isillmqljiiiiii division of regional medical programs A communication device designed to speed ITUI-V 16, 1968 the exchange of news, IIC)SPITAT,S NINGA 7 I' Tl' Totirnal -)f the Arierica n flos-pital information and data on As-sociation Featti.res lZe,@ionil %ledical Procyram-s Regional Medical Programs T issue @f@OC[ Ti 'EAL,), -,he ' t@17ial of +L@,e Americ ftospit,,l'i '@.s-,,ociatic,,n, c-it,lii-eci t,-;[,ect (-,F Regional @leci@c-,-tl the\- 11,e a reprin rolat Inc,, to t oF ail of thi@ material is it if)i,,fare(-i in tli t I' s7,ic, includinc-,,, tl,'Le index. cl It c nc)ted that, ti,c ftll )i-c)ceeci ij-(T< oF the American Ilo-@p,@t,il @@-snciarl'()ii Ini ititional (-,oiiFeT-eiLce oil tiospit,il@ aT,,l s, liel(i ()II ItLile c IM,, d reporte@'@ i- t niate-@ "-I , ii (@ Tioi@ @ el n'@ e(I 1 tec! and i,-@ I' fe made ci,,,,ctila'l@ic, tlie,,,r ;irc@ i,e@'-cl@%- iii the near 1-titLire. U.S. DEPARI'MENR OF HEAI,TH., EDI-TCA'1'10-@. AND 'W-ELFARI, Bethesda, Maryland 20014 printed from HOSPITALS Journal of Re the American Hospital Associati Volume 42 July 1, 1968 Printed in U.S.A. ,JOUITNAL OF THE Volume 42 AMERICAN HOSPITAL Number 13 ASSOCIATION July 1, 1968 Published semimonthly by the American Hospital Association Edwin L. Crosby, M.D., executive vice president and director SPECIAL REPORT 21 Conference on' Hospital Involvement in Regional Medical Programs 0 Highlights of Two-Day Proceedings o Keynote Address by Jack Masur, M.D., All Hospitals are Not Equal Regional Medical Programs: Case Studies Memo from 48 1. Intermountain Program Focuses on Community Hospitals the editor C. Hilmon Castle, M.D. Urban centers lead in research, but regional programs focus We met Dr. Leona Baumgart- on community hospitals, where most health care is delivered. ner, the distinguished public 52 2. Albany Program Emphasizes health worker, for the first time Community Strengths, Relationships at a meeting at headquarters Frank M. Woolsey Jr., M.D. the other day. We have always Initial activities in the regional medical programs serve as guides associated her with the campaign for total program planning and provide feedback on results. to substitute the unambiguous 56 3. Academic and Public Agencies Work "flammable" for "inflammable" Together in Missouri Program on gasoline trucks and the like. Vernon E. Wilson, M.D. "Flammable," clearly prefer- Missouri program projects enlist the aid of academic and public able, is now widely accepted. But agencies to improve the quality and availability of health care. that isn't the case with "flam- 60 4. Local Action Groups Involve matory" and, strangely enough, Communities in Kansas Program neither the second nor the third Charles E. Lewis, M.D. edition of the unabridged Mer- A network of projects carried out by local action groups is riam-Webster lists it, sticking the basis of the Kansas Regional Medical Program's operation. with "inflammatory" despite the 63 Regional Medical Programs: not" meaning of the prefix "in." The View from the Hospital That led us to look for some Two leaders in the hospital field were interviewed for their views other opposites, such as "ept" on the proper role of the hospital in Regional Medical Programs. for "inept." "Ept" isn't a word 65 Trends in Blood Banking (Part Two) : in either of the big books. We Component Therapy, Frozen Storage Promise have never heard the adjectival Fullest Use of Blood Resources 49 ruth" as the opposite of "ruth- Dorothy W. Green less" and, although "ruth" does The use of packed red cells, frozen cells, and other types of make the Second Edition, the component therapy is a boon to patients and to blood banking. Third recognizes, quite rightly, MATERIALS MANAGEMENT its disuse and drops it. 70 Evaluating and Standardizing New Products On the other hand" "couth," Albert Carroll as in "uncouth," has grown from The committee evaluating new hospital products should think the Second to the Third. In the about use, costs, waste-for these also improve standards. Second, "couth" is limited to the PHARMACY DIGEST unfamiliar "familiarity" mean- 75 Pharmacists Realign Goals with ing of the word but in the Third New Laws, Health Programs it comes into full bloom as the LAUNDRY DIGEST opposite of "uncouth" in all of 78 Differences Noted Between Soaps and Detergents that word's definitions. ENVIRONMENTAL SANITATION DIGEST e 80 Salmonellae Found in Enzymatic Drain Cleaners HOSPITALS is published the first and sixteenth of each month by the American Hospital Association, 840 North Lake Shore Drive, Chicago, Ill. 60611. Tel. 645-9400, Area Code 312, Cable Address AMHOSP. Second class postage paid at Chicago, Illinois. SUBSCRIPTION RATES: $7 for 1 year; $12 for 2 years; $16 for 3 Years. Single copies 50 cents; except the two-part August 1, Guide Issue $3.50. (Subscribers outside the United States and Canada add $1 per year for postage.) CHANGE OF ADDRESS: Notice should include the old as well as the new addrers, including ZIP code number. Four weeks' notice is required. The local postmaster should be notified. @1968, by the American Hospital Association, all rights reserved. Printed in the U.SA. SPECIAL REPORT Regional Medical Programs were authorized under P.L. 89-239, signed by President Lyndon B. Johnson in October 1965 with the specific intent of improving the nation's health resources for the diagnosis and treatment of heart disease, cancer, stroke, and related diseases. The legislation called for an effective partnership between the federal government and hospitals, physicians, medical schools, research institutions, and voluntary and public health agencies to improve patient care for these categorical diseases. In November 1967, the American Hospital Association ex- pressed full support of the Regional Medical Programs and voted to undertake the development of activities and ma- terials that would be mutually helpful to hospitals and Re- gional Medical Programs. In this issue of H 0 S P I TA L S, J.A.H.A., is an editorial (Page 47) pressed full support of the Regional Medical Programs and gional Medical Programs. Also, four articles appear describing Regional Medical Programs that are now operational. On June 13-14, the AHA sponsored an Invitational Confer- ence on Hospital Involvement in Regional Medical Programs. The purpose: to clarify issues, air differences of opinions, identify common goals, and, on the basis of these discussions, recommend regional and national methods for accomplishing these goals. The following eight pages of the Journal contain a special report on the Invitational Conference, concluding with its keynote address by Jack Masur, M.D. More Hospital Involvement Needed: Group Views Regional Medical Programs OSPITAL involvement in Regional Medical Pro- ning process, cooperative arrangements, and specific Hgrams so far has been disproportionate to the RMP's that are already operational in various parts potential contribution hospitals can and should play of the nation. in the diagnosis and treatment of heart disease, HOSPITAL INVOLVEMENT cancer, stroke, and related diseases, in the opinion D. Eugene Sibery, executive director, Greater De- of most speakers and panel members at the Ameri- troit Area Hospital Council, Detroit, emphasized that can Hospital Association's Invitational Conference on the hospital must be a major participant in the pro- Hospital Involvement in Regional Medical Programs cess of planning Regional Medical Programs. Mr. held at AHA Headquarters, Chicago, June 13 and 14, Sibery declared that hospitals provide an unparalleled Nearly 100 persons affiliated with hospitals, Re- organizational structure that "marshals the largest gional Medical Programs, and the AHA attended the reservoir of community health resources, involves on conference to review the developing relationships be- its governing board a cross-section of community tween hospitals and Regional Medical Programs. Ed- leadership to provide broad community involvement, win L. Crosby, M.D., director, American Hospital As- continuously identifies changing community needs sociation, was general chairman of the conference. and develops means to be responsive to those needs, Dr. Crosby expressed the AHA's continued interest responds to the needs of physicians and other health in and support of Regional Medical Programs. He told care professionals, and permits physicians to organize the participants that the conference could help clarify into a meaningful group for the provision of insti- the role hospitals should play in the administration tutionally related health care." of the programs, Mr. Sibery also pointed out that hospitals are the Other speakers discussed the concept of Regional focal point at which medical theory can be converted Medical Programs, the role of hospitals in the plan- into practice, continuing education of medical and able by most participants in the conference, empiri- representative such as a trustee, chief of staff, or cal evidence was presented that demonstrated, at full-time director of medical education being a mem- least numerically, that hospital representatives have ber of the Regional Advisory Group. Under the law been engaged in Regional Medical Programs to a con- (P.L. 89-239) that group has the final regional re- siderable extent. sponsibility for decision-making in terms of the na- Roland L. Peterson, chief, Planning Branch, Divi- ture and scope of the program. Involvement, by our sion of Regional Medical Programs, National Insti- measure, can also include membership on the several tutes of Health, Bethesda, Md., reiterated the intent planning and review groups which are now generally of P.L. 89-239: "Linkage with and among hospitals found in all Regional Medical Programs. These latter and other major health resources is a categorical planning and review groups-variously referred to imperative of the law that established Regional Med- as 'planning task forces,' 'planning subcommittees,' ical Programs." 