping ma- " James P. De Marco and Shirley A. Snavely, "Nurse Staffing With a Data Processing System," American Use Journal of Nursing, October 1963. Raymond H. Giesler, "How Many Hospitals " Jacqueline A. Drew and Mark S. Blumberg, "What Automatic Data Processing Equipment,"Hospitals, Jan- Happens to Medication Orders?" American Journal of Journal of the American Hospital Association, Nursing, July 1962. uary 1, 1964.

46 and similar less ad- no such patient,reenter; no such order, chines, desk calculators, reenter; no suchfrequency, check; or vanced equipment, whentheir use was limited to unreasonable order, check. business developments. In most instances, theorder will be However, widening adoptionof the computer proper and the operatorwill verify the It will be stored in the for helping withpatient care and other complex order correctly. system's memory and used inother pro- technical activities promises tobring into the hos- cedures such as; pital real improvements inquality of patient care, 1. It will be added to the 4-hour as well aslowered dollar costs and savingsin the medication schedule for that par- man-hours and energydemanded of scarce per- ticular nurses' station. sonnel.Moreover, the computerlends itself 2. It will be made part of the hospital functions, patient's profile. readily to shared use among 3. It will be included in the such as patient care andbusiness, and among pharmacy order output. hospitals and other users. 4. It will he the basis for verify- The computer will makepossible an improved ing the administration of thedrug level of patient care by reducing oreliminating each 4 hours. physicians' 5. The last order dose given will delays and errors in carrying out be indicated so that inquiry can be orders, by reducing the nurses'load of paper- made as to whether or not the work, and by providingother aids to patient doctorwishestoreorderthis care. How suchgains may be achieved isde- medication. scribed as follows, in reference tothe total hos- 6. Finally, the order stored in the memory system will serve asthe pital information systembeing developed in the Ohio ( discussing initiation of a patient charge. Children's Hospital of Akron, When the time comes for this medi- the procedural sequencebeginning with the cation to be administered, the output physician's order for a medication asit is han- printer will produce this medication dled by the nurse or other operatorof the com- order along with all others pertaining puter input unit) : 32 to the particular stationin room and bed sequence.Inherent in this medi- If a physician prescribes"tetracycline cation schedule is a code number that 250 mg. caps. every 4 hrs.,"for a pa- can be utilized bythe nurse to verify tient, the operator will enterthe pa- that all medications on that schedule tient's number and medicationorder by were given.The patient's medical numeric code in the input unit.The profile will be automatically updated control system will immediatelydecode so that the doctorwill know that this the information and print itin English, medication was administered, at what on the adjacent outputprinter.Thus, time, and by whom.This controlled for example :"432671147041 Jones, order procedure as shown in this exam- : 403-1,tetracycline cap., 250 mg. ple offers seven advantages : .F.04 hrs., oral."After visually verifying 1. The order has been verified this with the physician's writtenorder, to reduce errors. the operator will depress the"transmit" 2. Nursing clerical effort is min- button, causing the order to remain in imal, because medication cards, the system.If the printback does not record card filing, and charting agree with theoriginal order or if the have been eliminated. operator hesitates beyond a presentin- 3. All documents are legible. terval, the control system will rejectthe 4. The scheduling and control order.If the nurse uses a nonexistent of this order has been handled patient number, order code, or fre- automatically. quency, the machinewill immediately 5. The patient charge is entered notify her by indicating the type of for accounting. error and correctiveprocedure such as : 6. The drug inventoryisre- lieved and updated by the amount " Charles M. Campbell, "InformationSystem for a given. Short-Term Hospital," Hospitals, Journal ofthe Amer- 7. The order has been com- ican Hospital Association, January 1, 1964. pared automatically with patient 47 characteristics for an unreasonable ter), will provide additional help to the physician. order and allergy check. The computer will save path nts' time and The procedure for handlingphysicians or- money by helping to avoid errors or oversights ders for laboratory tests, X-rays, andall other on appointments, diets, or other factors involved major hospital functions will providesimilar in stays at hospitals. The computer helps to im- gains in communication, recordkeeping,and prove the system of admitting patients to hos- control. pitals, by its ability to communicate instantan- The computer can perform manyother func- eously to each of the different units involved in- tions important in specializedpatient care situa- formation related to scheduling of appointments tions.For example, in mental hospitals it can and to facilitate arrangements for actions by sev- help score' personality and make other tests to eral different units in proper sequence. A spe- analyze the progress of patients toward cure,and cific case in point is the frequent need for special provide a convenient instrument for notingob- medication, or a diet change, the day before a servations of the behavior of patients in need of patient is scheduled to undergo an X-ray proce- constant watching.Dr. Bernard Glueck, in an dure.Failure to get information on such re- article on the use of computers in patient carein quirements communicated in time--not only to such hospitals, describes how, in aninstallation all nursing personnel involved but also to phar- having many convenient computer terminals at macy, dietary, and radiology departmentswill which staff members could constantly report ob- result in needless wastes of time and money. A servation on patients, the computer could predict slip-up is likely to cause a delay requiring the that an individual was likely to attempt to escape patient to spend at least 1 more day in the host. or become violent andgive an appropriate warn- pital than would have been needed otherwise. ing in time for needed precautions to be taken. The computer can expand income and reduce Individual staff members could not have at their expenses of the hospital by increasing the occu- fingertips observations on the patient made by all pancy or usage rates of beds and other facilities staff members during the day or daysbefore an and by reducing inventories and personnel episode.The computer, assembling, accumu- needed.Under present circumstances, many lating, and weighing the actions of patients re- hospitals operate with substantial proportions of ported according to a carefully developed pro- beds always unused (on the average, according to gram, would inform theappropriate personnel American Hospital Association statistics, about about an individual patient's behavior if a desig- one-fourth of all short-term hospital beds are nated warning threshold was approaching.33 vacant at all times) and with low use of operating The computer can raise th,. quality of patient room and other specialized facilities.As a result, care by improving the storageand retrieval of the hospital's income, as well as its opportunity patient medical records and by helping to infor service, is lessened.To some extent this is at- terpret EKG, X-ray and other pictorial repre- tributable to delays in communication between sentations of illness.With the case histories of nursing stations, admitting, and other depart- many individual patients stored andclassified ments.Hospital computer systems can provide in the computer, it is easy for the physician to channels of information and scheduling arrange- refer to past experience in treating particular ments to minimize such unused capacity.Simi- patients.Availability of such data in convenient larly, computers can save money for the hospital form will also facilitate professional review or by showing the minimum levels of inventory re- audit of patient treatment. The use of the com- quired to meet actual needs of the dietary, puter in interpreting EKG and X-ray reports, pharmacy, and related departments and by and for diagnostic analysis utilizing statistical scheduling nursing and other staff time require- techniques on the basis of information stored in ments in relation to actual and expected needs. the computer (as described earlier in this chap- These applications of the computer can substantially reduce a hospital's capital fund require- " Bernard C. Glueck, "The Use of Computers in Patient Care," Mental Hospitals, April 1965. ments as well as its operating costs.

48 Computers are currently, The computer can greatlyimprove the opera- and national basis. being used as teaching machines andin medical tion of billing, accounting,and other depart- These activities will expand when ments by raising thelevels of speed, accuracy, research. hospitals get computers linked and detail in which operations canbe carried on. more and more The procedures used incarrying out doctor's by remote data transmission.It is expected that orders, for example, assureinstantaneous re- ultimately regional and national networks of ports to the accountingdepartment on charges hospitals with computers will be available, to to the patient formedication or special services. pool information instantaneously when cases of This reduces possibilities formissing charges or serious communicable diseases arediagnosed, reporting charges after thepatient has been dis- thereby aiding control of epidemics, as well as charged from the hospital.One of the most providing a general store of immediately re- difficult problems of thehospital's accounting trievable information on medical casehistories. department is the multiplicityand variety in provisions of medical cost coverageplans.Many The Slow Pace of Computer Adoption. hospitals must contend withhundreds of third- Adoption of the computer in hospitals has been of party arrangementsin billing for treatment quite slow by comparison with the pace of com- become inpatients.This problem, which will puterization in fields such as insurance,trade, of the Medicare tensified when the provisions Discussion of the possibil- effect, can be handledmuch and transportation. programs take ity of using the computer in hospitalapplications better by the computer thanby procedures pres- dates back to 1958 or earlier.Yet, as of 1965, ently in effect in most hospitals. only a small number of the Nation'shospitals These are only a few of the manyprocedures There are various in the business department asit relates to the have computer installations. advance in computer adop- functions of the hospital forwhich the computer reasons for the slow offersspecial advantages.Apart from such tion. purely accounting applications,the computer Hospitals are currently following orplanning makes it easier to do special costanalyses and several different approaches to computerappli- relatedadministrative and statisticalstudies cations.It would be hard to list and t.ountall needed to improve hospital management.The the possible applications of the computerin a Medicare program specificallyrequires hospitals hospital, but they can be groupedinto three to provide reportsthat necessitate cost account- categories: ing, which will be a newpractice in most hos- 1. Selected operational applications,such as pitals.The computer can providecalculations inventory, and other repetitive procedures or patient billing, accounting, involving either simple repetitive data processing operationsin the busi- complex analyses such as areneeded in various also computation, scheduling, The computer is ness department; departments of the hospital. and data-arranging work in thelaboratories and valuable aid in the clinicallabora- an especially departments. large volume of compu- in medical records and dietetic tory; which requires a diagnosis of illness tations in preparing reports on theresults of tests, 2. Applications related to and continuing clinical careanalyses, and to and a large volume of paperwork tosummarize medical research of various kinds. repoe-s forindividual patients.The computer for pa- can also take over asubstantial load of paper- 3. Total hospital information systems control, work in the medical recordsdepartment, the tient care, consisting of communication, activities of many pharmacy, and the dietary department. data processing and scheduling diagnostic, The computer can help carryout manyother kinds, embracing also the business, applications re- programs, such as medicalresearch, teaching, and other clinical and research further to teach- and communicable diseasecontrol, especially ferred to above, and extending when computer networks develop on aregional ing and other applications. 49 Most hospitals that have computers are using has a central installation in Peoria, Ill., handling them mainly in the first categoryespecially in the payroll, accounts payable, general ledgers, the business functions.A smaller number of and other accounting applications for hospitals hospitals are using computers to aid in diagnosis, in Michigan, Illinois, and Iowa (including one in clinical research, and in related applications hospital 550 miles from Peoria). Other regional involved in the second category. and local groups are sponsored by hospital as- Very few hospitals, thus far, are actively work- sociations and local planning councils. ing toward making the computer the basis of a The hospitals in which use of the computer has total hospital information system.In fact, up to been focused on diagnostic and medical research 1965 there were no hospitals in which such a applications have mostly been institutions con- comprehensive system was actually in operation. nected with medical schools.Among them are Nevertheless, most hospitals that currently limit many large, well-known institutions, such as the their computer applications to business and simi- Presbyterian Hospital (associated with Columbia lar functions, or to medical research activities, University) in New York City, the University of expect to expand them toward the total hospital Texas M.D. Anderson Hospital and Tumor In- information system concept eventually. stitute (Houston), the University of California in many hospitals it would be difficult to justify Hospital (Los Angeles), Massachusetts General the costs of computer installation and operation Hospital (Boston), and the University of Mis- if the equipment continues to be used mainly for souri Medical Center (St. Louis). business functions and related mass data process- Progress toward achieving an operational hos- ing applications.Computer feasibility studies pital information system has been slow.After have often shown that its use does not result in several years of effort and substantial expendi- lower costs of data and record processing in the tures of funds toward developing total hospital hospital's business operations, by comparison with information systems, such systems are still not conventional equipment presently in use.Faced ready, in any hospital, to take over the full role by such evidence, many hospital authorities have for which they were planned.They are ap- shied away from introducing the computer.In proaching readiness at two hospitals, Children's some hospitals, where the decision was made to Hospital in Akron and at the hospital of the go ahead with computer installation,it was Veterans Administration in Washington, D.C., partly the greater speed and detail made possible and sooner or later will show whether they can by the computer in providing patient bills and perform a; well as is hoped.During the first accounting information, and partly expectations year or two after the systems in these hospitals of the ultimate extension of the computer's appli- start to handle physician's orders and related cations, that led to adoption of the computer. clinical applications, these systems will be work- Plans for the growth of these hospitals were de- ing simultaneously with, and duplicating, the signed to include eventual reliance on a total inhospitals' existing communication, control, and formation system based on the computer. recording systems.These will not be abandoned Different patterns of equipment ownership until the new system is completely tested. and shared usage may be found among hospitals At the Akron hospital the foundation for full- that are using computers.Many large hospitals scale operation has been laid, after much effort have their own individual computer installations. and patient experimentation.Basic computer In other cases, regional and local groups have hardware has been acquired and installed, con- set up arrangements for shared use of computers, sisting of a battery of equipment at the central usually for business-type applications.Some of unit and 15 input-output terminals located at these are local groups which utilize computer nursing stations and key department centers. services in conjunction with the area Blue Cross The installation has been providing useful in- organization. A regionwide approach is taken formation for a limited number of hospital func- by the 12 hospitals and other institutions of the tions on a routine basis, and has been operated Sisters of the Third Order of St. Francis, which successfully in test runs of operations nearly al)-

50 obvious importance is proaching total information systemspecifica- study and discussion. Of be done study of costs in severalcategories: Equipment tions.But much more work remains to installation and con- of total hospital rental (or purchase) costs, before an independent system development (programs, information communication andcontrol will be version cc sts, software eta ) , and routineoperation (mainly personnel) . functioning.34 Among other factors that mustbe considered The Veterans Administration(VA) pian pro- hapital information are: Differencesin capacity, speed, andflexibil- vides for an "automated equipment offered by individual VA hospitals ity and other properres of system" that will service possibilities of shar- using teleprocessing competing manufacturers; and also provide a network service bureaus, communication to embrace all VApatient care ing computer equipment, using into other contractual sharing ar- institutions.The Veterans AdministrationHos- or entering rangements with computer usersthat may re- pital in Washington, D.C.is the site of the pilot development work is proceed- duce costs (but also may reducethe convenience system, where the it will be feasible It appears likely that afunctioning hospital of the system) ; extent to which ing. software, i.e., standard information system will be achievedin the Wash- to make use of standard by equipment manufactur- ington hospital in 1966-67.During the initial programs prepared service to a class of users, such period, the system will stillbe considered experi- ers as a special It may take another year or twobefore as hospitals. mental. adapting soft- replace previous meth- The problem of preparing and the system will completely of Early in the 1970's, if all goes ware for usein the individual hospital is one ods of operation. putting the computer well, the VA is likely to have agrowing network the most costly elements of information systems to work in variousapplications. It calls for in- of hospitals with operational of the hospital's functioning out of regional computercenters tensive and continuing study of the pro- which will provide time-sharedservice instanta- procedures, and for repeated testing neously to individual hospitals aswell as to the grams that aredeveloped. of qualified per- VA central office in Washington. The question of availability sonnel to prepare programs, carry onoperations, Future Pace and Its Implications.Of wide and properly maintain thehospital's computer interest is the question ofhow rapidly use of installation is another aspect ofmajor impor- the computer may beexpected to spread among tance. the more than 7,000 hospitalsin the Nation. Special problems of a particularhospital may The answer will dependlargely on how long it delay or complicate decisions onautomation. will take to demonstrate,from the experience The attitudes of a hospital's trustees,profession- of hospitals that havecomputers, that sub- al staff, or other personneltoward adopting the stantial gains can be realizedfrom its application computer may be a majorfactor affecting deci- not only in diagnostic,research, and business de- sions. Reluctance to install it isoften attributable partment applications,but also, in the wide vari- to awareness thatthe equipment cannot realize ety of applicationsthat make up a total hospital its promise unless personnelin all affected de- information system. partments are willingand competent to use it The authorities at eachindividual hospital properly. Human beings mustbe depended on for which the installation of computerequipment to provide the computerwith data input as is being considered must firstdecide on the kinds needed, and to make proper useof its potentially of applications they areprincipally interested in great output of timelycommunications, detailed Other- and their priorities.Then they must prepare calculations, and summarizedrecords. for several weighty decisions. wise, installation is likely tobe a waste of time Choices of the kind of hardware( i.e., com- and money. puter equipment) toacquire call for extensive Most hospitals ser;ouslyconsidering installation of computer equipmentbegin with one or Speeds Information 34 Charles M. Campbell, "Akron more feasibilitystudies.There is a developing Systems Slowly," Modern Hospital,April 1965. 51 the se- outside consultantsfor selection will thereafter during tendency toward using quence appearcontinually at the top such studies, not onlybecause of the advantage of the display; a drugspecific-dose ma- of using unbiasedadvisers in contrast torelying trix comes up, after whichthe physician of representativesof selects the proper dose.After dosage solely on recommendations called up, manufacturers, but alsobecause of the selection, the route matrix is compute,' and the physician selectsthe desired value of a detailedreview of the hospital's proce- continues with se- if the route. The ordering dures by qualifiedoutside experts, even lectionof drug administrationfre- decision is not to install acomputer. quency, afterwhich the physician must Equipment currently beingordered or installed verify the complece order asit now ap- large capacity and speedof oper- pears at the topof the display.Finally, has increasingly the complete order is identifiedin re- ation, and providespractically simultaneous serv- gard to the patientfor whom itis ice to multiple users,for completely differing op- intended. equipment was erations.Whereas much older Systems of this kind can bedeveloped to help equip- based exclusively onpunch cards, new reduce the amount ofpaperwork required of of different types ofterminals ment makes use doctors and nurses, saveman-hours, reduce pos- and terminal equipmentdepending on the par- aid in improving for sibilities of error, and otherwise ticular application :Typewriters, templates patient care. They may alsobe useful in train- telephones, optical scan- typewriter keyboards, ing medical and paramedicalpersonnel. ners, andvideo screens. The pace at which computerswill spread be- of a project for devel- An interesting example tween now and 1970will probably be moderate. equipment in accordance oping methods of using Computer acquisitions will beconfined mainly with special needs inthe medical field is thework which will initially use the Hospital (Mountain to larger hospitals, being done at El Camino equipment mainly in business,laboratory, diag- View, Calif.) .This project is an effort towork Time-sharing utiliz- nostic, and research applications. out phases of ahospital information system arrangements among groupsof hospitals will also device, to replace or ing a video input-output spread, making it possiblefor medium-sized and The purpose supplement keyboardterminals. smaller hospitals to obtaininstantaneous elec- particular subsystem in the is to uevelop, for each tronic data processing services. medication, lab- operation of a hospitalsuch as After 1970, the spread of computers among etc.sequences of matrixdis- oratory, radiology, hospitals will be more rapid.By 1975, it may plays for showing on a screen.The physician hospitals, as well using a "light be expected that most large cancommunicate his orders by as many smallerfacilities, will depend on com- pen," which he touches to aspot on the screen, least on membership in the ar- puters of their own, or at to show hischoice among alternatives in a network of hospital computerservices, to ray presented tohim at the display unit. ss carry out a widevariety of hospital functions. The procedure worksthis way: If these expectations arerealized, the man- After identifying himself tothe sys- power implicationof the spread of computer use tem with a magneticcard, the physician during the next 10 years will notbecome substan- with sequences is immediately presented tial until late in those years.Currently, hospi- listing all of his mostfrequent information handling tasks.Assuming he tals that install computers for usein business ap- chooses "medical orders"and then plications assign between 5 to12 persons to staff with an "medications," he is presented them : Programers, systemsanalysts, console op- array of drugclasses.Among these In some he chooses "car- erators, and keypunch operators. (it may be assumed) the diotonics."Then, from the cardio- cases, these personsrepresent net additions to tonicsdisplay, he chooses"digitalis total hospital staff; inothers, the number of per- This drug leaf," the drug he wants. sons added tothe computer staffequals or falls a- Hospital Information SystemExperiment (Sun- short of the numberof jobs displaced bythe nyvale, Calif.: LockheedMissiles & Space Co., 197,), adoption of the computer(displaced employees LMSC-894033.

52 Central Service, Pharmacy, and Laundry. being usually transferred tothe computer unit The main function of central service is to provide or elsewhere) .Slightly larger staffswill be supplies and equipment used by all departments needed with widening of thefunctions for which that render patient care, meeting their require- the computer is used.Perhaps savings in personnel may become mostevident in situations ment regarding time of delivery, quality, quan- providing for shared use of computersby sev- tity, and condition for use.The scope of the services rendered depends on the individual hos- eral hospitals, insteadof individual computer pital.Typically, they include the following: installations. Although someindividualhospitalswill 1. Receiving, storing, contraing inventory, quickly realize substantiallaborsavings from the and distributing sterile and unsterile supplies pur- installation of computers,especially in business chased from manufacturers, including disposable departments, the health serviceindustry as a items and commercially prepared! intravenous whole is not likely to realizesignificant net sav- and external solutions. ings before 1970.As 1975 approaches,savings 2. Collecting, cleaning, sterilizing and other in manpower may becomesubstantialin clini- processing, and redistributing of reusable instru- cal laboratory, medicalrecords, dietary and other ments and supplies, such as surgical gloves, departmentsas well as the businessdepartment. needles and syringes, catheters, and treatment This is unlikely to cause layoffsof hospital per- trays or sets used by the medical, surgical, and sonnel, considering the assuredgrowth of de- obstetrical departments. mand for hospital beds.The effect will be to 3. Maintaining and issuing portable apparatus increase the number of patientswho can be serv- such as resuscitators, oxygen tents, wheelchairs, iced with existing personnel,reducing the neces- orthopedic appliances, surgical and emergency sity for expansion of staffs in somedepartments. equipment, and providing instruction in use of Other costs, as well as labor costs,will be held such apparatus and equipment. down and levels of quality in patient carewill Central service is attached to the division of rise. nursing in many hospitals; in others the central Apart from the effects on manpowerneeds and service supervisor reports either to the chief of costs and quality of patient careresulting from pharmacy, the head of the operating room, or actual adoption of the computer,the spread of to an assistant hospital administratlr. A grow- interest in its possible adoption islikely to have ing trend is toward consolidating the central some effect on the amountof manpower needed service unit with other services (the hospital in hospitals because of feasibilitystudies con- laundry, the hospital pharmacy, and general ducted in many hospitals during the yearsahead. stores)to form a central service department Hospital administrators learn from thesestudies headed by an assistant administrator. not only how computers maybe used, but also The staff of the central service unit usually how fairly simple improvements in records, pro- ranges in size from 5 employees in hospitalswith cedures, or equipment can bring about substan- 50 to 99 beds to 32 employees or more in large tial gains in efficiency. hospitals.It usually includes one or more registered nurses and practical nurses; the remain- Developments Affecting Hospital Supply and ing staff typically consists of assistants and mes- sengers trained on the job.In some hospitals, Service volunteers help in this unit. Another major category in which technologi- In most hospitals, central service is headed by cal developments in health service establishments a registered nurse,but opinions differ among are occurring ishospital supply and service. hospital experts on whether this is necessary. A The hospital departments concerned include: trend is growing toward heading the service with Pharmacy, central service (processing of medical an experienced manager nottrained as a nurse, and surgical supplies and equipment), laundry, but to have a professional nurse as a memberof housekeeping, and general building maintenance. the advisory committee on central service. 53 ,...M11,11111111.,

The development of specialized, centralized shown that a large proportion of nursing time units for service of medical and surgical supplies ( about one-sixth, according to one study)is and equipment is a major step toward improved spent maintaining records concerned with medi- hospital management, reducing labor require- cations and preparing single doses.Aside from ments through greater efficiencyin processing the high cost of this system, it has numerous se- supplies. Up to a decade or so ago, central serv- rious imperfections, including the possibility of ice did not exist as a separate service in most medication errors, lack of flexibility in dosage hospitals. Where it is not separate, the steriliza- patterns, and imperfect summary records for at- tion and other processing work is done in the tending physicians to use." individual nursing units.Sterilization equip- Two approaches are being taken toward rem- ment tends to be duplicated on manyhospital edying this situation.One is the use of a spe- floors; this means that nursing personnel, whose cially developed system involving a mechanized primary job should be patient care, are fre- drug station and specially designed drug cart quently distracted by needs for processing sup- at each nurse station, which has built-in controls plies or equipment. to assure that errors in administering medication A typical example of laborsavings from adop- are avoided and that costs of drugs arecharged tion of the central service principle is shownby to the patient.It uses electronic locking mech- a study over aperiod of years .)f central service anisms and addressograph plates, on principles activities in one general hospital.In 1955, the resembling those of vending machines.The preparationofacatheterizationsetup was other approach involves use of medications pack- carried out, as needed, by a registered nurse in a aged for single dose use, in strips, or otherwise. nursing unit.This involved 18 workload items, One of the obstacles to the spread of the mech 4r of which were unsterile, and took61/2 minutes. anized system is that some States have legal pro- Beginning in 1956, the same setup was prepared hibitions against the use of mechanical means in advance, by a nurse aide in central service. for dispensing drugs.Legal and professional re- The procedure then involved 13 items, 2 of quirements concerning the personal participation which were unsterile, and took less than 1 min- of the pharmacist in dispensing drugs to patients ute.Today a catheterization setup can be pur- are also considered in some instances tobe bar- chased in completely prepackaged, sterile form, riers retarding growth of single dose packaging for one time use, at reasonable cost.3'In this of medications. form it involves practically no labor requirements Improvements in hospital laundry techniques inside the hospital.Currently, central service promise significant reductions in manpower re- functions are undergoing drastic changes in quirements.Whether or not laundry service is many hospitals because' of thespreading use of included in the administrative control which such "disposables."This trend is resulting in supervises central service in a particular hospital, significant further reductions in man-hour re- it is usually situated near central service in the quirements.The extent and significance of the hospital building.This is convenient, because, adoption of disposables is discussed more fully in like surgical supplies, some hospital linens must a later section. be sterilized after laundering.Most work done Improvenzents inhospital pharmacy serv- in the hospital laundry, however, does not require ice are being introdaccd to overcooze inade- cleanliness higher than that maintained in hotel quacies in conventional methods of dispensing linen supply. drugs to hospital inpatients.The older and still Many hospital laundries have been keeping prevalent method requires nursing personnel to up with the steady pace of improvementin equip- measure medications for patients from bulkpack- ment used in the laundry industry.In so doing, ages supplied by the pharmacy.Studies have hospitals have realized noticeable gains in labor-

" Josephine A. Jones, Progress in Patient Care Pro- " Mark S. Blumberg, "Packaging of Hospital Medi- cedures (Evanston,Ill.:American Hospital Supply cation," American Journal of Hospital Pharmacy, June Corp., 1965), p. 13. 1962.

54 saving.Many examples can be found, but only The preassembled meals are delivered immedi- one will be cited here.At Mercy Hospital, Mus- ately to patients, often by dietary department kegon, Mich., it was found that the replacement workers, minimizing the time required for pa- of two washers and tw' extractors by two new tient feeding on the part of nursing personnel. model washer-extractors made unnecessary the Many of the new systems replace arrangements work of three employees (who were thereupon under which bulk-cooked food are delivered to transferred to other departments) even though nursing units.The older system requires nurs- a substantial increase in thepatient care working personnel to spend much time preparing and load occurred soon after the new equipment was serving food trays. installed. Improvements in kitchen and serving equip- Currently under development is a continuous ment have not only made it possible to shift duties conveyor washing-drying-ironing systemsaid to from nursing to kitchen personnel but have re- promise spectacular gains in man-hours.Ad- duced manpower requirements in the kitchen. vances in automatic mark reading,inspecting, In St. Luke's Hospital, St. Paul, Minn., for folding, sorting, and bundling are also ex- example, a changeover to new equipment to pected."But the equipment will be relatively handle an increase in patient load was made expensive, and may be beyond the reach of small during an expansion of hospital facilities; man- hospitals. power requirements in the dietary department A trend that seems to be gaining momentum increased only 3 percent, while meals served at present, especially among smallhospitals, is went up over 20 percent.' the purchase of services from outside laundries Other innovations that have been significant on contract.This movement may accelerate if in some hospitals have involved increased reliance contractors adopt the new automated equipment on food preparation outside the hospital by con- and are thereby enabled to perform services tracted services.One type of service is the same atlowercostthanthehospital'slaundry as some airlines use.Microwave ovens are in- department. stalled in the hospital kitchen to heat the pre- Because of these trends toward laborsaving cooked frozen dishes delivered by the contractor. machinery and outside contracting, and a possi- In many hospitals, automatic food vending areas bility that use of disposable bed linens ( not used have taken over 1. lit of the load of food prepara- much up to now) and other linen items will tion, providing snacks or light dishes for hospi- grow, the number of laundry workers in hospitals tal personnel, guests, and ambulatory patients. may decline substantially in the future.But in There has been a revolution in the dietary de- all likelihood, the effects will be felt slowly and partment's formula room, based on the purchas- gradually over the next 10 to 20 years. ability of prefilled disposable infant nursing bottles.In Akron Children's Hospital, for example, The Dietary Service.Technological develop- the use of these bottles in place of preparing ments in food preparation and service are re- formulas on the premises and cleaning and filling sultinginsubstantiallaborsavingsaffecting baby bottles has made it possible to transfer three kitchen work and food delivery.Kitchens are employees to other work. being designed with new equipment, often all- Hospital feeding involves many problems as- electric, including improved ranges, refrigerators, sociated with special dietary needs of patients, conveyor units for assembling trays, and dumb- "withholds,"andchangesinfoodmenus. waiters and carts for delivering trays to nursing Many hospitals are finding that the great mass of units.Carts are equipped with hot compart- paperwork required to operate dietary departments for trays holding the main course and ments can be reduced by improved data process- cold compartments for salad anc: dessert dishes. ing methods.Several hospitals are enlisting the

" Mark S. Blumberg, "New Hospital Laundry Tech- D. R. Sohlstrom and R. Sudeith, "Technological niques Are Coming," Modern Hospital, May 1962, p. Change in a Hospital," Employment Service Review, 14. May 19R5, pp. 25-26.

55 services of the electronic computer to plan menus (or several limes by a single patient) are called and analyze iliventoi disposables ; products reprocessed for multiple- patient use, in the traditional way, are known as The SwitchtoDisposables.Tremendous reusables. changes are being made in the materials used to Earlier discussion has referred to disposable make the everyday articles consumed in hospitals. catheter setups and formula-filled baby bottles. Products meant to be thrown away after one These are only a few of the items currently being usemade of paper, plastics, and other inexpen- used in disposable form by some hospitals, and sive materialsare taking the place of many by no means the most important. A full list, as items that require cleaning, sterilizing, or other presented in exhibit 4, shows that disposable items reprocessing.Products designed for use one time are available to take the place of many important

EXHIBIT4DISPOSABLE PRODUCTS USED IN HEALTH FACILITIES " Central supply Culture tubes Intravenous therapy arm- Cytology specimen collection boards Sterilization bags sets Medical collection bags Sterilization wraps Funnels and beakers Medicine cups Stopcocks Micro hematocrit tubes Medicine droppers Petri dishes Oxygen canopies Food service Pipettes Razors Aprons Specimen cups Sheets and pillowcases Cups Sputum cups Slippers Flatware Urine specimen bottles Straws, drinking Napkins Wintrobe tubes Tubes for feeding, enema, intravenous, fluid, oxygen, Plates Sandwich bags Obstretrics stomach, and urinary Service sets for isolation cases drainage Breast pads Water carafes Tray covers Diapers Surgery General Nurser system with formula Tape measure, newborn Anesthesia airways Umbilical clamps Ashtrays Caps Hypodermic needles Gloves (surgical, examination) Patient Intravenous administration Masks sets Microtome blades Basins Mortuary packs Surgical binders Bathmats Soap dishes Surgical blades Syringes Bedpan covers Bed underpads Surgical operating drapes Tongue blades Surgical shoe covers Towels Blood administration and Surgical tubing a collection sets n. Thumb forceps Suture cutter Urinal covers Catheters (urethral, Foley) Washcloths Cleaning cloths Trays Waste collection bags Cotton-tipped applicators Wipes Denture cups Exchange transfusion Drinking glass covers Foley catheter Laboratory Enema administration sets Irrigation (some prefilled with enema Lumbar puncture Animal cages solution) Spinal anesthesia Basal metabolism mouthpiece Examination gowns Surgical preparation Blood lancets Head halters for cervical Suture removal Blood specimen collection sets traction Urethral catheter Cover slips for microscopy Identification products Venous pressure

Source: American Medical Association.Report of the Commissionon the Cost of Medical Care, vol. III (Chicago: American Medical Association, 1964), p. 73.

56 ious types of hypodermicneedles and some other products handled andprocessed by thecentral major products, are shown intable 6. supply, pharmacy, laundry,and dietary departments.They represent an important sourceof TABLE 6. SHORT-TERMNON-FEDERAL HOSPI- reductionsin the need forlabor in such TALS PURCHASE OFSELECTED DISPOSABLE departments. PRODUCTS, 1958, 1960, AND 1962 There are several reasonsfor the success of [Percent] disposables: 1. Patient Saf.,ty.Theopportunity for cross- Product 1958 1960 1962 infection through reuse ofarticles that have been improperly is virtually processed and sterilized 11.7 66.3 88. 0 disposables often Hypodermic needles eliminated.Studies show that Hypodermic syringes, without provide articles for patient carethat are closer needles (1) 26.5 43. 0 to sterile and morefree of pyrogens(fever- Hypodermic syringes, with 1 27.7 78. 0 inducing substances formedby a microorgan- needles 19. processed reusables. Hypodermic syringe, medicated ism), than traditionally cartridge and needle (1) 34.9 46. 0 include 2. PatientComfort.Disposables Sterile surgical blades (1) 69.9 85. 0 items that cause less painand discomfort than Plastic tubes 78.7 88.0 100. 0 their reusable counterparts.Needles used for Surgical gloves (1) 38.8 50. 0 21.7 42. 0 injection one time are sharper,and cause less Plastic examining gloves (1) pain, on the average,than those which are re- used, even if resharpened.Disposable catheters 1 Not available. SOURCE: Armbuster, Moore, andMacKerell, Inc. with the same insidediameters as reusable rub- smaller outer cir- ber catheters usually have a The rapid progress in adoptionof these items cumference, and therefore bringless discomfort reflects readiness on the part of many super- to the patient. visors in central supply to acceptdisposables. 3. Efficiency andEconomy. -- Personnel do The trend toward disposableshas not been not have to spendtime in rinsing, soaking, count- equally rapid in the laundry anddietary de- items to ing, packaging, or other steps to restore partments.Use of disposable urderpadsfor useable condition.This is particularly impor- beds is widespread, but otherwise mostbed linens tant in saving the timeof nurses, technicians, and still in use are of standard textilematerials.Rel- other scarce olrsonnel.In addition, economies atively few hospitals are usingplastic dishes, but result from eliminating the costof materials used it is generally expected thattheir use will spread, in reprocessing (cleaners,sterile solutions, pow- especially because of advantagesof disposable der for surgical gloves, etc.) . dishes in reducing cross-infection.Ultimately, hospital dietary departments may eveninstall affected by Among the most important items equipment that will stamp outdishes from plas- the switch to disposablesisthe hypodermic tic sheets, producing cupsand plates de- needle, which requires much laborin cleaning, mand." '11 sterilizing, and sharpening if reusables areused. More than one-half billion proceduresrequiring Materials Handling and Storage.In practi- the use of a sterile hypodermic needle were per- cally every sizable hospitalthereisconstant formed in the Nation's hospitals during1963, movement of thousandsof objects throughoutthe and over 60 percent of the needlesused were of day.Steriledressings,cleanedinstruments, medications, meals a disposable type.Another important category packaged disposable products, It is be- consists of surgical trays and setups. at Mark A. Freedman, "Unknown Usage Trends Cre- lieved that nearly half of the surgical traysused ate Hazards in HospitalDesign," Hospitals, journal of in 1963 were of the disposable type.Estimates the American HospitalAssociation, December 1, 1964, on the pace of spreadof disposables, among var- p. 106-108. 57 244-295 0--437---5 a

mai

"Instant dishes" are the product of this device.Dishes are formed from large sheets of plastic, heated until it is moldable, then vacuum-formed in the shape desired. on trays, clean linen,and many other items Such improved gear and systems not only pro- needed by patients and hospital staff move vide greater capacity and convenience for mov- steadily from the service departments to nursing ing materials, but in some instances produce units and treatment areas.In the opposite di- substantial and directly evident savings in time rection go the used instruments and meal trays, for nurses and other personnel.For example, soiled linen, and trosh, back to be cleaned, proc- the modern vertical conveyor (replacing the essed, or disposed of. dumbwaiter) is equipped to eject a tray or bas- This constant flow requires equipment of all ket to a roller track at the designated floor where kinds for materials handling.In older hospital it can be stored and picked up at any convenient buildings standard carts, elevators, dumbwaiters, time. The modern pneumatic tube system elim- laundry chutes, and conventional airtube sys- inates the need for employees working at a cen- tems are used.Newly built and renovated hos- tral transfer station to redirect carrier cylinders, pitals use specially designed carts, automatic as required inconventional systems.Carriers tube systems, and horizontal and vertical con- can now move directly,automatically, from or- veyor systems.(See drawing page 61.) igin to final destination station.In hospitals