'local advisory committees,' and 'local action groups' Mr. Peterson pointed out that failure to comply -have two broad areas of responsibility: (1) the with this policy has resulted in the rejection by the planning of operational programs and activities, in- National Advisory Council for Regional Medical Pro- cluding the establishment of priorities and needs, and grams of several initial planning grant applications (2) the review and recommendation to the Regional involving very prestigious institutions and person- Advisory Group of individual operational projects alities. meriting local approval." Mr. Peterson, before presenting data that showed Community and teaching hospitals, both large and how many hospital representatives are currently small, are represented by some 1000 hospital persons active in Regional Medical Programs, gave an oper- on all 54 regional advisory groups, according to Mr. ational definition of hospital involvement: Peterson. These hospital representatives also are "There are two different aspects of Regional Medi- active on planning task forces and subcommittees and cal Programs. The first distinction relates to the plan- local action or advisory groups. Nearly 600 hospitals, ning and development of a decision-making process almost every state hospital association, and a number as a part of that planning activity. Hospital involve- of hospital planning agencies are included in this ment in this aspect of Regional Medical Programs is group of hospital representatives. (See Tables 1, 2, defined as a hospital administrator or other hospital and 3.) TABLE 1-REPRESENTATION OF HOSPITAL PEOPLE ON RMP DECISION- MAKING AND PLANNING GROUPS Total No. No. Hospital Involved People Percentage TOTAL 4589 1007 22 Regional Advisory Groups 1956 300 15 RMP Planning and Review Groups* 2633 707 27 @@Includes both RMP Pla..ing Task Forces and Subcommittees, and Local Advisory or Action Groups. TABLE 2-BREAKDOWN OF HOSPITAL REPRESENTATION ON RMP DECI- SION MAKING AND PLANNING GROUPS Planning Regional and Advisory Review Groups Groups Total Percentage TOTAL 300 707 1007 100 Hospital Staff: Hospital Administrators 133 297 430 43 Chiefs of Medical Staff 14 58 72 7 Chiefs of Service 34 42 76 8 Boards of Trustees 9 57 66 7 DME's and Other Hospital MD's 35 138 173 17 Nurses and Other Allied Health 15 86 101 10 State and Local Hospital Associations 36 19 55 5 Hospital Planning Agencies 24 10 34 3 TABLE 3-BREAKDOWN OF HOSPITALS, BY KIND AND SIZE, INVOLVED OR PARTICIPATING IN REGIONAL MEDICAL PROGRAMS KIND SIZE (Number of Beds) Total Number 100- 200- 300 and of Hospitals Community Teaching 0-99 199 299 over Planning and Decision-making 551 81 0/0 19% 3 3 clo 2 6 clo 15% 260/o (54 Regions) Operational Activities 531 9 1 C/, 9 0/0 60 clo 16 0/0 9 C/o 1 5 0/0 (13 Regions) ment, it was generally agreed, means far more than merely belonging to regional advisory groups and subcommittees. At the concluding session, Frederick N. Elliott, M.D., assistant to the director of the American Hos- pital Association, reviewed the issues discussed at the conference. Dr. Elliott stated that most participants in the conference felt hospital involvement in Re- gional Medical Programs was far less than was de- sirable. "The monetary basis of Regional Medical Pro- grams," Dr. Elliott declared, "dove'cails with agencies and institutions already receiving substantial federal AFTER DISCUSSING hospital involvement in their respective Re- funds of one sort or another-namely, university gional Medical Programs, speakers answered questions from the hospitals and medical centers. Because such institu- floor. Seated from left to right: J. Gard on Borrow, M.D., coordinator, tions and agencies already have close ties with the Georgia Regional Medical Program, Atlanta; Paul D. Ward, coordina- federal government, they have become grantees for tor, California Regional Medical Program San Francisco; and Stanley W. Olson, M.D., coordinator, Tennessee-Mid-South Regional Medical Regional Medical Programs for reasons other than Program, Nashville. the main one that should dictate allocation of these funds: need. This procedure," Dr. Elliott continued, Mr. Peterson further noted that "these hospital "discriminates against hospitals not affiliated with people constitute some 22 per cent of the total num- universities and medical centers. In other words, Re- bei, of individuals serving on these planning and de- gional Medical Programs are not utilizing the po- cision-making groups. In comparison with other par- tential of community hospitals to the fullest in pur- ticipating groups, this is a favorable percentage. For suing the intent of P.L. 89-239." example, private practitioners, including medical so- Dr. Elliott emphasized that community hospitals ciet@@ representatives, constitute about 24 per cent of are the focal point of health care; as areawide plan- the total; medical school officials about 18 per cent; ning and comprehensive health care programs evolve, voluntary and official health agency representatives community hospitals will offer even greater potential about 16 per cent; and public representatives about for Regional Medical Programs. And, finally, Dr. 11 per cent." Elliott pointed out, as the AHA restructures itself on a regional basis, it will be in an even better position to OBJECTIONS TO RMP'S relate hospitals to Regional Medical Programs. Although Mr. Peterson's figures proved that hos- CONCLUSIONS AND RECOMMENDATIONS pital people are involved in Regional Medical Pro- grams to a considerable degree, most of the con- The issues discussed during the conference were ference's participants were not impressed by the summarized by Mr. Sibery. He spoke against tradi- numerical basis of his argument. Hospital involve- tionalism, parochialism, and provincialism in the hos- THE CONFERENCE was held in the Hall of States at the American Hospital Association Headquarters in Chicago. AM pital and health care field, simultaneously praising gional Medical Programs must recognize this concept the potential of P.L. 89-239 and P.L. 89-749 (Com- and support it." prehensive Health Planning and Public Health Ser- Mr. Sibery recommended that the American Hos- vices Amendments of 1966). pital Association both lead and define the role of hos- "There is a new concept of the hospital that is pitals in the implementation of both P.L. 89-239 and evolving," he said, "one which recognizes that hos- P.L. 89-749. In particular, he urged that this issue be pitals are corporate, entities for the provision of com- studied thoroughly and acted upon during the 1968 prehensive health care to the community, entities annual meeting of the AHA at Atlantic City, Sept. composed of medical and paramedical personnel, the 16-19. administrator, and the board of trustees, who are The federal government, Mr. Sibery suggested, community leaders. While the private sector has needs to coordinate the administration of Regional taken the initiative in many areas of health care, the Medical Programs and comprehensive health planning federal government has tried to fill the remaining legislation at the national, regional, and state levels. gaps and will continue to do so. In the past, hospitals The mutual objective of both legislative acts is to have placedtoo much emphasis on inpatient care, too provide health care for all Americans, he said, and little on other areas of health care. The new, evolving intelligent, complementary planning and administra- concept of the hospital makes it an integral compo- tion, with the full recognition of hospitals' potential, nent of a comprehensive health