58 that have shifted from old to modernairtube portant in regard to trucks carrying soiled or systems, the employees who haddone this cen- contaminated materials.In addition, the per- tral dispatching work have becomeavailable sonnel who previously had to push the trucks for other jobs. will be freed for other duties.'" A hospital consultant who hasemphasized the need for improved materials handling concepts Communications and Maintenance. Various in the design of hospitals, has beenresponsible new methods of communications arebeing intro- for several innovations in supply movementand duced into hospitals, bringing improved service storage.Among them are the "Nurserver", and and care to patients and saving staff effort. new systems forusing hospital carts based on Perhaps the most useful, widespread improve- the fact that patient care requirementsfor linens ment is the bedside intercom with whichpatients and certain other supplies are predictable.The can communicatewithnurses.Thishelps "Nurserver" is a two-way storage cabinetin- nurses avoid unnecessary trips, whilepatients get stalled in every patient room.It has one set of improved service.In many hospitals, systems two doors on the corridorside, another set inside are being installed forpocket-size pagers, by the room.Half of the cabinet is for clean, ster- which nurses, doctors, and other hospital staff ile objects, the other for soiled objects.These who must be on call (emergency aide, mainte- cabinets permit routine supplying ofpatient nance engineer, security guard, etc.)can be rooms with standardquantities of linens, some reached even when they are not at their usual medications, and other supplies, and thetaking stations. away of used materials,without requiring the Closed-circuit TV is being installed in some supply staff to leave the corridor.Supply of hospitals and is used in a variety of ways : To patient rooms is done from the corridorside, re- permit nurses to monitor disturbed or other pa- lying on use of standardized prestockedlinen tients who should be under frequent visual ob- and other supply carts.One or more carts is servation, to enable visiting children to talk to a sent completely stocked to everynursing unit parent who cannot be visited, to help inteaching medical and other staff, and for other purposes. daily.The carts are returned to the service departments for restocking nightly.This elimi- Another development being adopted to facili- moni- nates work by the nursing unitpersonnel in com- tate communication is the remote control puting what supplies need to be replenished from toring systems for control of temperature in Improve- laundry or central supply sources.42 operating rooms and other areas." The same type of supply cart is used inplace ments in communication are particularlyim- of rigid shelving to provide storage spacein cen- portant in relation to engineering maintenance Systems have been developed tral supply areas.This provides advantages in in large hospitals. mobility and flexibility within the area and helps which permit one man, seated at a control center, reduce the work in keeping stocks complete. to monitor or control temperatures and humidity A further development in the use of these and to check on fire hazards, security, and other carts is being introduced in aCalifornia hos- conditions, in a large number o buildings or engineer pitalan automatic cart transportation system. areas. At the console where the control sits are indicators providing the control informa- This system makes it possible to lift and move tion he needs and a TV-type screen on which he them to a carts on a conveyor or track, bringing can project schematic diagramsfor important It elim- receiving station as preselected by dial. mechanical systems in all buildings for guidance inates traffic of trucks along corridors and in in his control decisions.Some conditions, in- elevators, where the trucks compete for space volving threatened or actual danger of fire or with wheeled and ambulatory patients and hospital visitors and staff.This is particularly im- 43 "New Conveyor System Moves All Supplies," Modern Hospital, February 1965, p. 95. " Profile on Gordon Friesen," Hospital Administra- " "Hospital Communications," Architectural Record, tion in Canada, October 1961. March 1962, p. 181. breakdown of vital mechanical systems(boilers, nance has beenachieved by adoption of improved Efficiency in cleaning hos- air conditioning, refrigeration,etc.)will turn cleaning equipment. installa- on loud alarms, pital floors has improved through the These monitoring systems notonly increase tion of centrally powered vacuumcleaning sys- automatic floor scrubbers safety in the large hospitals inwhich they are tems and use of large installed, but also save moneyby increasing and polishers.The latter are particularly effec- which tile efficiency in consumption offuel and electricity tive in many of the newer hospitals in There is also a growing and by reducing labor costsfor building main- flooring is widely used. trend toward carpeted floors in hospitals, notonly tenance.Substantial laborsavings have resulted Some from their installation.For example, at Mem- in corridors, but even in patients' rooms. be phis Baptist Memorial Hospital 8jobs were elim- studies have shown the carpeted floors can inated, freeing men for otherduties, when an kept to higher standards of asepsis(using vac- early version of the system wasadopted several uum cleaning,shampooing, and cleaning with than floors covered by years ago to control10 buildings. More recently, disinfectant solutions) Moreover, the amount of after the hospital expanded tobecome a scattered vinyl asbestos tile. complex of 19 buildings (including asatellite man-hours needed to clean carpetedfloors ap- unit located a mile away from themain center) , pear to be slightlylower than the amount to the maintenance monitoring system was ex- clean tile floors. panded and improved.The chief engineer of this hospital has estimated thathe would have Improvements in the Functioning andDesign staff if the had to add 16 men to his 70-man of Health Facilities improved system had not been installed.45 One of the recent trends in smallerhospitals Technological advances in healthservice fa- engineering has been toward contracting out cilities differ widely in nature, rangingfrom the This has always been the maintenance services. direct application of new scientificdiscoveries to practice in servicing some equipment,especially adaptations of materials, equipment, ortech- equipment if manufacturers supplying complex niques developed originally for otherindustries. repair services. also provide maintenance and Among the most important categoriesof inno- complete The new trend is toward the use of a vations are certain developments notalways by con- package of maintenance services offered thought of as technological in nature,but cer- available to work tractors who have staffs readily tainly so considered in relation to thehealth serv- utilities, eliminating the need for on all basic ice industry : Improvements in thedesign of phy- maintenance workers in the hospital's ownwork sical structures, in organization forpatient care, force. and in management methods. hospi- Use of a contractor's workers instead of Proposed improvements in the designof hos- tal staff is also a growing trend inhospital house- pitals' physical structures are oftenassociated maintenance.This developmentis keeping with proposals for changes in theirfunctional partly the result of the growth of businessfirms cleanup structure.This is not only evident in plans de- which provide floor cleaning and other but also services to office buildings, schools, andother veloped for many individual hospitals, planners In many instances, these firms in the general trend of thought among large structures. Both kinds of improve- offer cleaning services at rates which savehospi- in the hospital field. tals substantial money and enable them to reduce ment efforts are stimulated bythe problems and their responsibilities in employingmaintenance opportunities that result from theavailability of forces. new kinds ofequipment and by the new tech- Apart from this trend, some savings in man- niques constantly being introducedin hospital power requirementsin housekeeping mainte- activities.Innovations in nursing care, in surgical techniques, and in the handlingof supplies "HospitalEngineerMonitors 19Buildings," developments that have impelled Modern Hospital, April 1964. are among the

60 Contaminated supplies trayveyor Sterile supplies trayveyor-7 Hot food and soiled dish trayveyor t---

An integrated automatic transportation systememploys the concept of separate units to transport sterile and contaminated supplies.This is a central "core" type installation. changes in the physical and organizational de- power have received particular attention, since sign of hospitals. payrolls represent the major proportion of hospital costs.The nurse shortage, as well as the Research and Planning on Hospital Improve- basic importance of quality of nursing care, has ment. Many of the features of organizational led to many studies and programs for improving and physical arrangements in today's health fa- the supervision and utilization of nursing perrem- cilities owe their origin to reforms initiated by nel.These include shifting routine duties from Florence Nightingale in the middle of the last staff nurses to auxiliary workers, and improving century. Since then, many changes in organiza- the physical arrangements of nursing units. tional and structural design have occurred, re- The scope of activities related to planning and flecting contributions from the fields of medicine, research on hospital administration is very broad. nursing, hospital administration, and architec- It will be possible here to cite only a few develop- ture, but up to recently the changes have taken ments of special interest from the standpoint of place at a fairly slow pace. manpower implications. Efforts at improving the organizational and One important development has been the ap- physical characteristics of health service estab- pearance of agencies that provide groupsof in- lishments were stepped up after World War II. dividual hospitals with research guidance, oper- The Hill-Burton program, established in 1946 ating yardsticks, and other services aimed at rais- to provide Federal financial aid in the construc- ing staff efficiency and quality of performance. tion of hospitals, stimulated new thinking on Some are local groups, others operate on a re- hospital architecture.An amendment to the gional or nationwide basis.The Commission law in 1950 recognized that the provision of forAdministrative Services inHospitals structures and beds was not sufficient to assure (CASH), organized in 1963, provides a group of that adequate hospital and clinic services were more than 80 hospitals located in southernCal- furnished, and authorized research, experiments, ifornia with managemerengineering services, and demonstrations toward improving the serv- paid for by a small nivitthly subscription fee ices provided by hospitals.Funds under this based on the size of the hospital.The first ma- program were not made available until 1956, jor effort of CASH was a study of nursing serv- but since then a number of projects related to ice, which culminated in a program offering the improvement of hospital utilization, admin- consultant guidance in individual hospitals for istration, equipment, and building design have raising efficiency in nursing care.It is reported been carried out under the sponsorship of the that this program has brought about substantial U.S. Public Health Service.Participating in reductions in number of man-hours required per these projects have been hospitals, universities, patientdayintheparticipatinghospitals. professional associations, and other qualified CASH plans to set up similar programs to cover groups and individuals.Meanwhile, local plan- other areas of the hospital.46 ning councils, medical groups, groups of archi- Another agency, which is sponsored by the tects, hospital administrators, Blue Cross offi- American Hospital Association, furnishes yard- cials, and consultants have been acting on their stick information on productivity and costs to own to plan the improvement of healthfacilities help hospitals assess their performance.The in their areas.In 1948 a national profes- program is called Hospital Administrative Serv- sional organization of hospital consultants was ices (HAS). It services roughly 1,000 hospitals established. located throughout the Nation, providing highly In connection with programs for building hos- detailed data covering activities in nearly all hospitals during the past 15 years, much effort has pital departments.The basic reports give aver- been devoted to research, not only on materials, equipment, and building design, but also on " Robert H. Edgecumbe, "The CASH Approach toHospital Management Engineering,"Hospitals, hospital organizations and management. Meth- Journal of the American Hospital Association, March ods of improving efficiency in the use of man- 16, 1965.

62 ages and ranges for along list of items (such ac Growth of the community approach toward meals prepared per man-hour, laundry pounds planning and coordination of health and related per man-hour, nursingman-hours per patient facilities and services has been aided byprovi- sions added to the Hill-Burton program in1964, day). Special studies are also carried out for hospitalsorgroupsrequestinganalytical which authorize grants to defray half of the costs information. of community planning agencies. A somewhat different service is offered by the Functional Concepts and Structural Design Commission on Professional and Hospital Activi- of Hospitals. A leading architect andhospital ties (CPHA) , directed by Dr. Virgil N.Slee at planner has made these observations about recent Ann Arbor, Mich.This group, which is spon- trends in architectural planning of patient care associa- sored by several hospital and medical facilities : 47 tions, supplies hospitals with a subscription serv- with The change from the era of long ice for processing their medical records, and stays, bed rest, and indigent patients to yardsticks needed for professional auditingof the present era of short stays, early am- medical care.The program is referred to as the bulation, and third-party payers has Professional Activity Study ( PAS) .It includes brought equally great changes in con- providing guidance to the hospital in the training cepts of patient accommodations.The of medicai records librarians in PASprocedures, large open ward with continual visual supervision by the nurse in charge, and mechanical processing of abstracts of medical a small cluster ofutilities for use by staff reports, and preparation ofperiodic reports and patients, have given way to the in- printed by the computer which summarizethe dividual room with lavatory, toilet, and individual hospital's data on professional care of sometimes shower.Visual supervision patients.These reports may then be compared, has been partly relinquished to electronic supervision...Importance of in reference to items of particular concern tothe travel paths and distance have inhospital, with averages and ranges shown by creased, so many plans have been devel- groups of comparable hospitals.Some 300 hos- oped with the aim of shortening total pitals in the Midwest and Canada are participat- distances traveled when caring for pa- ing in this yardstick program, which emphasizes tients. factors such as lengtxL of hospital stays, and usage Many planners have emphasized the need for of X-rays, laboratory tests, surgical operating close study of movements of staff, patients,and procedures, or drugs, in hospital treatment of supplies in designing hospitals. The innovations specific conditions. which hospital consultants have introducedhave The construction and improvement of private included not only improved materials handling nonprofit hospitals usually needs the support of equipment, but also improved floor layouts and the loca.. community.In recent years, there has other features to maximize the time nurses can been a growing trend toward organized com- give to direct patient care.In many of the hos- munity participation in the planning of hospitals. pitals they have helped to design, floor layouts This approach has emphasized identification of either omit or deemphasize the "nursing station," the unmet needs for hospital care in the com- a feature of conventionallydesigned nursing munity as a whole, and especially avoidance of units.In order to release nurses from incidental overlaps in plans for new hospital projects, that paperwork, supply tasks or related routine, and might result from providing expensive, seldom to move them closer to thebedside, these hos- used equipment already available in existing pitals utilize a "ward se, rotary" to handle mes- hospitals.When overlaps occur, the community sages and similar work at asmall administra- suffers from a waste of capital funds on outlays tion center, and a supply technician at a supply that could have been used to get equipment or center, on each nursing floor.Pneumatic tubes facilities actually needed.Unnecessarily high 47 Robert J. Pelletier, "Search For A Therapeutic overhead costs and waste in the use of specialized Environment," Hospitals, Journal of the American Hos- manpower also result when excesscapacity exists. pital Association, February 1, 1965. 63 . X

...1041rolt

Circular nursing units reduce steps of hospital staff.The distance from the hub to any patient's room is less than 10 feet.

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This shows an exterior view of two such units. and facilities for charting are provided in each three-person nursing team concept, in which ap- patient's room.In many of these hospitals each propriate duties are divided between the profes- staff nurse is supplied with a shortwave radio sional nurse ( who heads the team) , a licensed receiver so she can be located at any time as she practical nurse, and a nurse aide. With this con- makes the rounds of patient rooms. The func- cept in use, the hospital may achieveoptimum tioning and design of a nursing unit in some utilization of the skills of personnel at each level. modern hospitals are based on the developing Emphasis on reducing the amount of walking

64 that nurses must do has led other architects to- of his personal needs, including administering his ward the use of circular nursing units.Some own medication.In these units fewer hospital studies show advantages in this floor plan from personnel are needed, so hospital costs to the reducing travel paths and providing better visual patient are lower. observation for nurses, but the circular plan is A related development is the spread of "half- sometimes criticized as lacking flexibility and ef- way houses" for recovering mental patients.Pa- ficiency in other respects. tients living in these residences may take outside In a category by itself is the Atomedic hospi- jobs and otherwise start to resume normal self- tal, which provides comprehensive facilities for care, with assurance that trained personnel are up to 40 patients in a unique circular structure. available to give them specialized help if they This completely new kind of hospital is built of need it. aluminum panels and other light structural ele- The development of such new approaches to ments that allow for easy transportation, rapid patient care, which recognize the wide range of assembly, and minimum maintenance.The cir- distinct needs patients may have at different cular shape accommodates a central activity core times, is associated with growing acceptance of surounded by 22 rooms for patients.Basic pa- the principleof"progressive patientcare." tient care equipment and suppliessterilizers, Architectural designs growing out of this con- X-rays,monitoringequipment,medication, cept give examples of how the forms of patient linens, etc.are kept in the central core.The care facilities are molded to follow their function. Atomedic hospital has no space or staff for food The concept of progressive patient care calls preparation or laundering; these services are sup- for the "tailoring of hospital services to meet the plied from the outside.Thus far three Atomedic patient's needs, (to place) the right patient in hospitals have been built, one in Montgomery, the right bed, with the right services, at the right Ala., the other at the 1964-65 World's Fair in time. "" The range of approaches includes: New York City, and one in Mexico.The de- 1. Intensive care.For critically and seriously sign is particularly well adapted to the concept ill patients who arc unable to communicate their of a small satellite hospital which is autonomous needs or who require continuous nursing care for most types of general patient care, but de- and close observation. pendent on a centrally located large hospital for 2. Intermediate nursing care.For (a) pa- specialized services. tients requiring a moderate amount of nursing An important trend in nursing ( are plans has care, some of whom may be ambulatory or able been the development of intensive care units in to participate in caring for themselves; (b) ter- hospitals for postoperative patients or other pa- minally ill patients. tients who may be in critical condition, such as 3. Self-care.Hospital or nursing home care victims of coronary attacks.In many hospitals these units are set up in the form of small open for ambulatory and self-sufficient persons who re- wards in which patients can be watched con- quire mainly diagnostic, therapeutic, or constantly by nurses on duty.Other types of inten- valescent services. sive care units provide greater privacy for the 4. Long-term care.Hospital or nursing home patient by the use of partitions separating in- care for patients requiring prolonged medical or dividual patient areas, without diminishing op- nursing care, rehabilitative services, or aid in portunities for close supervision by nurses. learning to adjust to disability. At the opposite extreme from intensive nurs- 5. Home care.For persons who can be ade- ing care units are quarters designed for ambula- quately cared for in the home through the ex- tory patients.In such units, skilled nursing care tension of certain hospital services. may be at a minimum.In a new unit at Monte- fibre Hospital in New York City, for example, " Elements of Progressive Patient Care (Washing- ton:U.S. Department of Health, Education, and meals are served to the ambulatory patient in the Welfare, Public Health Service, September 1962), PHS cafeteria, and the patient is responsible for most Publication 930-Cl.

65 6. Outpatient care.Forambulatory patients X-ray and drilling equipment, manydentists living outside the hospital whoneed diagnostic, are making use of theservices of dental hygienists curative, preventive, andrehabilitative services. who administer some dental procedures in treating patients, and of trained dental assistantswho Thesedifferentapproaches may involve handle administrative duties. merely architectural modificationin a single hospital structure of modest size, orthey may Effect of Design Changes on Manpower Re- call for differentiation ofstructures--either to a quirements. The design and materials used in limited extent or in large-scale completedevel- the construction of a health facilitycontinue to opments such as areenvisaged in a modern re- influence the size and characteristics of the fa- gional medical center.(See drawing.) cility's staff for many years after it is built.Hos- The expanded use of hospital outpatientde- pital architects are increasingly giving attention partments and emergency roomsby ambulatory to factors which will affectthe need for labor to patients reflects the spread of progressivepatient operate the hospital.For example, some hos- care concepts.Some patients now making use pital designers and builders choose wall and floor of these facilities might have been bedpatients coverings mainly with regard to attractiveness, under past conditions.Others might have gone sound-absorbing characteristics, or effects on to a private physician's office. asepsis.Others pay close attention to the ques- Trends toward physical centralization of ar- tion of ease in cleaning, liecause of its impor- rangements for patient care are alsoevident in tance in ultimatehousekeeping costs and the private medical practice.In the past few years, amount of manpower needed formaintenance. a substantialnumber of physicians have made Plans for new buildings vary from the stand- arrangements for establishingoffices in the hos- point of the buildings' adaptability to future pital building.Here they can treat their private changes in structure.In some hospitals, the patients and have ready access to thehospital's question of flexibility has been a major factor in specialized equipment.Other physicians in pri- architectural decisions on materials and space vate practice try to locatetheir offices in the arrangement.However, many hospitalsare neighborhood of the hospitals on which they have constructed with built-in equipment or other uses staff connections, to assure ready access tothe of space that may be useful or attractive when hospital's specialized equipment. - the hospital is built, but uselessyet difficult to But there are also trends in other directions. alter- 40 years later.In general, it is worth Many physicians now practice withrelatively noting that the future pace of technological less dependence on hospitals. Theproportion of change in the Nation's hospitals will be affected physicians in group practice has been rising by the extent to which hospital structures con- steadily in recent years.Such medical groups tain such features as adequate space for conduits tend to acquire extensive equipment,capable to accommodate extra wiring, oxygen, orother staffs of nursing and technical personnel,and utilities, walls built to allow for expansion or con- to locate in well-designed, autonomousstruc- traction of space units, and avoid building-in tures. The organization, equipment,and related equipment of doubtful permanence. arrangements in the office suites ofphysicians Recent trends in hospital design have varying, in solo or partnership practice are proportion- even conflicting effects onthe amount of man- ately more modest, but are constantly beingim- power needed. Sonic aspectsof the evolution of proved through efficient planning and design. hospital layouts result in an increase in the num- By appropriate use of equipment arid staffin ber of personnel per patient, while others re- his own office, the practitioner of today isable sult in laborsaving.The trend away from the to care for many more patientsin the course of open ward, toward privateand semiprivate a day than waspossible a few decades ago. The rooms, has contributedtoward increasing the same principle has worked togreatly increase personnel needed for nursing care (and inciden- dentists' productivity.In addition to improved tally, increasing costs of hospital care) .On the

66 other hand, improvements in design and equip- emphasis on laborsaving t vident in many new ment resulting in greater working convenience hospital designs.In new hospitals by one de- and shorter walking distance for patient care signer, for example, the ratios of personnel per personnel have contributed toward reducing patient have been substantially lower than the needs for staff.The net effect of changes in the national average of 2.4 for short-term general use of hospital structures up to recently has prob- hospitals.At Holy Cross Hc,spital, San Fernan- ably been to increase demands for personnel per do, Calif., the ratio is 1.7; at Carroll County patient.Eventually, this will be offset by the General Hospital, Westminster, Md., it is 1.4.

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The regional medical center provides a wide spectrum of services and facilities for both the inpatient and outpatient.(Source: Department of Health, Education, and Welfare.) 67 An even lower ratio --lessthan 1.0is reported Since many technological developments are Atomedic hospital, but this re- more likely tobe incorporated in new than in at the circular demand for flects partly the fact thatseveral services at this older hospitals, the Nation's future by the paci. hospital are performed by outside contractors. health manpower will be influenced A renovation and addition toSt. Luke's Hos- at which its hospitals arebeing built or reno- fac- pital, St. Paul, Minn.,completed in 1963, pro- vated.The Bill - Burton program and other building at a high level vides an example ofsignificant savings in the tors have kept hospital But the number of hospital beds amount of manpowerneeded because of the use in recent years. Figures on nursing person - in obsolete hospitals being replacedby new facili- of circular design. proportion of total nel required showed that the newcircular design ties each year is only a small It is difficult to forecast what the units required 22 percentfewer nursing person- hospital beds. 1975, but itis doubtful nel than the rectangular unitsthey replaced.4 turnover will be by whether more than a fourth of theNation's hos- " Dennis R. Sohlstrom and RussellSudeith, "Tech- pital beds at that time will be inhospitals less nological Change in a Hospital," EmploymentService Reviews May 1965. than 10 years old.

68 3 Outlook For Health Manpower, 1965-75

Preceding chapters have dealt with basic char- governments to spend money on health care; acteristics and recent trends affecting health (2) the anticipated nature and composition of facilities and health manpower, and with the health service facilities and activities, which es- changing technology of the health service indus- pecially refers to expected shifts in importance try. This chapter examines the trends and among types of services that will be required-- changes that may be expected during the next e.g., growth in use of nursing home beds in com- decade and their implications.It gives projec- parison with use of hospital beds, increased use tions to 1975 of manpower requirements in the of drugs in treatmeat of mental illness (and major occupation groups, and discusses the consequent reduction in average hospital stays), changes in work content likely to affect particu- etc.;(3) productivity trends, as they vary in lar health occupations.On this foundation, particular kinds of health facilities and activi- some conclusions are drawn concerning efforts tiesthat is, the changes in the ratio of output needed to adjust the supply of health manpower (as measured in units of health service per- to meet future demands. formed) to input (as measured by man-hours), The number and kinds of manpower that will both in the purpose and functioning of the health be required in health service establishments in service industry as a whole, and in specific activities, such as childbirths, appendectomies, laun- future years depend on three interrelated fac- dering, serving meals, and other elements of tors: (1) The total demand for health services workload. that may be expectedwhich will be influenced Expectations regarding trends which reflect to some extent by basic factors such as the birth these three factors are summarized below.They rate and the general health of the population; provide a framework for projecting manpower but more substantially during the next decade requirements among occupation groups in the by the ability and willingness of families and health service industry during the next decade.

69 Expected Trends in Demand and to about 2 million in 1975, from about 1.7 mil: lion in 1965.Most of the increase will occur in Productivity Affecting Health Jobs short-term general hospitals. A sharp increase may be expected in the number of beds in nurs- The following expectations affecting future ing homes, estimated at 500,000 in 1965.By in trends in the amount of manpower required 1975, they will possibly number 1.2 million, ex- the health service industry appear reasonable : ceeding the number of beds in short-term hos- 1. The total demand for health servicesin picals.1 (See chart 6.) hospitals, nursing homes, and other health fa- The growth in number of nursing home beds cilities will increase between 1965 and 1975 at by comparison with hospital beds will be accom- rates moderately higher than those of the recent panied by other changes in the composition of past.This increase will result from rising per- healthfacilities.Outpatient departments of sonal incomes and increased desire for health hospitals will expand.The number of outpa- care on the part of consumers andpublic au- tient visits in hospitals is likely to increase to over thorities, which will lead to higher expenditures 180 million in 1975, 50 million more visits than for health and continued growth of programs in 1965.Hospital home care programs, which such as Medicare and other health programs up to recently had been provided in only a few being provided by new legislation. hospitals, are likely to be established on a wide The rate of increase in the total demand for scaleunder theimpetusoftheMedicare health services (whether expressed in terms of programs. dollars or man - hours) will depend partly on the The increase in the importance of nursing composition of demand among the different homes, hospital outpatient care, home health components, i.e., facilities and services.Activity programs, and related programs of progressive in some facilities may rise rapidly in the next patient care will probably result in substantial yeas or two, but this will not necessarily mean lowering of the average requirement for paid that the trend in total demand for patient care time of employees in the health service industry for the whole decade 1965-75 will rise sharply as a whole to care for cases. Only about afourth above the trend for the past decade. A moderate as much employee time is required to carefor rise over past trends may be expected, reflecting a patient in a nursing home as is needed, on the the start of the Medicare programs, which pro- average, in a short-term general hospital.Cases vide benefits to aged people that are, as yet, lim- handled in home care programs probably will ited in scope and duration.The beginning of also require a relatively low amount of employee operations of the two main parts of the program time.Still less employee time may be needed for in July 1966 and January 1967 may bring a surge patient care in expanded outpatient programs. of applications in some localities by aged people These reductions in man-hour requirements per immediately in need of care ( some of whom had patient case will perhaps be offset by a tempo- been deferring needed surgery or other treat- rary increase in the employee/patient ratiofor ments until they could obtain benefits) .But bed cases handled in short-term general hospitals after the initial group of Medicare applications has been handled, the total demand for health 1 These projections of number of beds in hospitals care during ensuing years will probably be only and nursing homes are based on various sources of information and opinion, including estimates in "Hos- moderately higher than during the past decade- - pitalsRetrospect and Prospect," by John R. Mc- unlesstheMedicare programisexpanded Gibony, M.D. (Hospitals, Journal of the American through new legislation. Hospital Association, October 16, 1964), data from sur- 2. The relative importance of various types of veys by Public Health Service and theAmerican Nurs ing Homes Association, and opinions on the future health care facilities and activities will sho-w effects of Medicare programs expressed by officials of significant shifts between 1965 and 1975.Avail- the Department of Health, Education, and Welfare, able data and informed judgments suggest that the American Hospital Associations and other pro- the total number of hospital beds is likely to grow fessional associations.

70 of "-. -yr ''eo,r".1WA''''

" II

Millions of beds 4

Nursing itornes

Federal hospitals

Short-term hospitals

Psychiatric hospitals Tuberculosis and 0 long-term hospitals 1965 1970 1975

Source. Estimates, U S Department of Labor, Manpower Administration; Office of Manpower Policy, Evaluation, and ftesearch iSeeapp. table c-5.)

early in the decade, but eventually the net effect nursing homes have required that at least one of shifts in the composition of facilities used and professional nurse be on the staff before a home on manpower requirements in the health service is considered as meeting adequate skilled nursing industry is likely to be downward, reversing the standards.This trend is likely to continue. An- trend of the past decade. other important factor working in this direction The increased importance of extended care will be the Medicare programs' requirement that and relatLd facilities for health care, such as nurs- acceptable nursing homes have a full-time pro- ing homes, outpatient care, and home care, will fessional nurse on the staff, and provide 24-hour have significant effects on manpower require- nursing service by professionalor practical ments.In general, they will result in some em- nurses. phasis on needs for professional and other trained Growth and changes in trends relating to the personnelespecially registered and practical character of medical and other health treatment nurses and technicians.They will also provide required by patients will also affect the num- many jobs for aides, attendants, laundry and ber and type of health workers in various ways. dietary workers, including the practically new Past trends in utilization of certain clinical serv- category of "home health aides." ices are shown in table 7.These indicate the The growth in the number of patients in nurs- number of specific categories of services pro- ing homes will be a significant factor contribut- vided, per hospital admission, in 1946, 1954, and ing to a rise in demand for professional and prac- 1961 in a representative sample of short-term tical nurses.During the last few years, an inhospitals.In 1961 diagnostic X-rays per patient creasing number of state authorities that regulate reached a level three times as high as it had been

71 Table 7. TRENDS IN UTILIZATION OFSELECTED ingly improve productivity, lowering man-hour HOSPITAL ITEMS AND SERVICES :RATIOS PER requirements per unit of service provided. Auto- HOSPITAL ADMISSION,1 1946,1954, AND 1961 mation in the clinical. laboratory will spread, reducing the labor requirements for many tests. Ratio of utilization Man-hour requirements per unit will also decline per admission I for X-rays and related diagnostic procedures. I tern The use of disposables and other changes affect- 1946 1954 11961 ing the supply function will not only eliminate certain activities, thereby reducing man-hour re- Different generic drugs 4.675.97 7.30 quirements in central services and in the nursing Laboratory procedures 3 194.32 6.36 units; these changes will be especially significant Diagnostic X-ray procedures. ...1. 50 3. lb 4. 42 to the extent that they relea:,eprofessional nurses .43 Times operating room used 49 .46 for bedside patient care. The rise in awareness among hospitaladministrators of potentialities I In a sample of general hospitals. for payroll and other cost savings arelikely to SOURCE: Report of .ce Commission on Cost ofMedical result also in the installation of improvedinfor- Care, vol. I (Chicago: American MedicalAssociation, mation handling equipment, and adoption of 1964), p. 148. otherproductivity-promotinginnovations,in in 1946. Laboratory procedures doubled in num- functions such as food service, laundry, house- ber during these 15 years, and the numberof keeping, plant maintenance, and office work. drugs administered also rose substantially over Increased use of improved materials handling and communication equipment will result in this period.On the other hand, there was a slight decline in use of the operating room. some productivitygains.Among innovations, Looking toward the future, it seems safe to perhaps the most substantial potential source of predict on the basis of these and similar data that productivity gains that will be translated into the use of X-ray and laboratory staffs and equip- savings in hospital manpower will be the com- ment and the number of newmedications admin- puterbut it is not likely that its effects on pro- istered will continue to rise sharply. ductivity trends in the health service industry It is doubtful that the frequency of use of sur- will be felt significantly until after 1970. be gery will decline, i.e., thatthe 1946-61 trend will The demand for labor in hospitals will also eased, as time goes on, by the tendency of hospital continue.It seems more likely that use of the operating room will increase in the period ahead, administrators to rely on contractors or suppliers in view of an expected rise in the birth trend and outside the hospital to carry out certain func- the development of new advances in surgical tions.These include :Laundry service, house- techniquesin treating cardiovascular impair- cleaning, food service, and processing of business Available data indicate ments, utilization of artificialbody parts and and medir',1 records. hospitals currently other prosthetics, implanting electronicdevices that fewe in 5 percent of and transplanting organs, and other techniques. use outsiu tractors for these services, but by will Demands for specialized professional nurses will 1975 perhaps I in 10 hospitals, if not more, functions be intensified, not only because of the importance rely on outside firms to handle these of improving pro- of nurse specialists as assistants in operating room or parts of them, aF a means procedures, but also because more use of surgical ductivity in hospitals. directly the effect procedures will result in increased need for post- It is not possible to estimate operative nursing care of patients in intensive of productivity improvement resultingfrom tecl workers patient care units. nological change on the future need for 3. Productivity in the health service industry in the health service industry, becauseof lack of How- willimproveduringthedecade1965-75. adequate data for measuring productivity. Changes in technology affecting specific functions ever, the combinedeffects of shifts in demand of hospitals and other health facilities will increas- for patient services and of technologicalimprove. r

ments are broadly reflected in data on the em- million in 1970 and 3.6 million in 1975.This ployee/patient ratio in health facilities.These implies an overall percentage increase of em- figures have been used to aid in projecting total ployment in the health service industry of 33 manpower requirements in the healthservice in- percent from 1965 to 1975.This expected rise dustry in 1975, as described in a note on produc- in employment in the health service industry tivity projections in the Statistical Appendix. will be paralleled by increases in the total num- The projections of manpower requirements are ber of persons engaged in health activities.(See presented in the section that follows. chapter 1 for estimates of the number of persons in health occupations outside of the health service industry as defined here.) Employment in Health Occupations The rate of employment growth will be higher 1965-75 in the first half than in the second half of the decade. Over the whole 10 years, employment Ten years from now, employment in the health growth is likely to occur at an average rate slightly service industry will have expanded greatly. The lower than was experienced during the decade number of jobs that will have to be filled cannot before 1965.As indicated in the appendix note be predicted accurately, but available informa- on productivity, during the past 10 years many tion provides a reasonable basis for outlining factors contributed to an increase in hospital broadly what health manpower requirements are employment at a faster rate than the rise in the likely to be.Estimates of employment(i.e., patient load. During the 10 years that lie ahead, number of filledjobs)in major occupation however, total labor requirements will probably groups in the health serviceindustry in 1965, grow less rapidlymainly because of the growth 1970, and 1975 are presented in table 8.These are based on estimates of1965 employment in major occupation groups previously presented in Table 8. ESTIMATED EMPLOYMENT IN HEALTH table 2. SERVICE INDUSTRY, BY OCCUPATION GROUP, The projections in table 8 should be consid- 1965, 1970, AND 1975 1 ered to represent expected orders of magnitude Number of employ- rather than precise figures.They were devel- ees (thousands) oped by translating into numbers of full-time Occupation group equivalent jobs the effects of expectations regard- 1965 1970 1975 ing growth and change discussed in the previous sectiondemand for health services, productivity and technology, and related factors affecting em- Total employment 2,7003,150 600 ployment in health service establishments. The Administrative and office 500 570 600 expectations were based partly on statistical evi- Dietary personnel 235 265 295 dence, partly on factual data, somewhat on sub- Laundry, housekeeping, and jective judgments.The numbers of jobs pro- maintenance 280 320 345 160 jected on the basis of these expectations, as shown Medical laboratory personnel 100 130 Medical records personnel 35 39 42 in table 8, likewise had to be esJimated by using Nursing personnel 1,2001,415 1,700 a mixture of statistical calculations, expertopin- Pharmacists 11 12 13 ion, and ordinary judgment. The methodology Rehabilitative and other tech- used in deriving the projections is discussed in nicians 120 150 185 52 the Statistical Appendix, which provides a de- X-ray technologists 30 40 All other employees 189 209 208 tailed analysis of concepts and data related to productivity and demand factors. I Employment expressed as full-time equivalents. The projections in table 8 suggest that full- SOURCE: U.S. Department of Labor; Manpower Ad- time equivalent jobs in the health service in- ministration; Office of Manpower Policy, Evaluation, dustry may rise from 2.7 million in 1965 to 3.1 and Research.(See text and Statistical Appendix.)