care system. Re- is necessary if that objective is to be reached. All Hospitals Are Not Eqtial by JACK MASUR, M.D. FEW WEEKS ago, some of us old fellows were sit- paramedical health workers and administrators. And ik ting around, stroking our clean-shaven chins, on that note of perplexity, the old men went home and ruminating on the spate of health legislation we to rest for the next day at the office. have had in the last few years. How can we imple- Several days ago, I prepared to come to this con- ment the new programs? How can we recruit and ference to count the "cost" of our Regional Medical retain enough competent staff for Medicare, Medi- Program as we leave the talking stage and enter the caid, Health Professions Education Assistance, Re- doing stage. There entered my mind a story-the gional Medical Programs, and Comprehensive Health story of the seriously sick man: Planning? What is a true partnership for health? Minister: "Have you made your peace with the How do we mobilize the resources of men and wom- Lord and renounced the devil?" en, money and facilities, and time and understanding Patient: "Considering the fix I'm in, I'm not going to achieve these worthy goals for Americans? to make an enemy of anybody." Over the second cup of tea, one of the more literate IMPORTANT THINGS HAPPEN members of our cadre quoted the oft-forgotten pas- sage from the Gospel according to St. Luke: A hospital is a place where important things hap- "For which of you, desiring to build a tower, does pen every day. It is a place where people who are not first sit down and count the cost, whether he has sick and in trouble are sent to get help. It is a place enough to complete it? where doctors and nurses and other trained workers "Otherwise, when he has laid a foundation, and is strive to diagnose, to cure, and to console them. It is not able to finish, all who see it begin to mock him, a house where all of us endeavor to better the people saying, who are brought to us ... so that the sick may re- "'This man began to build, and was not able to cover their health by the care and diligence of doc- finish.' " tors and nurses and others. We all agreed that "cost" should not be read like In thousands of hospitals we concern ourselves a fundamentalist. We thought it would be more pru- only with today's patients, We use what we were dent to count the "cost" of our tower in appropria- taught long ago: we use what we have gained from tions and doctors, hospitals and group practices, our own experiences; and perhaps we may also use what we have gleaned from the writings of others Jack Masur, M.D., is assistant surgeon general and director, who are more learned than we. Clinical Center, National Institutes of Health, United States Public Health Service, Bethesda, Md. In some hospitals-not many hospitals, and cer- tainly not enough hospitals-we concern ourselves a geographic area-utilizing local enterprise and with today's patients and with tomorrow's patients. responsibility-to improve the quality, efficiency, and In these centers, teachers prepare young men and availability of health care. women for the health professions. In these centers, This is a time of trouble. Violence around us, war many kinds of doctors and scientists engage in re- in Vietnam, riots in the cities, student@ revolts, search for the acquisition of new knowledge. In marches and demonstrations, readjustments in gov- these few hundred hospitals, where there are per- ernment financing-these all contribute to what is sons with lifelong commitments to teaching and to called the ordeal of change in our society. It will be clinical research, we are more likely to witness the hard to make constructive changes in the rigid pat- restless pursuit of excellence in the care of the sick terns of health care. There are plenty of long-term and the reaching out for more effective ways to pre- problems which burden the polyprofessional com- vent suffering in the future. plex in which hospital administrators, trustees, physi- The reason we are gathered here is that we now cians, coordinators, and public officials serve through- have the chance, through RMP, to bring to many, out this nation. I select just three of these problems many other hospitals that are concerned only with for special mention at the opening of this conference today's patients /the know-how that is continuously on hospital involvement in regional medical pro- being improved in the larger centers of learning and grams. They are crucial, I believe, in the future teaching. determination of whether there will be a place for All hospitals are not equal. About 20 years ago, the voluntary system in the health scheme of our under the Hospital Survey and Construction Act, we country. Let us spend a few moments on (1) costs embarked on a program to increase the number of and quality, (2) doctors and management, and (3) hospitals and to improve the geographic distribution planning and government. of hospitals, with special emphasis on economic need Our people want and deserve the best hospitals of the states and on the attraction of physicians to we can design, equip, staff, and operate. It makes rural areas. good sense for all of us in government at the local, Government funds have supported the construction state, and federal levels to nourish and sustain vol- of many small hospitals in all parts of this country. untary hospitals and health agencies so that we can There have been many beneficent results from the use all that is good in the voluntary system to carry government subsidy in the creation of so many new out the public responsibility. hospitals in the past two decades. But we must face up to the fact that in 1968, two-thirds of our gen- COSTS AND QUALITY eral hospitals are under 100 beds. In fact, three out Ever since the end of World War II, people in our of four general (nonfederal) hospitals are under 200 society have wanted and needed and expected more beds. In terms of the number of hospitals-not the health care. The massive growth in prepayment and proportion of beds-we are a country of mostly small insurance protection for the families of working men hospitals. and women did not suffice. A prosperous nation was Small hospitals are useful for delivering babies urged to provide more government assistance to the and setting broken bones, but I hardly need remind aged, the handicapped, and the poor. During the past you of the limitations of lack of house staff, diffi- few years, Congress has responded with legislation culties of recruitment of professional and technical authorizing enormous new medical programs. Our staff, and absence of other resources to deal with the hospitals have not been overwhelmed. They have modern diagnosis, treatment, and rehabilitation of accepted the greater load. They have adjusted to the patients with heart diseases, cancers, strokes, and demands for higher wages by health workers, who related diseases. have been in short supply. Costs have escalated FAILURE IN REGIONAL PLANNING rapidly: more than two and a half times as fast in 1966 as in previous years. And they are now rising To acquire proper perspective, we ought to re- even more sharply. member that a basic premise in the formulation of For some time now the atmosphere has been pol- the original Hospital Survey and Construction Act luted with a lot of pejorative rhetoric about hospitals, in 1946 was the introduction of regional planning as doctors, and dollars, and the high cost of being sick, the essential mechanism for articulating small, me- of getting well, and of dying. Speech writers para- dium, and large hospitals. For a variety of reasons- phrase the professional analyses of trends in an af- professional chauvinism, medical economics, institu- fluent period when the demands exceed the supply, tional autonomy, civic pride-we have failed since and we are told from many platforms that there are 1947 to achieve effective systems of regional planning. serious deficiencies in the organization, financing, Like many other good ideas, this type of collective and-delivery of health services in the United States. voluntary planning, through representative regional There is even some perseveration about the uncon- organizations, takes more than 20 years to consum- trolled runaway escalation of medical costs. We are mate. The Regional Medical Programs now afford us admonished to bring the costs down but to keep the the opportunity to improve the odds in favor of that quality up. random patient going to the random doctor who Unfortunately, some of the "badmouth" talk about sends him to the random hospital. Or, to put it in rising wages without commensurate increases in pro- bureaucratic terminology, the Regional Medical Pro- ductivity leads to allegations of