73 244-295 0-67----6 in relative importance of facilities requiring rela- data limitations, a main obstacle is the factthat tively less labors such as nursing homes and out- persons trained for occupations at low levels of patient services.In some individual types of skill have been used, and undoubtedly willcon- facilities and in some occupations, the number tinue to be, to fill higher level health servicejobs. of jobs will grow more rapidly than ever before, In the nursing personnelcategory, for example, but in others, employment growth will taper off staffing patterns have frequently varied inac- as 1975 approaches. cordance with changing local supply-demand conditions.In many hospitals, duringemer- Expected Differences Among Occupation gencies nurse aides have had to be substituted for Groups practical nurses and licensed practicalnurses have filled in for professionalnurses.In spite The greatest expansion in number of jobs in of efforts to increase the supply of professionally the decade ahead will probably involve the X- trained nurses, itseems likely that such prac- ray and clinical laboratory departments.Jobs in tices will continue.The proportions of profes- these areas are likely to expand twiceas fast as sional and practical nursesamong the total nurs- jobs for health service employees in general, ing personnel group may therefore either decline mainly because of the sharp increases inuse of or increase in prevalence during the next 10 X-ray techniques and clinical laboratory testing years; it is difficult at this point to say which is during the next 10 years.Rising demands for more likely. employees in these departments will be only partly offset by the spread of automated labora- Implications of Technological Changeson the tory equipment and improved X-ray equipment. Job Outlook.The health service industry will Increases in number of jobs for nursing personnel provide expanding work opportunities tomen and rehabilitative and other technicians will also and women at all levels of age and educational be above average, chieflyas a result of improve- attainment, in practically allareas of the coun- ments in surgery and other clinical techniques re- try, during the next decade. A constantly in- quiring intensive care of patients by qualified creasing proportion of jobs in the health field paramedical personnel. will require years of initial training, but this will Employment expansion between 1965 and not mean that opportunities for the less educated 1975 will probably be sloweramong these groups: jobseekers will shrink.Thousands of workers Medical records personnel; dietary personnel, will be needed in jobs calling for low levels of laundry, housekeeping, and maintenanceperson- skill, for a long time to come,as a result of growth nel ;administrative and office personnel; and and of usual labor turnover. The technological pharmacists.The growth in jobs among these changes in hospitals and other health facilities groups will tend to decelerate in the latter half that will have the effect of reducingor eliminat- of the decade, when laborsaving effects ofpro- ing needs for workers with limited skillsare likely ductivity improvements are likely to have notice- to be adopted at a pace slow enough to leave able impacts. time for adjustments in the form of retraining Some of the variations likely to affect employ- programs and transfers to other jobs. ment levels do not show up as clearly between A summarized statement comparing the vari- these broad occupational categoriesas they would ous effects that major technological develop- if comparisons were available for specificoccu- ments will have on health manpower is given in pations within groups.There will be very sharp exhibit 5.Included are laborsaving, labor-de- increases in numbers employed insome individual manding, and job-altering effects.Some of the occupations and significant declines in others in innovations referred to, such as automated labo- various groups. ratory equipment, are already having significant But it would be very difficult to anticipate laborsaving effects. But even though automation trends in employment formore than a few indi- in the laboratory will be spreading rapidly dur- vidual occupations 10 years ahead.Apart from ing the next decade, the still more rapid increase 74 EXHIBIT 5MANPOWER ASPECTS OF MAJOR DEVELOPMLNTS IN HEALTH TECHNOLOGY

Innovation Status of spread in 1965 Expected pace of spread, Manpower effect 1965-75

Automated lab equipment. Some available in most large Rapid. Laborsaving. hospitals and labs. "Disposables". Some used in most hospitals Rapid. Laborsaving. New advanced surgical tech- Some types available in some Moderate. Labor demanding; niques, equipment, etc. large hospitals. changes in skills and jobs. Use of computer. Limited applications, in few Slow until 1970; mod- Laborsaving; some new hospitals. erate, 1970-75. jobs. Management improvement Beginning to spread. Slow until 1970; mod- Laborsaving. programs. erate, 1970-75. Advanced hospital design. Relatively few hospitals. Slow. Laborsaving.

in the volume of laboratory tests required will pace at which pending major innovations will make it unlikely that automation will cause any be introduced appears likely to be moderate laboratory workers to lose their jobs. The other enough.If the existing urgent problem of short- major innovations in patient care facilities that ages of trained health manpower can be solved have laborsaving effects are likely to spread in the next few years, by training and develop- slowly, without materially diminishing the de- ing the large numbers of manpower now needed mand for workers, until perhaps the latter half in traditional health jobs, it should not be hard of the decade. to train as many people in the use of new tech- Since the general effect of innovations in the niques as will be needed by the actual adoption health field is primarily to raise the quality of of innovations, without unusual efforts on the health care, they tend on the whole to increase part of training authorities.Special efforts will the demand for manpower trained in new skills be needed, of course, if programs are adopted rather than reduce the demand for labor. They for spreading certain specific new health tech- not only create new kinds of jobs, but broaden nologies.If a policy decision of the Federal existing jobs by requiring them to incorporate Government were to call for fast action to set new skills.The computer is an example of an up a fully adequate network of kidney dialysis innovation that will have several effects: Broad- centers, for example, throughout the United ening the jobs of laboratory workers, nurses and Stays, top priority would have to be given to a others; bringing a new category of electronic data program for accelerated training of thousands specialists into hospitals; and eventually also ef- of medical and paramedical specialists in arti- fecting substantial laborsavings among clerical ficial kidney machine procedures. and related other groups, which may reduce their proportions among the hospital labor force. Limitations of Projections It is conceivable that new health technologies The rates of growth shown by the projections could.pread at a pace faster than the trained presented here reflect the fact that they are based people needed to man them could be developed, on a specific definition of health manpower. (See but this does not seem likely to occur.The chapter I.)That is, the estimated growth in employment shown for nurses and technicians 2 Source: U.S. Departmentof Labor; Manpowe- Administration; Office of Manpower Policy, Evalua- for example, does not reflect the growth in num- tion, and Research. bers of these workers expected in schools, inde-

75 pendent practice, etc., or other employments ex- is affected by the fact that there are gaps in data cluded from the definition of healthservice em- on certain important areas.Among subjects on ployment used here.Projections of total em- which there is a lack of up-to-date, reliable infor- ployment in the health field oremployment in mation are : The number of skilled care nursing individual occupations based on otherdefinitions homes and their bed capacity and employment : would preably show different rates of change age, description, and rateof replacement of hos- even if they werederived from the same assump- pitalstructures and equipment; quantitative tions and estimating procedures.' data of various kinds on the spread of new tech- Another aspect of the projectionsrelated to nological developments in health facilities; pro- the definition of employment usedwhich should ductivity data, La terms related to trends of out- be borne in mind involves the fact thatonly gov- put per man-hour in hospitals.Such data need ernment-operated hospitals and nursinghomes to be developed.Until they become available, are included here.Other government health projections of the amount and kinds of man- service activities are omitted.Looking to the power needed willcontinue to be very uncertain. future,itispossiblethat new government- Lack of such data is one of the reasons for the sponsored activities for providing healthservices omission from this study of projections forindi- through the employment of disadvantaged per- vidual occupations within the occupation groups. sons may ultimatelyfurnish a significant source Such data are needed for making thekind of of demand for health manpower. Forexample, reliable projections required to plan training pro- home health care services providedby Federal grams for specificoccupations. and State agencies (such as those sponsoredby It should be mentioned that for purposesof the Office of Economic Opportunity) or byother planning manpower development programs,the agencies in local communities, may growin im- projections furnished here need supplementation portance as a result of thechanging pattern of in another important respect.As estimates of health services being brought about by theMedi- employment (full-time equivalent) they show ex- care program and other newdevelopments. In pected increases in the number of jobsthat will addition to such programs, efforts at greater(or need to be filled. To plan training programs,it less) use of the labor of other persons notin- is necessary to anticipate the totalnumber of cluded in employment figures, such ashospital persons (full- andpart-time) who will enter patients and unpaid volunteer workers, mayaf- these jobs in the futurenot only thoseneeded fect future requirements for healthworkers in to fill new jobs, but alsoreplacements for any low-skilled categories. workers who are separated.This requires esti- Aside from the definitions on which the pro- mates which include projectionsof turnover rates jections are based, other limitations shouldbe among variousoccupations, for it will make con- mentioned:!The reliability of the projections siderable difference in an estimate ofthe number of trainees needed in the futureif it is assumed The expected rate of growth in employmentin the that employees will stay in aparticular occupa- "health service industry" indicated by theseprojec- tion 20 years, on the average, ascompared with tions (full-time equivalent) is lower, forexample, than projections of the total number of wage and salary people at sufficiently workers in SIC 80.Medical and Other HealthServ- ing their ability to hire enough (2) training output capacity ofthe ices (see Statistical Appendix). attractive pay) ; employ- health manpower training system(including its capac- It should be noted that the projections of through programs of ment shown in table 8, as theprobable number of ity to attract enough trainees, If assumptions actually filled jobs (in terms of full-timeequivalents) loans, scholarships, and stipends, etc.). are lower, in almost alloccupation groups, than the were made providingfor new programs of operating numbers of workers that would be estimated asthe subsidy payments to hospitals, and forloans, scholar- estimates accord- The figures shown are based on anassumption ships, and other training incentives, need. would have that recent and current trends and conditionsaffecting ing to the concept of "actual" employment approach those that would be health service employment will continue,especially in to be revised, and would of "needs." regard to: (1) Fiscal capacity of the facilities(affect- made according to agreed standards

76 an expectation that they will stay in their jobs A typical example of a rapidly growing 2 years,Sch projections would have to take specialized job is that of the inhalation therapist. info account such factors as expected changes in This occupation has recently been added to the wage levels, or related factors which could induce group of technicians for which training is regu- already trained people to stay on the job or to lated and approved by the American Medical attract those who have previously quit to return Association and associated professional associa- to work.This would raise questions concerning tions.So far, seven schools have been approved which, at present answers, can only be guessed. to give this training.Training for other special- For example, does it seem likely that in the ties (prosthetic technicians and medicalemer- next few years a stepping-up of minimum wage gency technicians)isgivenin some junior protection will occur, completely removing the colleges, as well as in on-the-job courses.5Train- differentials now affecting health serviceem- ing for the other jobs mentioned is available ployees by comparison with other workers?If either in institutional courses or in on-the-job so, a general rise in the wage structure of the training. health service industry would ensue, since a raise Surgical technicians may already be found in in the pay of lower skill categories is likely to re- many hospitals, working together with profes- sult in upward adjustment in the salaries paid sional nurses who are operating-room specialists. to higher skill groups.Labor turnover among These technicians are either licensed practical hospital employees would probably decline, some nurses trained in "scrubbing" or unlicensed per- health service workers who had quit would re- sonnel who "picked up" their skill in the Armed turn to jobs in health facilities, and the number Forces or who were trained on the job in a hos- of persons who will need training in health occu- pital.A division of the American Hospital pations would in this case be smaller than other- Association is currently developing training pro- wise.On the other hand, if increases in mini- grams in a related specialty called surgical tech- mum hourly wages remain insufficient to close nical aide (operating-room technician),under arrangements provided by an on-the-job training the gap between earnings in health service and program contract with the U.S. Department of other industries, it is not likely that they will af- Labor. fect the supply of health manpower significantly. Among new jobs likely to become more and more prominent in the health service field during the next 10 years will be those related to the New and Changing Occupations spread of the electronic computer and the use of other electronic devices.Eventually, many Advances in medical science and health tech- jobs will become available in hospitals for pro- nology are bringing about constant change in gramers, systems analysts, console operators, card- the kinds of work cone by health workers and punch(orother input machine)operators. the emergence of many new jobs.Such changes Many other positions will open up for highly are altering traditional occupational patterns in trained medical electronic technicians and med- the health service industry. ical engineers who will be needed to meet re- Some of the new jobs added ina large num- quirements for on-the-spot availability of special- ber of hospitals include: Inhalation therapist, ists to repair, modify or design equipment. Most prosthetic (or orthopedic) technician, medical of these jobs will be set up on hospital staffs, but emergency technician, surgical technician, blood some of them will be filled by employees of firms bank technician, medical electronic engineer, offering contract services to hospitals. electronic instrument technician, ward secretary Changes in the content of old-line health (or floor manager),ward supply technician, and electronicdata Robert E. Kinsinger, Education for Health Tech- processing and maintenance nicians, An Overview (Washington: American Asso- specialists of various kinds. ciation of Junior Colleges, 1965).

77 service occupations, follow characteristic patterns The answers will probably have to which differ from one job to the next. One pat- come from professional nursing itself. Most of the technical patient care serv- tern is illustrated by the impact of automated ices that professional nursing has al- equipment in the clinical laboratory.Medical ready abandoned have not bcen beyond technologists who previously had spent most of the physical or intellectual powers of their time conducting simple tests by manual nurses, nor are most of the devices of methods are now able to set up machinery for the future likely to be clearly beyond doing a large number of such tests at once, or nursings' scope. The answer seems rather to be based on whether or not pro- to supervise assistants in doing this; they them- fessional nursing can come to accept selves are freed to do more complicated tests or specialization among hospital nurses as to conduct research.In this case, technological necessary and worthwhile.... change has taken routine and drudgery out of Physicians recognize nurses' special the job of the professional worker, shifting it to abilities; witness the neurosurgeons and A orthopedic surgeons who have their the machine.Somewhat different patterns are own scrub nurses travel with them followed in the application of other innovations. when they are required to operate in For example, to utilize specialized equipment several hospitals.Pediatric nursing, such as artificial kidney machines, inhalation obstetric nursing, and psychiatric nurs- therapy equipment, or physical therapy devices, ing are tacitly recognized as clinical nurses or other trained health workers must either specialties within the area of hospital nursing.... learn their functions and incorporate them in The professional nursing postgrad- the general range of skills they use, or they may uate educational system is not geared turn them over to other people who acquire toward this kind of specialization, but training in the new specialties. rather toward specialization based on The continuing spread of technological innova- the number of years spent in college tions in the health field will always offer new and the level of the nursing degree. A master's or doctor's degree in nursing challenges, as well as opportunities, to profes- education, to my mind, provides no sional groups, especially to nurses.In past years, better educational basis for a profes- the introduction of new devices in the hospital sional nurse to serve on a hyperbaric often resulted in the nurse's learning to use them care unit, a coronary monitoring unit, as the doctor's assistant.Many years ago, the or an artificial kidney unit in a hospital than does the education of a nurse with- nurse was responsible for many other duties, out such academic degrees.It would which since have been taken over by specialists seem that the only fair measure of a X-ray operation, laboratory testing, electrocar- professional nurse's ability to handle diography, dietetics, medical social work, medi- these specialized responsibilities would cal records maintenance, physical and occupa- be specialized training and experience tional therapy, health education, and others. In in such units.... recent years, the development of new special- These problems are facing the nursing profes- ties such as inhalation therapist and surgical sion at a time when many related questions technician illustrates that this process is continu- affecting the future development of nursing and ing. A question that constantly arises is: Which nurse training need to be answered and when specialized areas should be retained by the nurs- the shortage of professional nurses is steadily ing profession as it continues to evolve under growing more critical.The shortage of nurses conditions of advancing health technology? seems likely to accelerate splitting off of special- Dr. Mark Blumberg of Stanford Research In- ized duties from the nurse's jurisdiction, causing stitute, who has pioneered in analyzing the im- the assignment of these tasks to a growing list of plications of technological advances in the hospi- technicians trained in particular new techniques. tal field, has this to say about the question : The changing character of health occupations and the proliferation of new health service jobs, Mark S. Blumberg, "Special Care Units", Modern Hospital, January 1965. complicates some of the problems of planning