inefficient manage- grams can be the orderly process required for the ment. However much we hospital people may feel organization and coordination of health services in put upon by those who would penalize the so-called inefficiencies, the hard cold fact is that few people the hospital and doctor are in a sort of obligatory understand why hospital costs have gone up so symbiosis; more and more the doctor's professional steadily and so rapidly. We have not succeeded in activity is at the hospital. It has been reported that explaining the inextricable relationship between nowadays at least halt of the income of the average quality and costs. Although the people want the best physician-and for some specialists 100 per cent of that modern medicine can provide, most of them do income-is earned at the hospital. not yet accept the fact that the higher quality of As new state laws and additional court decisions hospital care justifies the higher costs. make it abundantly clear that the quality of medical practice in a hospital is indeed the responsibility of DOCTORS AND MANAGEMENT the governing board, physicians will want to par- Most of you are familiar with the fable which was ticipate in the decisions of trustees. The point in our recounted earlier this year in the report of the See- discussion here is that the services prescribed by the retary's Advisory Committee on Hospital Effective- doctor for the patient in the hospital account for a ness: large part of the costs of care. A way needs to be "The intelligent visitor from Mars was interrogat- found to make the physician aware of these costs and ing a hospital administrator on the purposes, func- to obtain his continual cooperation in ordering what tions, and administration of a hospital. The Martian is needed for the proper care of the patient. was told that the doctors in the hospital order the It is this dichotomy that must be dealt with before procedures for patients and thus determine how the we can make any sense out of the exhortations to resources are used and what work members of the lower costs and still maintain high quality. staff do-that the physicians decide which patients to admit and when to dismiss them. PLANNING AND GOVERNMENT "'And where do these important persons stand in Earlier I referred to the Hospital Survey and Con- your organization?' the man from Mars asked. struction Act-the popular Hill-Burton program " 'Actually, they stand outside the organization,' which is generally accepted as a happy example of the hospital administrator explained. 'They are paid fruitful collaboration of federal government, state by our customers and they must observe certain government, local government, and voluntary agen- rules, but by tradition the hospital must not inter- cies. I believe that all who are responsible for the fere or seek to influence their decisions.' Regional Medical Programs will find it useful to " 'But you must be joking!' the visitor exclaimed. study carefully the long-term achievements and 'As anyone can plainly see, such an arrangement shortcomings of the Hill-Burton activities, bearing would be impossible to manage.' in mind that the program has a different states- "The administrator acknowledged that it was not relations structure. easy. The intelligent visitor was heard to mutter as You will recall that during the great depression he was leaving: there were 1200 counties, with a population of 15 " 'Impossible-or very, very expensive.' million people, that had no hospital facilities. During As our health programs grow bigger and more the hard times of the 1930s, we made do with what costly, as our hospitals and health organizations have we had, and there was no hospital construction. more stress, there is a relentless trend toward admin- During World War II, we built a small number of istrative centralization and toward enlargement of simple hospital structures to cope with the emer- executive power-within the hospital as well as in gency requirements of communities crowded with governmental jurisdictions. It will be fascinating to workers in shipyards, airplane factories, and indus- observe the efficacy of innovative managerial tech- trial war plants. niques such as product commonality, cost-benefit In 1946, Congress enacted the law which incorpo- analyses, and programming-planning-budgeting sys- rated the major recommendations of the Commission tems in the guidance and control of massive expen- on Hospital Care, a joint effort of the American Hos- ditures in hospital care, health services, and bio- pital Association and the United States Public Health medical research. Service. We look at the lessons of 20 years of history Be that as it may, I think many of us are con- and conclude that the Hill-Burton activities have vinced that we are long overdue in devising ways served the nation well. They have subsidized the and means of having more involvement of doctors in construction of more than 300,000 hospital beds and the institutional affairs of hospitals-more authority several thousand health units, including nursing and more responsibility for staff physicians and den- homes, diagnostic and treatment centers, chronic dis- tists in the making of policy, in the getting and ease hospitals, and rehabilitation facilities. More than spending of money, and in sustaining professional half the hospitals constructed with Hill-Burton sup- discipline. port have been in areas that had no hospitals: about The personality of a hospital is split. It defies one-fourth of the projects have been in areas that analysis by conventional methods of consulting man- previously had only unacceptable hospital beds. agement therapists because of the bizarre relation- There has been an improved distribution of doctors ships between the trusteeship-superintendency and and nurses; the average level of architectural and en- the medical staff. The dual control of hospital activi- gineering design has been greatly improved through- ties which the man from Mars had a hard time out the country. Of considerable importance is the understanding is, in my judgment, a threat to the sur- fact that enabling legislation at both federal and vival of the voluntary hospital and ultimately jeop- state levels brought representatives of consumer and ardizes the proper care of patients. More than ever, community interests, as well as nongovernment hos- pital officials, into the policy-making structure of high costs. In the course of time, there will be a state health departments. better acceptance of high costs if we continue to These have been gratifying achievements. There strive to remedy some of our professional and admin- have been some failings, some deficiencies. In a pro- istrative weaknesses. gram of this size and complexity, wide variations in One of the most satisfying results of an effective performance by government at all levels slowed RMP effort throughout the country will be the im- progress: handicaps included inadequate staffing, pro provement of the environment of more hospitals for forma surveys, rigidity in administration, lack of ad- learning and the improvement of the capacity of ministrative research, and the approval of too many more hospitals for applying new and better methods small hospitals. But as we confess those things we of treatment. have left undone that we ought to have done in the This is a room full of sincere realists. You know Hill-Burton program, the most notable deficiency has and I know that we shall not have instant change, been in areawide planning. In 1952, the President's despite those who are impatient with the shortage of Commission on the Health Needs of the Nation called easy answers. We ought to remember the classic for a wider range of goals for regional systems of phrase, "inevitability of gradualism," as we search health services. These objectives would have entailed for the right answers to the limitations of health ser- a heavy commitment of medical schools and teaching vices provided by the combined voluntary and public hospitals in extension services, postgraduate educa- health systems in America. tion for all levels of health personnel, appraisal And now I conclude. I have sought some brief studies, and sharing of medical, technical, and admin- expression of what I hope RMP will do for patients- istrative resources. The realization of the grand strat- how it will help doctors to heal the sick and to keep egy was not achieved because of (1) the traditional the well in good health. I submit this portion of the reluctance of medical school faculties to project their Code for Physicians written 700 years ago: services beyond the campus, (2) the shortage of med- ". . . If physicians more learned than I wish to ical teachers, and (3) the burgeoning of biomedical counsel me, inspire me with confidence in and obedi- research programs. ence toward the recognition of them, for the study of science is great ... grant me the strength and oppor- A NEW OPPORTUNITY tunity always to correct what I have acquired, always And now we come to Regional Medical Programs. to extend its domain; . . . man . . . today can dis- And, once again, we must consider the fix we're in. cover his errors of yesterday, and tomorrow he may We can all agree that RMP has become an organiza- obtain new light on what he thinks himself sure of tional imperative. The good that we are doing in our today."