78 to meetmeet current and anticipatedshortages of physician, nurse, and paramedical specialists who health manpowerespecially to the extent that are the leaders andmainstays in the health man- they call for personnel with years of specialized power team.Nor should emphasis on imme- increasing training.At the same time, they provide oppor- diate needs mean that programs for tunities for adapting some health jobs to the skill, professional standards, and relatedrequire- capacities of less-trained persons who canthereby ments for health jobs wouldbe neglected. A make useful contributions to the needs ofpatient realistic balance between quantity and quality of care in entirely newkinds of careers. health personnel has to be maintained.Efforts to set new and higher standardsfor health jobs should not exceed the pace at whichpersonnel Developing and Conserving the trained at higher standards are likely tobecome Health Manpower Supply available, either by upgrade training of present workers or recruitment of new graduates. According to many observers, shortagesof The critical problem of health manpower health manpower have been chronic for25 years shortages has been receiving increasing attention or more.The dearth of trained personnel has from leaders and specialists in the twobroad been getting worse just when Medicareand other fields involvedthe health professions and the recently enacted programs havegenerated new general field of manpower economicsduring demands for health workers.Perhaps efforts the past year.The efforts they urge tend to critical shortages, if followed to deal with today's follow parallel lines. A few recent statementsby through vigorously, will succeed, duringthe dec- these leaders may be quoted here. At theWhite ade ahead, in bringing to an endthe chronic House Conference on Health, held inWashing- shortage of qualified health personnel. Lowell T. Coggeshall The various efforts needed to expand,develop, ton in November 1965, Dr. the panel and conserve the supply of trainedhealth per- said, summarizing the discussion at sonnel will demand cooperation from manydif- sessions on health professions'education,as ferent groups and agencies, from thenational to follows: the local level.Success in erasing manpower Education for the health professions shortages is more likely to be achieved if general and their coworkers at all levels must agreement can be reached onthe need for giving bereexaminedandstrengthened. needs, spe- New and continuing incentives to at- priority to immediate problems and tract all people, includingthe under- cifically to achieve these urgent objectives:(1) privileged, to the health field mustbe To find and develop qualifiedpersonnel for developed. An outstanding exampleis assignment to existing health jobvacancies; (2) the vast reservoir of unskilled persons the to reduce turnoverlosses, minimizing the drain from which to expand and improve personnel now employed in health health manpower situation. Asignifi- on trained cant part of this reservoirinvolves the care facilities.Long-range plans should be inte- youth of low income families.This im- grated with efforts to meet theneeds of the portant national health resourcehas yet present and near future,since planning well to be adequatelytapped.Further- ahead will lack relevance if currentshortages more,manydisadvantagedmight achieve useful and productiveemploy- are permitted to get worse. ment in the health fields eventhough Immediate problems require stress on pro- they may not be qualified forprofes- grams for fullutilization of active and inactive sional education. We mustfind a way persons already trainedin health specialties, and to reach into alleconomic strata to on projects totrain quickly people who can per- augment the health manpowerpool. skilled and ...Experience and education can be form technical jobs now done by transferable and provide for thedevel- professional personnel.This emphasis implies opment of new toe ofhealth profes- no need forneglecting programs for expanding sional....Horizontalandvertical the training of new practitionersin those health mobility will become more and more professions that require lengthytrainingthe essential if we are to break downthe 79 artificial barriers which separate one practical nursesmuch manpower will segment of the health manpowerpool remainunderutilized....The um. from another. We must findpositive freezing of many existing barriers in means to encourage personsof ability and among professional and semiprofes- to move up the careerladder as their sional groups cannot be left solely to talents permit. them.It requires the participation of third partieseducational authorities, The need for vertical mobility inhealth jobs financial agencies (insurance) , govern- was particularlystressed by Dr. William H. Stew- ment. art, Surgeon General ofthe United States, dur- The February 1966 Conference was attended ing his talk at the White House Conference : by representatives of professions and vocations, Artificial barriers separate one stra- institutionsand organizations,both govern- tum of the health manpowerpyramid mental and private, concerned with health man- from another, buttressed by such con- power problems at alllevels.At this meeting, siderations as academic credits.Can particular emphasis we devise career ladders topermit the many of the participants put highly capable practical nurse to move on the need forbetter development and inter- into professional nursing, the profes- change of information with which to dealwith sional nurse into medicine, the hygienist health manpower questwns.They stressed the into dentistry?Wouldn't all the dis- need for more knowledge on such subjects as ciplines ultimately gain from such ver- availability of financing, equipment and other tical mobility? material resources, consultant help, research re- At the Conference on job Development and sults, and other tools for coping with problems Training for Workers in Health Services, held of health manpower at National, State,and local in Washington during February 1966 under the levels. sponsorship of the U.S. Department of Labor Space does not permit more than brief con- and the U.S. Department of Health, Education, sideration of the many different programs needed and Welfare, Prof. Eli Ginzberg ofColumbia to expand and develop the manpowersupply. University, Chairman of the National Manpower The sections that follow sketch briefly someideas Advisory Committee, commented along these concerning specific elements on which consensus lines about the relationship between training and appears to be developing inreference to the three other programs for dealing with problems of the areas of particularsignificance:(1) Training, health manpower supply: (2) utilizing money incentives in health man- (3) needs for im- It is always an error to focus on in- power development programs, creasing the supply without simultane- proved information in health manpower. ously considering the wage structure and utilization patterns.If the latter are Programs for Training Health Manpower awry then, no matter how many are re- cruited and trained, the supply will still in be inadequate since dissatisfied workers Health manpower is being trained today will leave. The wage structures are still many different categories,in numerous types of out of line with the marketin many courses, in a variety offacilities.Much of the paramedical fields....If wages and training activity is a continuation oflong-estab- working conditions are made competi- Some of it was begun more tive, good training can help attract and lished programs. retain the expanding numbers that will recently, by private groups as well as govern- be required....Adequate education ment units.The question that is being raised and training opportunities must exist on all sides, asproblems of health manpower not only for persons entering the field, needs continue to be urgent, is : What shouldbe but also be built into the career process and be tied to promotional opportu- done that isn't being done or isn't done enough? nities....Unless steps are taken to Some steps described below reflect views ex- facilitate upgrading of persons even pressed by many of the experts consulted during across professionallines--i.e.,nurses and physicians; professional nurses and this study.

80 Probably the quickest and most eff ective way training projects should come from both govern- of reducing the shortage ofqualified nurses ment and private initiative.Such projects for the would be to bring back into active service alarge health workers can help to do away with proportion of the estimated half millioninactive widely held belief that hospitalemployement is professional nurses, more than half of whom are a dead-end, blindalley choice for an untrained Opportunity for growth, not women who havemaintained their licenses. To young worker. bring back these nurses requires greatexpansion only in personal expression but also inincome of refresher training courses, in projects set up through such training, will help to conserve the at convenient places and hours.If possible, ar- health manpower supply by reducing labor turn- rangements should be made toprovide also for over and increasingefficiency in health facilities. their subsequent employment underattractive Moreover, the establishment of career ladder conditions (regarding wages, hours, andpossibly training systems will help to expand the supply care of their preschoolchildren by nursery aides of the scarcest groups of health personnelthose quickly or trainees).Such programs have already been who require the longest training--more carried out successfully in many communitiesand than if the existing system of relying solely on individual hospitals.Refresher courses and retraining raw recruits is continued. lated arrangements should not only be expanded Programs for recruiting and training new re- in MDTA and other Federal Government spon- cruits to the health service industry, in bot1i pro- sored projects, but should be set up underthe fessional and nonprofessional jobs, shouldbe auspices of local governments and private au- expanded and utilized to the full.This segment thorities. They should be given considerationin of the health manpower training systemwill every community andfacility that seriously feels always be a main source of needed additions Many of the the pinch of the nurse shortage. to the health manpowersupply. Career ladder training projects forhealth programs for expandingfacilities for training workers should be established on a widescale, health manpower, such as the MDTA programs, the both within health facilities and in arrangements the Vocational Education Act of 1963, and between those facilities and vocationalschools, Nurse Training Act of 1964, are relatively new colleges, and professional schools, to facilitate and in early stages of development.They need upgrading of health workers.The particular continuing support and active cooperationfrom means provided, or arrangements tobe devel- institutions and professional groups atnational oped, will obviously vary between such alterna- and local community levels in order tofulfill their tives as helping a hospital orderly become quali- purposes.However, expansion of training fa- recruits fied as a practical nurse, helping practical nurses cilities will have little effect unless more The flow of to get the academic and othertraining needed enter the field of healthservice. health, to qualify for a professionallicense, or upgrad- recruits is not likely to be adequate unless ing a laboratory assistant to a higherlevel posi- careers become moreattractiveby offering im- and pro- tion in the laboratory. Some of these objectives proved pay levels, working conditions, will be difficult to achieve, such as working out motional opportunities, and unlessscholarships arrangements to help professional nursestoward are made morewidely available, as discussed in becoming physicians, but there is no reason why subsequent sections. proj- even this should notbe tried.Certainly, it More experimental and demonstration should not be difficult to set up many career train- ects are needed to developand show new meth- well ing projects that will help associate and diploma ods of training recruits for health jobs, as nurses (2- and 3-yeargraduates) toward bac- as approachesfor helping workers to get the calaureate degrees in nursing or in paramedical training needed for upgrading. Newapproaches specialties by providing adequate recognition and to training should be supported,especially to de- credit for past education and experience (which velop paramedical specialists to handletasks now is generally withheld at present) . being done by health professionals.Programs The impetus toward establishing career ladder for training people for some of the newkinds of 81 jobs that are emerging require experimentation in some instances fallen off, because of inade- to develop facilities, curriculum,and other re- quate recognition of the power of money incen- sources and arrangements. Anexample of such tives in the job market. efforts which is currently in progress is an ex- Competing for workers with industries or voca- perimental project to train as "assistant physi- tions that offer higher pay and easier hours and cians" men who were formerly medics and working conditions (often in return for a smaller corpsmen in the armedservices.In this project, requirement of investment intraining),the sponsored by the Duke University Medical Cen- health field has been losing ground steadily. To ter, the intention is to producesubprofessional redress the balance, deliberate harnessing of pecu- physicians' assistants (not to be confused with the niary incentives will be required.Such goals secretarial "physicians' assistants" who work in as increasing and stabilizing the workforce in doctors' offices) who can help with special tech- health service, improving efficiency, and perhaps niques such as kidney dialysis, use of hyperbaric even offsetting the rising costs ofhealth care can equipment, intensive care procedures.Similar be brought closer by putting money incentives experimentalprojectsrelatedtoneedsfor to work. people trained in a variety of specialties are being Scholarships and living allowance incentives undertaken by various institutions and agencies, should be made available to qualified candidates public and private, and will continue to be for training in critically scarce health occupa- needed. Some projects are focused on the prob- tions.Under existing and pending legislation lem of how to train older persons, handicapped, for aid to post high school training in the health and other disadvantaged individuals to fill in- professions, the only form of student aid available creasing needs for home health aides.Other on a large scale is tuition loans that mustbe re- projects aim at improving methods of training paid (at least in part). It is widely believed that surgicaltechnicians. Experimental programs reliance principally on the loan approach is in- will be particularly useful in developing ways of sufficient.Modifications to provide scholar- helping experienced health workers to get the ships to substantial numbers of qualified appli- additional training they need to advance on the cants, at least covering the first year's tuition and career ladder. livingcosts, and similar financial incentives, Demonstration programs will also be needed, could result in much higher recruitment response to show and explain to schools andhospital man- without greatly increasing the costs of recruit- agements the new successful approaches that are ment programs. being developed for training people to do special- The income needed by students for mainte- ized health jobs. nance during training should get major attention in programs for training subprofessional health personnel, whether under government or Harnessing Money Incentives private sponsorship. Patient care institutions have had to rely to a Salary structures in hospitals and other health substantial extent on the personal dedication of facilities should be shaped to attract and hold health workerstheir wish to be of service to employees interested incareer advancement. those in need of helpin order to operate satis- Arrangements are needed to promote vertical and horizontal mobility for employees in hos- factorily.This will always be true.But recent pitals and other health facilities and to set sal- trends indicate that under current conditions of growth and change, incentives such as altruism, ary scales that promise advancein incomes to service ideals, and professional pride, while still workers who grow in skill and responsibility. important, are not enough to attract and retain These arrangements should be geared to career the quantity and quality of personnel needed. training programs and other measures to improve It is coming to be widely under, 'pod thateffi- the skills of employees. ciency in utilizing staffs and facilities has suffered, Salary levels of workers in health facilities, and even that levels of patient care quality have especially those in low-paid jobs, should be raised

82 to parity with those paid in comparable employ- by economies in materials and man-hours. This ment in other fields by extension of provisions is a group incentive plan, conducted in conjunc- for Federal and State minimum wage and col- tion with a work simplification program designed lectivebargaining protections.Without the to raise productivity.Savings from efficiency stimulation of third-party influences, such as gains are shared with employees in the form of statutory requirements, itisdifficult to raise deferred payments (severance, retirement, and salary levels of health workers significantly.In death benefits). The plan has not only helped many communities, the influence of somelocal lower the hospital's operating costs, but has also hospital governing bodies works toward general aided in reducing labor turnover.'Of course, stagnation of hospital employees' pay.Under other hospitals have been able to improve effi- these conditions, managers of hospitals do not ciency and keep operating costs down, but the respond to conditions in the job market that call fact that employees of Memorial Hospital share for raising wages with the same alacrity shown in efficiency gains gives them a stake in improved by managers of other kinds of establishments, productivity.This principle has universal ap- with the result of ensuing losses of trained health peal and can make a significant contribution to- workers through turnover. ward raising the standards of manpower utiliza- The hourly minimum for hospital workers tion in the health service field if it spreads to should be set at a rate no lower than that of other hospitals. other workers; in Federal or State minimum wage laws, if relief of health manpower shortages is Needs for Information and Research Programs recognized as a major goal. "Profitsharing" plans suggest a way of reduc- More attention is being given to the subject ing operating costs and labor turnover in hos- of health manpower today than ever before, but pitals while raising employees' incomes.The very much remains to be done. A frequently outlook for proposals relying on money incen- expressed need is an imprcved system for inform- tives to increase the supply and quality of health ing individuals,agencies, and groups about manpower depends on an answer tothe ques- efforts that are being made to deal with health tion, "Where will the money come from?" Costs manpower problems in which they are interested. of hospital care have jumped so high during Another major need is to fill gaps in statistical recent years that it is understandable why gov- and factual information on health manpower erning boards show reluctance to increase costs and related subjects through systematic research. further through either wage structure changes Central, community-wide facilities and ar- that encourage career development or general rangements are needed in many areas to provide pay raises via minimum wagelegislation or col- better information on the community's needs and lective bargaining.There islittle doubt that resourcesfordevelopinghealthmanpower. further substantial increases in labor costs would Much needs to be done to make available in all provoke financial crises in some hospitals, yet it communities, to individuals, agencies, and groups seems inevitable that increases inthe average pay concerned, information on health manpower of hospital workers will take place in most hos- problems and resources available to help solve pitals in the next few years. them.In many communities there have been It is perhaps of interest that at least one hos- instances in which hospitals have not kno,,vn that pital has found a way of keeping operating costs financial support, expert advice, or other re- down while providing increased income to em- Donald C. Carner, A Program for Hospital Incen- ployees, by use of an incentive plan akin to tives (Madison: University of Wisconsin, Center for profit sharing.Memorial Hospital of Long the Study of Pioductivity Motivation, School of Com- Beach, Calif., a modern 400-bed voluntary hos- merce, 1965), and J. J. Jehring, AnEvaluation of the Merit Incentive Program at the Memorial Hospital of pital, adopted a "gain sharing" plan in 1961 Long Beach (Madison: University of Wisconsin, Cen- through which it has been distributing to em- ter for the Study of Productivity Motivation,School of ployees the savings in operating costs realized Commerce, April 1965). 83 sources were available to help them with man- scription of training programs of all kinds, by power problemsfrom Federal, State, or local which both recruits and experienced workers are government units, or from private agencies. learning either new or traditional health special- Two forms of local Liformation-spren ding and ties; on characteristics of inactive former health coordinating machinery are needed : workers; and on many other subjects related to 1. Conferences and continuing bodies at which the utilization, demand, and supply of health representation would include:Hospitals and workers, in local particular communities, in the other health service establishments that require Nation as a whole, and in other parts of the and employ health manpower, and schools and world in which the United States has obligations. other groups that help provide the supply, as Data now available on some of these subjects is well as professional and other groups concerned very incomplete or lacks the up-to-dateness or with the quality and quantity of manpower in frequency ofrecurrentcollectionneeded various health callings, and other interested gov- for guidance in planning health manpower ernmental and private agencies at Federal, State, programs. 2. Research projectson many individual and local levels. problems of health manpower needs and utiliza- A 2. A small central staff to provide continuing service such as:(a) Helping to maintain co- tion, ranging from specialized subjects related ordination among groups; (b)collecting and to specific health occupations in particular locali- circulating information on new community ac- ties to broader subjects affecting the economy as tivities related to health manpower; (c) assem- a whole. For example, it would be desirable to bling statistical information and estimates on study in detail the manpower implications, in current and future needs of health facilities for terms of number and kinds of health workers to manpower, by occupation, and how it is to be train, of providing vast and comprehensive mass balanced, currently and in the future, by either health examination and screening programs, newly trained recruits or former workers who based on new advances in health technology, or return to the health field (as shown by informa- of developing a mass system of dialysis treatment for kidney disease sufferers, in the Nation or tion supplied by training facilities licensure agen- in particular communities. Another example of cies, professional groups, etc.). Such informa- a subject that needs study is related to the needs tion will be of vital importance toward balanced planning and development of health manpower and the training resources of Federal Govern- ment agencies involved in health problems, both on a community and State-wide basis. at home and abroad, and how they affect gen- Research programs are needed to provide an- eral requirements and availability of health man- swers to many outstanding questions related to power.Still another example is the need for health manpower.It is apparent that many dif- studies of opportunities for fuller utilization of ferent kinds of research effort are needed to deal untapped or underutilized human resources in adequately with the changing needs and oppor- the many occupations included in health serv- tunities that will continue to develop in the field ice employmentopportunities for young per- of health manpower.These areas of need sons of school age and older, retired persons, mi- clearly sund out : norities, housewives, handicapped, and other 1. Prog-ams to fill gaps in statistics--on the groups who could serve in the health field. number of persons actually employed and the In regard to research on health manpower number of job vacancies in individual health problems, projects designed to experiment with occupations, among various types of health estab- developing new ways of meeting health man- lishments; on the number and kinds of employees power problems particularly deserve support. required in relation to existing and new methods Out of such experiments will come many of the and standards of health care, and in relation to ideas and insights needed to provide answers to differences in technological and other character- the questions that continue to arise in the chang- istics of health facilities; on the scope and de- ing field of health manpower.

84 Both the statistical and research programs and ment by the President of a President's Commit- projects and the action programs for improving tee on Health Manpower, and a National Ad- the machinery for spreading information on visory Commission on Health Manpower, on health manpower will require full participation May 7, 1966.The Commission is to study the of governmental and private groups from na- problem and submit recommendations within tional to local levels.This need appears to be Many similar groups are studying and generally recognized. The Federal Govern- a year. ment's awareness of the need to solve health developing plans to combat health manpower manpower shortages was shown in the appoint- shortages in communities throughout the Nation. Appendix A

A. Definition of the "Health ServiceIndustry"

The "health service industry" isa term used to designate both public and private "establishments primarily engaged in furnishing medical, surgical, and otherhealth services to persons." The quoted phrase is taken from the definition of Major Group 80 ofthe Standard Jndustrial Classification Code Medical and Other Health Services; however, SIC 80 includesonly privately owned establishments whereas establishme is owned by Federal, State, and localgovernment agencies are included in the health service industry in this report if theyare primaril,, engaged in giving care or service to patients. Under the SIC structure, government-owned hospitLisand nursing homes are classified outside of SIC 80.

Specifically, the components included in the healthservice industry and their SIC codes,are grouped as follows:

Hospitals: SIC 806 (privately ownedi.e., voluntaryor proprietary) . SIC 9180, 9280, 9380 (Federal-, State-, and local-owned,respectively).

Nursing and Rest Homes: SIC 8092, 9170, 9270, and 9370(privately owned).

Medical and Dental Laboratories: SIC 807 (privately owned). Offices and Other Health Service Establishments: SIC801, 802, 803, 804, and 8099 (privately owned by groups or individuals, providing the servicesof physicians, dentists, chiropractors,

optometrists, physical th,!rapists, associations operatingclinics, and related services).