-MAIMONIDES. hospitals is often overtaken by the resentment of [ON EDITORIAL NOTES -a matter of initiative health manpower. But Regional communications. Moreover, re- Medical Programs are overcoming gionalization enables individual these biases and limitations, more hospitals to benefit from health quickly in some regions than in care research and facilities they GIONAL Medical Programs rep- others, and the programs are be- lack but that exist elsewhere in R!resent an evolutionary part- coming viable, concerted eff orts their region. nership of the federal government toward the achievement of their In this issue of HOSPITALS, and physicians, hospitals, univer- goals. J.A.H.A., case studies of four opera- sity medical centers, and public Bridging the gap between medi- tional Regional Medical Programs and voluntary health agencies to cal research and patient care re- present evidence that the health combat heart disease, cancer, quires, above all, the development care objectives in the original leg- stroke, and related diseases-af- of continuing education and com- islation are being realized. Con- flictions that are responsible for 70 munication channels that enable gress is now considering the ex- per cent of deaths in this nation. medical and paramedical person- tension of P.L. 89-239 for another Regional Medical Programs are nel to keep abreast of the latest five years. If the extension is ap- attempting to reduce this percent- methods of treatment. Many hos- proved by Congress, it will be a age by reducing the time and space pitals are located at great dis- tribute to the current achieve- separating the latest research ad- tances from major medical centers, ments of Regional Medical Pro- vances in these disease categories and it is not always feasible for grams and, more significantly, a and the individuals who suffer physicians or other health person- very positive contribution toward from them. nel to travel hundreds of miles for the improved health of our nation. Increasing attention is being advanced training in the treatment A hospital is the logical focal turned to the initiative of individ- of heart disease, cancer, stroke, point of projects and developments ual hospitals in the development and related diseases. of Regional Medical Program ac- of plans by which they can con- Regional Medical Programs can tivity, since it is the dispenser of tribute to, as well as participate provide, at major medical centers, program achievements to the pa- in, the benefits Regional Medical special training based on research tient. What is implied, therefore, Programs offer. This attention is findings, to medical and paramedi- in the hospital's position is also reasonable, particularly since hos- cal personnel who, in turn, corn- essential-that the hospital recog- pitals' ability to provide health municate their knowledge to their nize and respond to its responsi- services to heart, cancer, and colleagues in community hospitals. bility to participate not only in stroke victims within their service Continuing education is imple- dispensing, but in planning and areas stands to gain through these mented in some cases via tele- implementation of projects with programs. phone, radio, and television net- all the creative energy that the It is no simple task to coordinate works that link the medical resources of the hospital will al- the leadership and manpower nec- centers, hospitals, clinics, and other low. Perhaps it goes without say- essary to achieve the intent of the agencies in a given region. ing that an overriding responsi- law. Voluntary hospital adminis- Regionalization maximizes hos- bility for those administering the trators, trustees, and physicians pitals' potential for providing pa- Regional Medical Programs is con- often are prejudiced against fed- tient care to victims of heart ducting the programs in a way eral participation in health care disease, cancer, stroke, and related that will foster and encourage this planning and practice. Moreover, diseases through continuing edu- all-important participation by hos- there is a critical shortage of cation programs and improved pitals. CASE STUDY: INTERMOUNTAINREGIONAL MEDICAL PROGRAM INTERMOUNTAIN PROGRAM FOCUSES ON COMMUNITY HOSPITALS by C. HILMON CASTLE, M.D. RGANIZED EFFORTS to improve 0 health manpower and facili- The Intermountain Regional Medi- ties in the Intermountain region of cal Program has established numerous the United States began to coalesce r rojects to improve health care delivery in community hospitals, the author re- in the fall of 1965 under tne ports. Among the specific goals of the impetus of federal funds and as- program are development of teaching sistance available through the faculties in community hospitals, crea- Regional Medical Programs legis- tion of better working relationships lation enacted as Public Law 89- among hospitals and local educational 239. The University of Utah and and research institutions, provision of the faculty of its College of Medi- new diagnostic facilities, and continu- cine became the hub of planning ing education of health professionals. meetings with state medical asso- ciations, county medical societies, ments within the region and with (OPPOSITE PAGE, LEFT) A computer network medical staffs of major ho sponsored by the Intermountain Regional @pita@s' other regional programs in the Medical Program serves five hospita and other medical leaders in tiie country, and developing systems Is from Intermountain region. The support a central computer capable of storig i. for sustaining interaction among million items of information. Hospitals en- of organized medicine and a broad rolled in the project use the central unit at spectrum of health workers was such groups. Explaining the pur- Lafter-Day Saints Hospital, Soft Lake City poses of the program to profession- (shown here), for programmed teaching, enlisted through discussions in al and lay communities, develop- screening patients, and immediate analyses major community meetings and of admitting tests. (OPPOSITE PAGE, RIGHT) regional workshops of the pur- ing methods for collecting data on Health care personnel at remote "ations, @eart disease, cancer, and stroke, such as the one shown here at LDS Children's poses and potential of the regional identifying needs within the re- Hospital, Salt Lake City, can receive diag- medical program,legislation. As a nostic data directly from the central comp ter gion that can be met by Pubic Law 0 compu result of these meetings, the health at Latter-Day Saints Hospital. Th ter 89-239, and formulating proper link provides physicians at Children's Hospi- professionals agreed to develop a tal with instctntaneous analyses of electro- regional medical program in a procedures for construction of pi- cardiograms, faster determination of pulmo- lot projects and methods for their nary disorders, and better monitoring of coherent geographical area with review and approval have required patients during heart catheterization and after strong economic and cultural ties, continuing efforts under the plan- cardiac surgery. an area composed of the state of Utah and portions of five adjacent ning grant. states-Nevada, Idaho, Montana, The critical mass of resources Wyoming, and Colorado. required to initiate the Intermoun- tain Regional Medical Program PRIORITIES ESTABLISHED was provided by the educational A planning grant for the Inter- institutions in the region, particu- mountain Regional Medical Pro- larly the University of Utah and its medical school. The presence of gram (IRMP) was obtained in .. . this medical school, with its inter- July 1966. Major planning efforts since then have been directed to- est in and commitment to commu- nity needs, has been an important ward recruiting and training a ingredient in IRMP progress to staff capable of meeting the chal- date. lenges of this new program, es- Major problems confronting the tablishing lines of communication IRMP include the scarcity of with all the organizational ele- health-planning personnel inter- ested in the regional medical pro- C. Hilmon Castle, M.D., is coordinator of gram, the territorial imperatives of