87 It should be noted that the health service industry as here defined does not includethe activities of offices, clinics, or laboratories operated by Federal, State, and local governmentswhich provide various types of public health servicessuch as mental and other health centers,examination and other diagnostic services, sanitation services, regulatory and other programs ofenvironmental hazard control. Some of these establishments provide services similar to those ofestablishments included in the definition of the health service industry, but since relatively little information is'available on the number of employees engaged in such services, their activities are referred to only incidentally.Also excluded are activities by persons in health occupationsif they are employed in industries that provide materials or services needed by the health serviceindustry, such as drug manufacture or wholesale and retail trade, and persons who may be trained or engaged in an occupation related to health service but are not employed in health service establishments. Appendix B

B. Sta'isticalAppendix Employment in Health-RelatedActivities 1. Differences AmongEstimates of Total Table activities differdepending on definitionsused. Estimates of employmentin health-related for differences columnar form the twoprincipal definitionalelements that account B-1 presents in employment status andbasis for expressing estimates of health-relatedemployment: First, the among The final columnfurnishes estimates of the number; second,establishment coverageexclusions. according to each of fivedefinitions, beginningwith the estimate of averageemployment in 1965 employment in SIC 80 aspublished by the Bureauof Labor Statistics. in the course of the presentstudy.They are presented All other estimatesshown were derived allow for a marginof error at least aslarge as as rangesbetween two figures,reflecting the need to shownbecause of lack ofsufficient basic data,statistical errors, rounding, indicated by the range the health field. and other limitationsaffecting most estimatesof employment in

for the Health ServiceIndustry 2. Productivity andManpower Projections

been made ofproductivity in thehealth service in- Until recently,relatively few studies have establishments are approaches to measuringproductivity in patient care dustry.Several alternative different concepts for They reflect different purposesof analysis and currently being investigated. the focus may rangefrom a expressing output andinput.In analyzing andmeasuring productivity, 89 244-295 O -67 - -7 Table B-1. DIFFERENCES AMONG ESTIMATES OFPAID EMPLOYMENT IN HEALTH-RELATED ACTIVITIES, 1965

Exclusions from employment as Estimate, Industry title Employment basis, as defined defined: Establishments such as as defined: (millions)

1. "Medical and Other Payroll employees only, full and Governn.ent hospitals, nursing 12.1 Health Services," part time (excludes physicians, homes. SIC 80. dentists, and other self-employed Government environmental and practitioners). other public health protective units. Nongovernment establishments outside SIC 80. 2. "Health Service a. Payroll employees only, expressed Government environmental and 2 2. 5-2. 8 Industry". as estimated full-time equiv- other public health protective alent (all full-time, plus half units. of part-time jobs). Nongovernment establishments outside SIC 80. b. Payroll employees only, full and Government environmental and 2 2. 9-3. 1 part time (not expressed as other public health protective full-time equivalent). units. Nongovernment establishments outside SIC 80. c. Both the payroll employees, full Government environmental and 2 3. 3-3. 5 and part time (not expressed other public health protective as full-time equivalents), and units. self-employed health prac- Nongovernment establishments titioners. outside SIC 80. 3. "All health-related All persons (on payrolls or self- None (with possible exception of 2 3. 7-4.0 activities". employed) engaged in health- borderline activities such as related paid activities, in all animal licensing and care, sewage industries, including manufactur- disposal, etc.). ing, trade, scientific, and government health-protective or patient care activities.

I Published by the Bureau of Labor Statistics. 2 As estimated in the present study. single narrow activity (such as testing blood samples, or serving meals topatients, etc.) to the broad area of a whole hospital department, or even morebroadly to the aggregate of service provided by the entire health service industry. Aside from the scope of analysis, approaches varydepending on whether an intertemporal or interspatialcomparison is the aim.Intertemporal analyses of productivity usually compare ratios of output per unit of input astrends over a period of years, whereasinterspatial analyses compare productivity ratios between establishments, departments, orother organizations or locations at a given point in time. In constructing productivity ratios for the health service industry,it is usual to express input in terms of human effort expended, quantified by figures foremployees or man-hours (it would also be possible to quantify nonlabor inputs, if desired). The output side may berepresented by either of two quite different concepts; (1) Services (activities) performed, or (2) results achieved.The services performed on activities basis refers to specific activities such as days of bed careprovided, physician visits, outpatients treated, urinalyses completed, bed sheets laundered, etc.All of these quantities may be readily determined by counting completed units or by calculating theirdollar values (adjusted for price change). The results basis is harder to quantify; it strives to express theachievement of the health service establishment (or the industry as a whole)in curing illness,preventing it, or otherwise

90 helping patients to attain specific health goalssuch as removing disfigurements,delivering healthy would have particular babies, etc.Both concepts are useful for specific purposes.The "results" basis the quality of medical relevance from the standpoint of analyzingeffectiveness of efforts to improve in measuring care. Up to the present,however, data limitations have stoodin the way of much progress the productivity of the industry from the standpointof "results." Efforts to measure output and productivityin health services in termsof "results" have recently Other been begun by Victor Fuchs and associatesof the National Bureau ofEconomic Research. examples of work on the measurement of outputrelated to this concept are citedin the Report of the Commission on the Cost of Medical Care ofthe American Medical Association(vol.I, pp. 119-136; vol. III, pp. 23-72) . Currently underway in the Department ofDefense is a project formeasuring productivity in hospitals operated by the Armed Forces onthe basis of both the results andservices performed (or Department, activities) concepts.These efforts, by David Schenker andother staff members of the aim at providing figures, per unit of laborinput, on "sick days saved" (i.e.,effective additional man- days produced) and on number of casescured, for various disorders, as well asfigures on number of laboratory examinations or other servicesperformed in the patient care facilitiesof the Armed Forces. Various other studies of output andproductivity in medical services havebeen carried I) a* using the "services performed" concept, asexpressed in different ways. Amongthese have been stu have measured output, in terms of physicians'fees (deflated for price change) .An exami.i., ?rice Behavior and Productivity in the MedicalMarket, by Joseph W. Garbarino(Institute of .'- masuri,.ig Relations, University of California, Berkeley,1960) . This concept is also the basis for productivity in programs now being conductedby the Hospital AdministrativeService (HAS) of the American Medical Association and bythe Commission for AdministrativeServices in Hospitals productivity has recently been (CASH), as described in chapter2. A similar program for measuring begun in the hospitals of the VeteransAdministration.Thus far, these programs formeasuring productivity in hospitals have stressedinterestablishment comparisons. Measurements of the effects of technologicalimprovements in improving the trend ofproductivity in the Nation's hospitals may ultimatelybecome available from the data beingcollected in the HAS program of the AmericanHospital Association. Meanwhile, thereis available from the regular annual statistical compilations of the AHA a series onemployee/patient ratios in hospitals datingback to1946. These ratios, which reflect the "servicesperformed" concept, are useful for analyzingand projecting manpower requirementsin the health service industry as a whole.They show the effect of technological and related factors affecting productivitytogether with changes in the quality ofclinical and personal of care provided inhospitals. The quality changes result fromchanges in the nature and composition services provided and in the number andkinds of personnel used, as well as technologicalimprovement. It does not seem possible to separate out theireffects in using the ratios. During the past decade, the employee/patientratio in hospitals has risen sharply.It is generally believed that this is due primarily to changes inthe quality of medical and personal careprovided in hospitals, which require greater use of laborin treating hospital patients.Available data do not permit conclusions to be drawn on whetherdecline in efficiency among hospitalemployees has contributed to the increase in hospital employment at afaster rate than the rise in the averagepatient load in hospitals.Apart from the question of efficiency,the following have been some of the developments requiring increased payroll-laborinput for patient care in hospitals during recent years: Increased use of nurse aides and orderlies, less useof nonpayroll employees such as student nursesand internes, greater use of technicians of manykinds.Among changes in quality of service havebeen these: Greater requirements for intensive carebecause of shorter average hospital stays and greater use by patients ofprivate and semiprivate accommodations. As indicated in the discussion thatfollows, in the present study an effort has been made torelate the assumptions stated in the text concerningexpected future trends in the character of healthservices demanded and in future trends in productivity to availabledata and estimates on the employee/patient ratio in hospitals and nursing homes. Thediscussion below makes the assumptions in the textexplicit in quantitative terms, as a basis for pi ojecting totalemployment in hospitals and nursing homes to 1975. Employee/patient ratios are available as the number offull-time equivalent employees per 100 patients (average daily patient census during theyear) for inpatientsas reported by the American Hospital Association.In accompanying table B-2, this ratio and itsunderlying figures on employment and number of patients are shown for 1955 and1965 in line 1 for each year.Line 2 for each year shows estimated employee/patient ratios in hospitalsafter adjustments were made to take separate account of :(1) Employees actually working with inpatient cases, and(2) employees actually allocated to outpatients and home care, allowingfor a large margin of error in this separation adjustment. The projected employee/patient ratios for 1975 are based onthese assumptions: (1) That by the end of the period 1965-75 employee/patientratios will have continued to grow at varying rates in each of the three typesof patient care services shown (inpatient,outpatient-home care, and nursing homes) .The varying rates reflect a probable greater increasein intensity of care among outpatients and home care casesthan among inpatients, and also some offsetting productivityim- provement in the case of hospital inpatient care; (2) A substantial growth in the importance, and thereforethe weighting effect, of the services other than inpatient care during the decade ahead. The dominating influence is that of the shift toward the importanceof patient care in outpatient clinics, home care services, and nursing homes (as compared withinpatient care) in the decade ahead. Rough estimates of the number of patients who will be cared for in allthree services are shown. When

Table B-2. ILLUSTRATION OF EFFECTS OF SHIFT IN EMPLOYEE/PATIENTRATIOS, 1955-75

Employees per Number of Number of Unit and type care 100 patients patients (averageemployees (full- (average day) day) (thousands)time equivalent) (thousands)

1955

Total: Hospitals, inpatient basis 93 1, 363 1, 300 Total: All patients (adjusted) 71 2, 063 1, 480 Hospitals, inpatients only 89 1, 363 1, 225 Hospitals, outpatients and home care 25 300 75 Nursing homes 45 400 180

1965 (preliminary)

Total: Hospitals, inpatient basis 134 1, 450 1, 950 Total: All patients (adjusted) 93 2, 350 2, 200 Hospitals, inpatients only 125 1, 450 1, 825 Hospitals, outpatients and home care 32 400 125 Nursing homes 50 500 250

1975

Total: Hospitals, inpatient basis 150 1, 600 2, 400 Total: All patients (adjusted) 83 3, 600 3, 000 Hospitals, inpatients only 125 1, 600 2, 000 Hospitals, outpatients and home care 40 1, 000 400 Nursing homes 60 1, 000 600

92 these estimates are related to the expectedemployee /patient ratios for1975, the results are figures shown for number of employees in table B-2. The estimates of average numbers ofpatients who will be cared fordaily in hospital outpatient data and are likely to be and home care departments and in nursinghomes in 1975 are based on sparse 1975 somewhat wide of the mark.However, the important fact is thatthey will be much larger in than in 1965, a period during which the averagenumber of hospital inpatients willhave increased health service only moderately.The result will be a more moderateincrease in total employment in because of the growth of these servicesoutside of hospital wards and rooms,which are characterized by low labor intensity, than would occur ifthe demand for hospital inpatientservices, which are characterized by high labor intensity, expandedequally rapidly. It will be noted that the totalfull-time equivalent hospital employmentfor 1975 is thereby projected to 3 million.To this, an estimated 600,000employees in practitioners' offices, laboratories, etc., for 1975 is added, to reachthe total estimate of 3,600,000 employeesin the health service industry in 1975.

3. Employment Estimates, 1965,and Projections, 1965-75

The estimates of employment in the healthservice industry in 1965 presented in texttable 2 are based on a large number of sources showing totalemployment for the early 1960's in individual occupations and industries (hospitals, nursinghomes, laboratories, practitioners) .The main sources were: (1) Annual data and specialstudies of hospital employment by theAmerican Hospital Association; (2) Estimates by the U.S. Public HealthService, based on Bureau of the Censusfigures and other sources (as extended,adjusted, and published in the Health ManpowerSource Book series) ; (3) Occupational Outlook Handbook, U.S.Department of Labor, Bureau of LaborStatistics; (4) Various other published sources, cited in thefootnotes and Selected References, andinformed opinions by experts. These estimates were checked, adjusted,and supplemented to fit control totals, to removein- consistencies, and to account for establishments oroccupations for which available information is sparse. For example, total employment in hospitals,estimated at 2 million in 1965, is based on thereported total of 1,952,000 in AHA-registeredhospitals, adjusted upward by 48,000 asrounded off to account for over 1,000 other hospitals or similar facilities, mostof which are known to be small. All employment estimates and projections arestated as full-time equivalentsi.e.,all full-time personnel plus one-half of all part-time personnel. In preparing the projections of employmentfor 1965-75 for text table 8 (projectedfrom text table 2 as a base), main reliance was placed onthe assumptions regarding totaldemand for health services and expected shifts in its compositionduring the decade ahead, and onproductivity expectations, as described briefly in the text, and in detail in thepreceding appendix note. The employment projections developed on this basis were later checkedby independent, simply extrapolatedprojections reflecting assumptions that the increased demand for manpowerin short-term hospitals resulting from Medicare and related programs will not beparalleled by equivalent increases in Federal andother government hospitals, which are notlikely to gain patients as a result of the Medicare program(in fact, they may lose some patients to voluntary andproprietary hospitals as a result of Medicare) .In a third step, these overall projections werealso checked for comparison by totalingindependently the calculations of expected demands for major occupational groups.The original projections had to be modified only slightly on the basis of these three checks. The projections of employment for the variousoccupational groups were made up individually, according to guidelines set by various benchmarks,studies, and opinions on projections of needsfor

93 each group (sources of which arementioned in the selected referencesand in the lists of experts indicated by evidence interviewed).The final figures were in someinstances adjusted or smoothed as such as data on expected expansionin demands or particular activities(lab tests, X-rays, etc.), esti- further mates of the expectedeffects of laborsaving resulting fromtechnological developments, and by consultation with experts. As indicatedearlier, the final projections ofemployment among occupational 1975as derived groups, when totaled, werefound to be close to the total employmentprojected for separately on the basis of assumptionstied to total employee/patient ratios. It should be emphasized that allemployment estimates are expressed in termsof full-time equivalent figures (full count of full-timeemployees, plus full-time equivalencyfor each two part-time workin terms of the number ers).As such, these estimates differ fromother estimates of employment stated of full- and part-time employees. The rate of growth in total employmentbetween1965and1975expected in these projections, covering the entire health serviceindustry as defined here, differs fromthe rates of growth that would be indicated if the projections ofemployment had been expressed in termsof SIC 80 (Medical and Other Health Services).The latter definition excludes employmentin Government hospitals and nursing horses, which is not likely toexpand at the same rate as employment in nongovernmenthospitals, mainly because of the unevenimpact of the Medicare program. It may be noted that the estimatesof1965-75employment growth for the health serviceindustry closely coincide with those stated forSIC 80 in the study by the U.S. LaborDepartment's Bureau of Labor Statistics published as America'sIndustrial and Occupational ManpowerRequirements., 1964 / 975, if allowances are madefor:(1) Differences in number of years,(2) treatment of full- and part-time employmert, and (3) industrydefinition. C. Appendix Tables

Table C-1. TRENDS IN HEALTH AND MEDICAL CARE ECONOMICS, SELECTEDYEARS, 1950-64

Item 1950 1955 1960 1964

Total expenditures for health and medical care:percent of gross national product 4.6 4. 7 5.4 5. 9 p Persons with hospital expense insurance protection: Number (millions) 77 108 132 151 Percent of U.S. population 49.1 65. 2 73.3 79. 2 Indexes of consumer and medical care prices (1957-59=100):

Consumer prices-all items 83.8 93. 3 103.1 109. 9 Consumer prices, services, excluding rent 75.4 90. 8 106.1 117. 0 Total, medical care 73.4 88. 6 108.1 119. 4 Surgical fees-tonsillectomy 81.5 92.' 107.9 118. 7 Dentists' fees 81.5 93. 1 104.7 114. 0 Optometric 89.5 93. 8 103.7 110. 7 Hospital room rates 57.8 83. 0 112.7 144. 9 Prescriptions and drugs 86.6 92. 7 102.3 98. 4

SOURCE: Expenditures from Social Security Adminis- hospital insurance from Health Insurance Council and tration; price indexes from the Bureau of Labor Statistics: Health Insurance Association of America.

95 Table C-2. TRENDS IN HOSPITAL TYPES, 1955-64

Hospitals Hospital beds

Type of hospital Percent 1964, Number, Percent 1964, Number,distribution percent 1964 distribution percent 1964 of number, increase (thou- of number, increase 1964 since 1955 sands) 1964 since 1955

All hospitals 7, 127 100. 0 2. 5 1, 696 100. 0 5. 7

Federal 441 6.2 1.0 175 10.3 -4.4

Non-Federal (type): Short-term general and other special 5, 712 80. 2 9. 1 721 42. 5 26. 9 Psychiatric 487 6. 8 -10. 1 691 40. 7 -2. 3 Tuberculosis 187 2. 6 -46. 1 40 2. 4 -42. 9 Long-term general and other special 300 4. 2 -25. 4 69 4. 1 -9. 2

SOURCE: American Hospital Association.

Table C-3. TRENDS IN HOSPITAL USE, 1955-64

Inpatient admissions, 1964Average daily patient censusNo. of outpatient visits, 1964

Type of hospital NumberPercentPercentNumberPercentPercentNumberPercentPercent (Thou- distri-increase 1964 distri-increase(thou- distri-increase sands) bution since (thou- bution since sands) bution since 1955 sands) 1964 1965 1955

All hospitals. 28,266 100.0 34.1 1, 421 100.0 4.3125,123 100. 0 78. 6

Federal 1,619 5.7 5.7 152 10.7 -3.2 30,620 24. 5 67. 7

Non-Federal: Short-term general and other special 25,987 91.9 36.1 550 38.7 35.1 91,430 73. 1 70. 6 Psychiatric 442 1.6 41.7 632 44.4 -6.6 1,120 .9 146. 2 Tuberculosis 62 .2 -28.7 28 2.0 -50.0 680 .5 - 43. 2 Long-term general and other special... 156 .6 - .6 59 4.2 -9.2 1,273 1. 0 15. 3

SOURCE: American Hospital Association.