the Intermountain Regional Medical Pro- gram and associate dean and associate pro- existing institutions and organi- fer'sor at the University of Utah CoUege of Medicine. zations, the natural resistance to change by organized professional and so on); clinical traineeships velop new ideas and perspectives groups, and the apprehension on in cardiology tailored to individual for the Regional Medical Program. the part of physicians of govern- needs; and visiting consultants and Respiratory therapy training for ment funded programs. Although teaching clinics for physicians in physicians, nurses, and techni- all of these problems have been remote communities who are un- cians. The training provides in- minimized in the Intermountain able to attend courses away from struction in the proper selection of region, they must be acknowledged their Practices. patients for special respiratory as major deterrents to rapid de- Cancer training and continuing therapy and the use of modern velopment of any regional medical education. The cancer training pro- equipment in community hospitals. program. @rarn includes refresher courses Endocrine and metabolic labo- EXPERIMENTAL PROJECTS for practicing physicians, seminars ratory determinations relevant to for pathologists, and a computer- cardiovascular diseases and can- All Pilot Projects of the IRMP ized regional tumor registry. The cer. The IRMP's newest project have been constructed as experi- program emphasizes retrieval of provides for laboratory analyses of ments, but with specific goals data for the purpose of identifying abnormalities in production of cer- based on documented needs with- educational needs of individual tain substances (catecholamines, in the region. Methods for evalua- practitioners and facility require- renin, aldosterone, pituitary hor- tion of progress are required in all ments within each community in mones, and others) not performed project designs. Many of the needs the region. - Continuous on-line computer the region. Each laboratory deter- were identified prior to the forma in existing clinical laboratories in tion of the IRMP and Several of monitoring of physiologic data. mination serves as a stimulus to the Projects discussed here have Data monitored for patients with development of a specific educa- emerged from existing strengths. acute myocardial infarction and tional program for the physician Most of the projects are aimed at Postoperative cardiac patients in or hospital staff member request- improving the capabilities of per- four hospitals is used to provide ing the test. Programs of clinical sonnel already trained as well as Patient services and information research into frequency of abnor- exploring methods for better util- to Physicians for decision-making malities and incidence of diseases ization of existing health man- under urgent circumstances. This related to hormone abnormalities power. Much planning has been project also provides screening are developing as a natural by- directed toward meeting the obvi- tests (such as pulmonary function product of this project. ous and serious health manpower tests and electrocardiograms) for needs of the region, but projects to large groups, as well as measure- CONCEPT AND APPROACH train new and different personnel ment and analysis of cardiac cath- The general concept and ap- have not yet emerged. eterization data while the proce- proach used in developing the Twelve pilot projects have been dure is being performed. IRMP is illustrated by the acute implemented in the IRMP over the The stroke project. This project cardiac care project for physicians past year: sponsors visits to small communi- and nurses. First, a "core faculty" Network for continuing educa- ties by consultants in stroke and was developed from a cadre of tion. The network connects the related diseases, plus a library and practicing internists, cardiologists, major community hospitals in the telephone consultation service and and nurses interested in teaching Intermountain region by means of an inservice clinical training pro- and providing exemplary coronary two-way radio communication and gram for physicians. care. The primary catalyst for the a distribution system for a variety Communication and information faculty has been a program of Of teaching aids, including taped exchange service. This service is concentrated three-day courses for television programs, broadcast tel- an instrument for obtaining feed- physicians and three-week courses evision, and closed-circuit systems back from the public and health for nurses, each held quarterly, and within institutions. An important professionals as to health needs conducted by a visiting faculty of element of this project is the es- and the extent to which the Re- nationally recognized stature. The tablishment of a teaching faculty, gional Medical Program is meeting confidence and capabilities within drawn from the IRMP staff, in the its stated purposes. The project the "core faculty" necessary to im- major community hospitals, with also serves to inform those inter- plementation and maintenance of the ultimate objective of creat- ested in the IRMP of program de- a continuous and extensive educa- ing an environment conducive to velopments through a monthly tion program in cardiology have learning and clinical research in newsletter and other conventional emerged as a result. the major community hospitals in communication techniques. Coronary care units in commu- the region. Training-feedback seminars. Ev- nity hospitals have served as the Educational and training pro- ery four months, seminars are primary focus of the heart disease gram in heart disease. This Pro- conducted by experts in medicine, education program, but the efforts grarn encompasses four interre- education, the social and behavior- of the "core faculty" extend far lated projects: acute cardiac care al sciences, and politics, to help beyond the confines of hospitals, training for physicians and nurs- the IRMP staff, Regional Advisory and the interest created in coro- es; cardiopulmonary resuscitation Group members, and other com- nary care has resulted in many courses for health professionals munity health leaders gain a bet- other benefits. For example. sev- and selected personnel who pro- ter understanding of the forces eral members of the "core 'facul- vide first aid (firemen, policemen, influencing health care and to de- ty" have initiated clinical research (RIGHT) PHYSICIANS gather for an instruc- tion session in the continuing professional education project sponsored by the Inter- mountain Regional Medical Program (IRMP) and broadcast from the University of Utah Medical Center under IRMP auspices. projects in the existing units; a Uniform system for collection and classification of data on coronary care patients is being developed for analysis of the value Of Coro- nary care units in altering mor- bidity and mortality of patients with ischemic heart disease; and the entire medical community has become interested in the use of equipment to continuously moni- tor physiological parameters such as arterial and venous pressures, cardiac output, ventilation, and blood gases. As a result of the educational program in heart disease, advanced methods of monitoring and treat- ing acute cardiac illness are likely to be extended to other community hospitals within the region as soon as the value of such techniques has been demonstrated more clear- ly. Interest in the feasibilty of coronary care units in small hos- pitals (less than 50 beds) and in methods of transporting patients with acute myocardial infarctions to special treatment units also was stimulated by the project. All of these benefits developed from the original effort to improve the knowledge and skills of selected physicians and nurses in acute cor- of acutely ill patients, laboratory fore, the functional elements of onary care. determinations, and consultations. programs such as the IRMP should The development of the acute The conviction is strong that con- be concentrated in community hos- coronary care training project em- tinuing education must take into pitals. The IRMP has already phasizes the value of beginning account the facilities and setting helped develop teaching faculties with a small but manageable por- in which a particular health ser- in community hospitals, created tion of a particular problem. As vice is provided. Also, involvement better working relationships among interest and understanding in- of both academic and practicing hospitals and the educational and crease and feedback on the initial communities in continuing educa- research institutions in the region, effort is obtained, direction is pro- tion is essential to a viable Re- provided new diagnostic facilities, vided for meeting larger needs in gional Medical Program that will and trained a broad spectrum of proper sequence. have significant impact on improv- health professionals. This progress ing the health care of patients marks only the beginning of a MEET EDUCATIONAL NEEDS with heart disease, cancer, stroke, program that has the potential of The primary thrust of the In- and related diseases. measurably improving the delivery termountain Regional Medical The projects developed to date of health care. The IRMP is com- Program has been to provide ad- in the IRMP emphasize the impor- mitted to working within the ex- ditional education to health pro- tant place of community hospitals isting patterns of medical practice, fessionals who already have had in any regional program. Univer- to continuous monitoring of re- formal training and experience. sity medical centers may provide gional needs, to exploration of new The Program's concern with con- the stimuli for education and re- ways to improve health manpower tinuing education includes not search in health care and provide and facilities, and to serving as an only practitioners' abilities to pro- models for study, but the bulk of integrating force among all the vide exemplary care, but also the health services will be delivered elements engaged in the care of availability of essential services within communities by community patient& with heart disease, can- such as physiologic monitoring hospitals and their staffs. There- cer, stroke, and related diseases. 0 MEDICAL CASE STUDY: ALBANY REGIONAL MEDICAL PROGRAM ALBANY PROGRAM EMPHASIZES COMMUNITY STRENGTHS, RELATIONSHIPS by FRANK M. WOOLSEY JR., M.D. HEN THE ALBANY Regional W Medical Program (ARMP) became the first regional program in the nation to be approved under Public Law 89-239, its organizers set as their primary goal the strengthening of community medi- cal resources and the promotion of cooperative relationships among all institutions, agencies, and indi- viduals concerned with improved patient care. Although leadership in the pro- gram has been assumed by Albany (N.Y.) College of Medicine of Union University, interregional meetings have been held through- out New York State and New Eng- land for the exchange of pertinent information on the prevention, de- tection, and management of heart disease, cancer, stroke, and allied diseases. The focus of the program is the community, particularly the com- munity hospital. The regional pro- AN IMPORTANT feature of the Albany Regional Medical Program is coordination of cancer gram gives to both the medical care in local areas. Here an area coordinator studies an isotope scan with a member of the college and community hospitals nuclear medicine staff at Ellis Hospital, Schenectady, N.Y. an opportunity to assume new re- sponsibilities and to develop more The following pilot projects have positive roles in community lead- Early approval of Regional Medical been designed to attack the more ership and service by responding Program operational projects has pressing problems identified in to the many opportunities residing guided realistic planning of the total the early stages of the program within regional medical programs. program, the author points out, and through establishment of adequate The pilot projects discussed in has helped sustain interest and mo- communication, identification of this article comprise the initial ac- mentum at the community level, which tivities of the Albany program and is the base point of activities to up. educational and training needs, are not representative of a com- grade the facilities and manpower es_ and supplying of educational and sential to the delivery of health care. training opportunities to meet those needs. Frank M. Woolsey jr., M.D., is associate plete regional program, but they Two-way radio network. The dean of the Albany (N.Y.) medical C"ilege of union University and professor and do fit the established and identifl- organizers of the Regional Medical chairman of the department of postgradu- ate medicine. able mold of the ARMP, Program concept, although seeking THE ALBANY regional program sponsors a training project for coronary care unit nurses to familiarize them with the special equip- ment and nursing techniques employed in coronary care. include a nu her of high schools IL that conduct adult education classes, to facilitate development of information and education pi-o- grams for adult groups. Such plo- grams should become especially effective information dissemination activities, since past experience has shown that the interaction be- tween teacher and ctudent during two-way radio conference en- hances the instruction potential not only for those who actively participate, but also for those who only listen. Eventually, headquar- ters of voluntary health a-encies and selected medical societies also A "JUKEBOX" automatic self-instruction device is being developed at Albany (N.Y.) Medical will be brought into the network. College under the auspices of the regional medical program. The device will be used in learn- In the past the two-way radio ing centers to be established in community hospitals throughout the region. facilities have been used almost entirely for the continuing educa- tion of practicing physicians, but originality, have wisely encour- the Albany program and because their use is being greatly diversi- aged each region to develop and the basis for effective regional in- fied. The ARMP is developing pro- expand its preexisting strengths. terrelationships is communication, grams to assist the rapid dissemi- One of the strengths of the Albany the ARMP's first pilot project was nation of information to allied region is in the two-way radio to expand the radio network to medical personnel, administrators, conference network developed include as many of the 87 hospi- members of boards of trustees, over a period of 12 years for con- tals within the Albany region as voluntary health agencies, selected tinuing medical education. This possible. At the end of 1967, after civic groups, and, as mentioned network probably is the nation's 9 months' operational activity, 35 above, adult education classes. The most sophisticated communication of the 87 hospitals were equipped same radio facilities will allow system devoted exclusively to pro- with two-way radio facilities. community and medical college fessional education. In addition, it is anticipated that personnel involved in the Albany To incorporate this feature into the network will be expanded to program to meet "on the air" for 'ABOVE) A regional project for nurse instruc- lion via two-way radio network is part of the Albany program's continuing education efforts . Here a group of nurses at the Berk- shire Medical Center, Pittsfield, Mass., par- ticipate in a medical conference broadcast originating from Albany, N.Y. (RIGHT) X-rays being used as teaching aids during a con- tinuing education radio broadcast are shown to physicians in a community hospital that participates in the communications program. informal conferences and forums. Postgraduate instruction devel- developed within community hos- Another project is twice-monthly opment panel. The development pitals as enticing innovations and radio conferences for nurses, in- panel will be used to identify the attractive opportunities for con- augurated in January 1968 with educational needs of practicing tinuous learning. The department broadcasts from 12 separate nurs- physicians. Approximately 80 of postgraduate medicine at Al- ing school faculties in New York, practitioners will assist in the bany Medical College is in the New England, and Ohio. identification of educational and process of formulating self-in- Community information coordi- training needs and will help deter- struction programs to be used in nators. Community coordinators mine the effectiveness of instruc- these learning centers. This de- and the professional staff of ARMP tion designed to alleviate those velopmental activity is financed are in direct personal communica- needs. It is anticipated that phy- under a contract with the National tion with the institutions and in- sicians' participation in carefully Library of Medicine. dividuals in the Regional Medical designed programs of continuing The design and configuration of Program. The community infor- education will improve their diag- the learning centers is experimen- mation coordinators are former nostic and treatment abilities and tal. Experience will be gained pharmaceutical manufacturers' thus enhance the quality of patient through careful evaluation of func- representatives who serve the pro- care. tion and the reaction of the learner gram by maintaining a continuous Community hospital learning to various items of equipment