96 1964 Table C-4. TRENDS IN HOSPITAL EMPLOYMENT,PAYROLLS, AND PATIENT RATIOS, 1955 AND

1964 employment (full-time 1964 Proportion, pay- Employee/ equivalent) payroll roll to total patient ratio1 expense

Type of hospital Number Percent Percent Million (thou- distribu- increase dollars, Percent,Percent,1964 1955 sands, tion, 1964since 1955 1964 1964 1955 1964)

0. 95 All hospitals 1, 887 100. 0 61. 4 7, 975 66. 3 64. 0 1. 33 79. 6 1. 28 1. 22 Federal 193 10. 2 . 5 1, 238 82.4

Non-Federal: Short-term general and other 61. 62. 42 2. 03 special 1, 333 70. 6 61. 4 5, 152 01. 7 .42 .28 Psychiatric 264 14. 0 40. 4 1, 189 73. 9 58. 2 63.91.05 .85 Tuberculosis 30 1.6 37.5 112 68. 7 Long-term general and other 66. 7 1. 13 .71 special 67 3. 6 42.6 284 69. 8

1 Number of employees divided by averagedaily pa- SOURCE: American Hospital Association. tient census.

Table: C-5. PROJECTED NUMBER OF HOSPITALS,NURSING HOMES, AND BEDS, 1965, 1970, AND1975

1965 1970 1975

Type of hospital Hospitals Hospitals Hospitals and nursing Beds and nursing Beds and nursing Beds homes Homes homes

All hospitals and nursing 32,500 3,100, 000 homes 21,123 2,203,000 27,350 2,700,0(,)

7,500 1,900, 000 All hospitals 7,123 1,703,000 7,350 1,800,000 400 200, 00C Federal . 443 174,000 400 180,000 Non-Federal short term 5,736 741,000 6,000 820,000 6,200 900, 000 700, 000 Non-Federal psychiatric 483 685,000 500 700,000 500 30,000 100 20, 000 Non-Federal tuberculosis .. 178 37,000 150 Non-Federal long term 283 66,000 300 70,000 300 80, 00C

000 1,200, 00C Nursing homes 14,000 500,000 20,000 900,000 25,

SOURCE: See Statistical Appendix. 97 Appendix D

D. Selected References

Health Economics

Advancing the Nation's Health.Mes:..ige From the President of the United States, January 7, 1965.

Harris, Seymour E.The Economics of American Medicine.New York: The Macmillan Co., 1964.

Klarman, Herbert E.The Economics of Health.New York: Columbia University Press, 1965.

Medical Care Financing and Utilization.Washington: U.S. Department of Health, Education, and Welfare, 1962, Health Economics Series No. 1.

1964 Annual Report.Washington: U.S. Department of Health, Education, and Welfare, 1964.

Report of the Commission on the Cost of Medical Care.Chicago: American Medical Association, 1964.

Survey of Current Business, National Income Number, July 1964.

99 Health Service Facilities

General Washington: U.S. Departmentof Commerce, Bureau County Business Patterns,First Quarter 1962. of the Census, 1963, p.20. Institutions.Washirr3ton: Development and Maintenanceof a National Inventoryof Hospitals and Health Service, February1965. U.S. Department of Health,Education, and Welfare, Public Washington: U.S. Depart- Hill-Burton State PlansANational Summary as ofJanuary 1, 1964. ment of Health,Education, and Welfare, PublicHealth Service, 1964. of Health, Education, Medical Groups in theUnited States, 1959.Washington: U.S. Department and Welfare, Public HealthService, July 1963. General's Consulting Group onMedical Physicians for a GrowingAmerica.Report of the Surgeon Welfare, 1959. Education.Washington: U.S. Departmentof Health, Education, and

Hospitals Hospital, February 1964. Block, Louis."Hospital Profiles: A Decade ofChange, 1953-1952," Modern Center Carner, Donald C. A Programfor Hospital Inceltives.Madison :University of Wisconsin, for the Study of ProductivityMotivation, School of Commerce,1965. Hospital of Jehring, John James. An Evaluationof the Merit IncentiveProgram at the Memorial Study of ProductivityMotiva- Long Beach.Madison: University ofWisconsin, Center for the tion, School of Commerce, April1965. Record Hospital Organization andManagement.Berwyn, Ill.: Physicians MacEachern, Malcolm T. 6 Co., 1957. Hospitals, Journal of theAmerican Hos- McGibony, John R."HospitalsRetrospect and Prospect," pital Association, October 16,1964. Philadelphia: W. B. Modern Concepts of HospitalAdministration.Edited by Joseph K. Owen. Saunders Co., 1962.

Nursing Homes Washington: U.S. Depart- Solon, Jerry, and others.Nursing Homes, Their Patientsand Their Care. ment of Health,Education, and Welfare, PublicHealth Service, 1957. Washington : U.S. Depart- Speir, Hugh B.Characteristics of Nursing Homes andRelated Facilities. ment of Health,Education, and Welfare, PublicHealth Service, 1963. Homes of Wash- Tucker, Elizabeth Lamberty, andSnyder, Mildred A.Personnel Time in Nursing

100 ington State.Washington: U. S. Department of Health,Education, and Welfare, Public Health Service, January 1958, Public Health Report73.85-95.

Vanston, A. Rorke, Abbe, Leslie M., and Hampton,Maury. A Comparative Study of40 Nursing Homes; Their Design and Use.Washington: U.S. Department of Health,Education, and Wel- fare, Public Health Service, 1965.

Health Manpower

General America's Industrial and Occupational ManpowerRequirements 1964-7.5.Washington: U.S. De- partment of Labor, Bureau of LaborStatistics, January 1, 1966.

"Commercial Medical Technology Schools," ModernHospital, December 1961.

Fincher, Cameron.Nursing and Paramedical Personnel in Georgia: A Surveyof Supply and Demand. Atlanta: Georgia State College, 1962.

Henning, John F. "MDTAThe Broad Program," AmericanJournal of Nursing, June 1964.

Hospital Personnel.Washington: U.S. Department of Health, Education,and Welfare, Public Health Service, October 1964.

Industry Wage Survey; Hospitals, Mid-1963.Washington: U.S. Department of Labor,Bureau of Labor Statistics, June 1964, BLS Bulletin 1409.

Manpower Report of the President and A Report onManpower Requirements, Resources, Utilization, and Training by the U.S. Department of Labor.Washington: U.S. Department of Labor, annually, beginning 1963.

Manpower Research and Training Under the ManpowerDevelopment and Training Act.Washing- ton: U.S. Department of Labor, annually,beginning 1963.

Medical Service Job Opportunities, San Francisco BayArea, 1964-66.Sacramento: State of Cali- fornia, Department of Employment, July 1964.

Nongovernment Hospitals.Washington: U.S. Department of Labor, Wage andHour and Public Contracts Divisions, January 1965.

Organizing a Dental Assistant Training Program.Washington: U.S. Department of Health, Educa- tion, and Welfare, 1965.

Pennell, Maryland Y., and Baker, Katherine I.Manpower in the 1960's.Washington: U.S. Depart- ment of Health, Education, and Welfare,Public Health Service, 1964, Health Manpower Source Book 263, sec. 18.

Pines, Ivicya."Danger in Our Medical Labs," Harper's Magazine, October19G3.

101 Prindle, Richard A., and Pennell, Maryland Y.1960 Industry and Occupational Data.Washington: U.S. Department of Health, Education, and Welfare, Public Health Service, 1963, Health Man- power Source Book 263, sec. 17.

West, Margaret D."Manpower for the Health Field: What are the Prospects?," Hospitals, Journal of the American Hospital Association, September 16, 1963.

Nursing Personnel

Conley, Veronica L.The Licensed Practical Nurse.Boston: Research Publishing Co., 1964. Health Occupations Supportive to Nursing: A Statement of Policies and Recommendations by the American Nurses' Association. New York: American Nurses' Association, 1965. Highlights from Survey of Psychiatric Aides.Washington: U.S. Department of Health, Education, and Welfare, Public Health Service, 1964. Levine, Eugene."Some Answers to the Nurse Shortage," Nursing Outlook, March 1964. Marshall, Eleanor D. and Moses, Evelyn D.Facts about Nursing. New York: American Nurses' Association, 1964. Mc Hale, Thomas."Why the Nursing Supply is Failing to Meet the Demand," Modern Hospital, September 1960. Nursing Personnel.Washington: U.S. Department of Health, Education, and Welfare, Public Health Service 1953, Health Manpower Source Book 263,sec. 2.

Orem, Dorothea E.Guides for Developing Curricula for the Education of Practical Nurses.Wash- ington: U.S. Department of Health, Education, and Welfare, 1966, Vocational Division Bulletin No. 274. A Position PaperEducational Preparation for Nurse Practitioners and Assistantsto Nurses. New York: American Nurses' Association, 1965. Shetland, Margaret L., and Murphy, Marion."Graduate Education in Public Health Nursing: Func- tional vs. Clinical Preparation," American Journal of Public Health, February 1965.

Spohn, Roberta E.The Future of Education for Professional Practice.New York: American Nurses' Association, 1962.

Stahl, Adele G. "MDTA Concerns for Nursing," American journal of Nursing, June1964. Swansburg, Russell G."We Can Do Something about the Nurse Shortage," RN, February 1965. Toward Quality in Nursing: Needs and Goals.Washington: The Surgeon General's Consultant Group on Nursing, 1963. Tschudin, Mary."Education Preparation Needed by the Nurse of the Future," Nursing Outlook, April 1964.

Yett, Donald E."The Nursing Shortage and the Nurse Training Act of 1964," Industrial and Labor Relations Review, January 1966.

Yett, Donald E."The Supply of Nurses: An Economist's View," Hospital Progress, February1965.

102 Occupations of Labor, ManpowerAd- Career Guide for DemandOccupations.Washington: U.S. Department ministration, Bureau of EmploymentSecurity, 1965. Washington: U.S. Departmentof Labor, Dictionary of Occupational Titles,vols. I and II, 3d edition; Security, U.S. EmploymentService, 1965. Manpower Administration,Bureau of Employment of Labor, ManpowerAdministration, Health Careers Guidebook.Washington: U.S. Department Bureau of Employment Security,1965. Washington: Organizational Analysis forHospitals and Related HealthServices. Job Descriptions and Security, U.S. U.S. Department of Labor,Manpower Administration,Bureau of Employment Employment Service, 1952. Washington: American As- Kinsinger, Robert E.Education for HealthTechniciansAn Overview. sociation of Junior Colleges,1965. Health Council, October 1961. New Careers in theHealth Sciences.New York: The National of Labor, Bureau Occupational Outlook Handbook,1963-64 Edition.Washington: U.S. Department of Labor Statistics, 1963.

Technological Developments

General Hospitals, Journal of Blumberg, Mark S."Hospital Automation: TheNeeds and the Prospects," the American HospitalAssociation, August 1, 1961. Hempstead, Conversion Prospects of theDefense Electronics Industry.Edited by John E. Ullmann. N.Y.: Hofstra University,1965. 1965-1970, Washington: U.S.Depart- Manpower for Medical ResearchRequirements and Resources ment of Health,Education, and Welfare, PublicHealth Service, 1963. July/August 1964. Pfeiffer, John E."How Technology Advancesthe Art of Medicine," Think,

The World of 1975.Menlo Park, Calif.: StanfordResearch Institute, 1964. Books, 1965. The World in 1984.Edited by Nigel Calder.2 vols.; Baltimore: Penguin

Diagnosis and Patient Care American Journal of Nursing,June 1964. Adams, John C."Hyperbaric Oxygen Therapy," 1964. Blumberg, Mark S."Electronics Can Expand X-rayCapability," Modern Hospital, January 20, 1961 through Bushor, William E."Medical Electronics,"Electronics, 5-part article, January 19, 1962. 103 Computers, Electrocardiography, and Public Health: A Report of Recent Studies.Washington: U.S. Department of Health, Education, and Welfare, Public Health Service, 1966.

Coronary Care Units.Washington: U.S. Department of Health, Education, and Welfare, Public Health Service, 1964.

Davis, John F."Medical Engineering," International Science and Technology, September 1964.

"Does Your Hospital Belong in U.S. Network of Kidney Dialysis Centers?," Modern Hospital, January 1965.

Farrier, Robert M."Problems of Electronic Monitoring," Hospitals, Journal of the American Hos- pital Association, April 1, 1963.

Geis ler, Philip H., and Williams, George E."Automation in the Clinical Laboratory," Hospital Topics, February 1963.

Griffin, Noyce L.Electronic and Related Electrical Equipment in Hospitals.Washington: U.S. Department of Health, Education, and Welfare, 1963.

"Instruments for Clinical Chemistry Labs," Chemical and Engineering News, December 9, 1963, and December 16, 1963.

Lasagna, Louis."Now Dr. Robot Enters the Scene," New York Times Magazine, June 16, 1963.

Rappaport, Arthur E."The Hospital Laboratory: A Look at the Future," Hospitals, Journal of the American Hospital Association, July 16, 1964.

Skole, Robert."Thermovision : Heat Pictures on an Oscilloscope Screen," Electronics, July 26, 1965.

"Survey Shows Widespread Acceptance of Electronic Instruments in U.S. Hospitals," Modern Hospital, November 1961.

Hospital Information Handling

Blumberg, Mark S.Computers for Hospitals.Menlo Park, Calif.: Stanford Research Institute, report presented October 22, 1963, at 4th International Congress of Medical Record Libraries, Chicago.

Borker, Kenneth, Kinkrough, Wilson, and Heller, William.The Medication Error Problem in Hos- pitals.Fayetteville, Ark.: University of Arkansas Medical Center, 1965.

Bowden, Joan."Computers," "Computers at Work," "Data Processing," Hospital Topics, November, December 1964; January 1965.

Campbell, Charles M."Akron Speeds Information Systems Slowly," Modern Hospital, April 1965.

Campbell, Charles M."Information System for a Short-Term Hospital," Hospitals, Journal of the American Hospital Association, January 1, 1964.

104 1 Giesler, Raymond H. "How Many Hospitals UseAutomatic Data Processing Equipment," Hospitals, Journal of the American Hospital Association, January1, 1964,

Glueck, Bernard C."The Use of Computers in Patient Care," MentalHospitals, April 1965.

Pacholski, Edward C."A Shared Installation is the Answer forSome," Hospital, Journal of the American Hospital Association, January 1,1964.

Hospital Supply and Services

Blumberg, Mark S."New Hospital Laundry Techniques are Coming," ModernHospital, May 1962.

Lech, Marie M. Hospital Central Services, A Survey of CurrentLiterature, Washington: U.S. De- partment of Health, Education, and Welfare,Public Health Service, vol. I, 1963.

McGibony, John R."A Special Report on Hospital Trends and CentralServices," Hospital Manage- ment, July 1964.

McGibony, John R., Lech, Marie M., and Davis, Ella H. AStudy of Hospital Central Medical and Surgical Supply Services.Washington :U.S. Department of Health, Education, and Welfare, Public Health Service, June 1965, 40 pages.

"New Conveyor System Moves all Supplies," Modern Hospital,February 1965.

Silverman, Fred and Rosenfield, Eugene D."Central Medical and Surgical Supply," Modern Con- cepts of Hospital Administration.Edited by Joseph Karleton.Philadelphia: W. B. Saunders Co., 1962.

Organization and Design of Health Facilities

Blumberg, Mark S."Special Care Units," Modern Hospital, January 1965.

Blumberg, Mark S."What Tasks Should Hospitals Perform?," Modern Hospital,November 1963.

Edgecumbe, Robert H."The CASH Approach to Hospital Management Engineering,"Hospitals, Journal of the American Hospital Association, March 16, 1965.

Elements of Progressive Patient Care.Washington :U.S. Department of Health, Education, and Welfare, Public Health Service, September 1962.

"First Aid for Hospitals," Business Automation, November 1963.

Groner, Pat N., Hess, Paul E., and McKillop, William."Hospital Administrative Services," Hospitals, Journal of the American Hospital Association, May 16, 1964.

Hospital Administrative Research.Washington: U.S. Department of Health, Education, and Welfare, June 1964.

Miller, Richard A."Hospitals," Architectural Forum, July 1962.

105 Pelletier, Robert 3."Search for a Therapeutic Environment," Hospitals, Journalof the American Hospital Association, February 1, 1965.

Sohlstrom, Dennis R., and Sudeith, Russell."Technological Change ina Hospital," Employment Service Review, May 1965. Appendix E

E. Interviews Consultants

Gordon A. Friesen Associates: Gordon A.Friesen, Walter Spilman.

Stanford Research institute: Dr. MarkBlumberg.

System Development Corporation: HaroldWilson.

Government Agencies

California State Department of Employment: G.S. Roche, Mrs. A. Covington.

U.S. Public Health Service

Division of Hospital and Medical Facilities:Philip Burgoon, Robert Fitzsimmons,Miss Helen Hollingsworth, Mrs. Marie Lech, R.N., JohnReece, Dr. A. E. Rik li, Mrs. MarySims, Miss Josephine Strachan, R.N.

Division of Nursing: Dr. Eugene Levine,Stanley Siegel. 107 Division of Public Health Methods: Dr. Richard A. Prindle, Mrs. MargaretD. West, Dr. Clem C. Linnenberg.

National Center for Health Statistics: Sidney Binder, Theodore D. Woolsey, Mrs.Maryland Y. Pennell.

Office of Surgeon General : Mrs. Lucile Petry Leone, R.N.

Hospital Administrative and Medical Staffs

Carroll County General Hospital (Westminister, Md.) :Joseph R. McFerron, Mrs. Janice Lovell.

Children's Hospital (Akron, Ohio) : Charles M. Campbell.

Georgetown Hospital (Washington, D.C.) : Dr. Ann Peterson.

Holy Cross Hospital (San Fernando, Calif.) : Sister Mary.

Holy Cross Hospital (Silver Spring, Md.) : Sister Justine Marie.

Kaiser Foundation Hospital (Oakland, Calif.) : D. Ernst.

Montefiore Hospital (Bronx, N.Y.) : Fred Silverman.

Veterans Administration (Washington, D.C.) : Dr. L. G. Christianson.

Professional Groups

American Hospital Association: Dr. James B. Hartgering, Colin Churchill, Theodore Gregory, Edward W. Weimer.

American Medical Association: Herman Gruber, Henry R. Mason, Dr. Grant Osborn, Christ N. Theodore.

American Nurses' Association: Miss Meryle V. Hutchison, R.N., Dr. Wanda E. McDowell, Miss Julia C. Thompson, R.N.

National Association for Practical Nurse Education and Service: Mrs. Veronica Conley, R.N.

National Committee for Careers in Medical Technology: Mrs. Dallas Johnson.

National League for Nursing: Dr. Barbara Tate, Miss Evelyn Zetter, R.N.

Supplier Firms

American Hospital Supply Corp.: William K. Henning.

108 International Business Machines Corp.:G. Kramer, F. W. Boegel.

Lockheed Missiles & Space Co.:H. H. Mathews, A. E. Sibley.

U.S. GOVERNMENT PRINTING OFFICE:19670-244-295 109