and flow of information among indi- centers. Many practicing physi- methods of presentation. Many of viduals, communities, and Albany cians no longer can take time away the educational needs identified by Medical College. In addition, they from practice for adequate in- the postgraduate instruction de- gather data and assess attitudes volvement in continuing medical velopment panel project will de- and reactions to the program in an education, so it has become advis- termine the design of instruction attempt to evaluate the amount of able to develop the community available through the learning progress being made toward ma- hospital as a center for continuing centers. Activities to date have jor objectives. They also help education and to devise methods bL-en concerned with the develop- organize and carry out data-gath- of helping those in practice to re- ment of programs and the es- ering techniques used for identi- ceive needed information. There- tablishment of equipment needs. fication of health care needs. fore, "learning centers" will be Careful evaluation of the use of ti-iese centers, each associated with physical facilities to organize the Disease, Cancer and Stroke"-had a medical library within a selected coronary care education and dem- to be dispelled, but almost without hospital, should prove useful in onstration program has been diffi- exception, those individuals con- determining the effect of learning cult. Progress has been steady, tacted have indicated their sym- centers on patient care. however, and the first classes now pathetic agreement *ith the Coronary care training and de- are being conducted at the medical concepts of the Albany Regional monstration programs. The admin- center. Medical Program. Administrators istration of Albany @edical Col- SUCCESSES AND PROBLEMS and staff members of community lege believes that the Regional hospitals often express the desire Medical Program should be de- The Albany Regional Medical for a closer working relationship veloped in such a way that the Program has been very successful with Albany Medical College and medical college faculty is not re- in conducting a program of infor- the medical center. Great interest quired to supply all the education- mation dissemination to inform in- has been shown in the developing al activities undertaken through dividuals and organizations of the opportunities for continuing edu- the program; therefore, the coro- Regional Medical Program legisla- cation and assistance in keeping nary care program has been de- tion and the opportunities residing professional knowledge and abil- signed to develop an educational within the developing program. ity updated, and in the training of and training cadre not only at Al- Hospital administrators, staff phy- allied medical personnel in great bany Medical Center, but also in sicians, governing board members, numbers. some of the larger community hos- voluntary health agencies, and The ARMP has produced impor- pitals. Members of this cadre may many others have been contacted. tant effects within the medical then give instruction to others In some instances, misconceptions center: responsibilities and oppor- within their local areas. about the program-misconcep- tunities vaguely recognized in the The recruitment of personnel tions based on the "Report of the past have been brought into focus and the acquisition of necessary President's Commission on Heart as the regional program entered its operational phase, and the pre- dominant attitude within the cen- ter has become one of interest, enthusiasm, and cooperation. The continuous planning that has accompanied ARMP activities is beginning to generate additional projects to strengthen individual and institutional interrelationships and effect improved patient care. Serious problems in the Albany Regional Medical Program have been limited to a scarcity of trained or trainable personnel, particularly skilled and highly trained professionals. The rela- tively slow activation of the post- graduate instruction development panel, for instance, is a result of difficulties in obtaining the needed supervisory personnel. Psycholo- gists, behavioral scientists, compu- ter and data processing experts, educational specialists, and other key personnel are in short supply. A temporary solution is the inter- mittent employment of consultants in those specialties until enough full-time staff is recruited for the program's expanding activities. Early approval of ARMP opera- tional projects has guided realistic planning of the total program and has helped sustain interest and momentum at the community lev- el. The resulting additional project applications will, when approved, expand the advantageous influ- ences of the Albany Region Medi- cal Program. MEOICAL CASE STUDY: MISSOURI REGIONAL MEDICAL PROGRAM ACADEMIC AND PUBLIC AGENCIES WORK TOGETHER IN MISSOURI PROGRAM by VERNON E. WILSON, M.D. A (OPPOSITE PAGE) In a research project spon- has reported that MRMP assis- sored by the Missouri Regional Medical Pro- Regional Medical Programs, the tance has made it possible in the gram, computer data is used to simulate and author says, can provide the impetus for last few months to save the lives test hospital routines and now bioengineer- ing equipment in the University of Missouri's cooperation hetween aU the academic of some 33 cardiac patients who Engineering Computer Laboratories. disciplines and health-oriented agencies died had not the might have in the effort to aid physicians in ae- MRMP project been in existence. fivering to each citizen the highest pos- The intensive cardiac care tech- liE MISSOURI Regional Medical sible quality of medical care, directly niques in practice at Springfield TProgram is concer@ed with re- to the patient in his own community, search and demonstration projects if possible, and at the lowest @sible Hospital also have been taught to in the development of techniques, cost. more than 200 Missouri nurses devices, and other aids to assist through a "Code Blue teaching the physician in delivering to each symposium" sponsored by the pro- citizen the highest possible quality gram. of medical care, in the patient's care" are being tested or put into Interregional cooperation. Ac- own community, if possible, at the practice. tivities in the Greater Kansas City lowest possible cost. . The Smithville project is de- area demonstrate that two Re- In the 10 months that the pro- signed to test the proposition that gional Medical Programs can work gram has been operative, a num- a community hospital can be the together effectively. A proposal base of operations from which phy- has been submitted for the devel- her of gratifying developments sicians can deliver comprehensive opment of a testing and demon- have shown that it will justify its health care to the surrounding pop- stration "laboratory" built around organizers' commitment to it and ulation. Comprehensive care in- the personnel and facilities at a contribute to some of the broad ciudes prevention, treatment, and large hospital formerly owned by goals of the Regional Medical Pro- rehabilitation, as well as considera- the city. This institution has been gram concept. tion of the social and emotional as- reorganized under a voluntary Initial efforts of the Missouri pects of illness. An important part board of trustees, which is estab- Regional Medical Program of the concept is a program of lishing a medical center complex (MRMP) have been focused on community education aimed at in- containing general hospital facili- early detection and improved forming the population of avail- ties, a center -for intensive treat- educational processes. However, able and possible treatment for ment of mental illness, and a activities in the program are heart disease, cancer, and stroke teaching and research complex expected to be dynamic and con- at the community hospital, as well that includes a dental school. tinually evolve in response to new as efforts at public indoctrination Since this hospital provides information provided through re- in measures for the prevention or much of the care received by the search and through new, imagi- early detection of these diseases. indigent population of the area, a native proposals arising from The program at Smithville con- major concern is the determina- local groups. Expansion of in- siders the whole individual and tion of whether better health care terregional cooperative endeavors the several factors that might have and improved delivery of that care also is expected as the program brought him to his state as a pa- to the poor will help reduce urban develops. tient; indeed, this is the kind of social tensions. INTERRELATED PROGRAMS patient care and consideration Bioengineers in medicine. A At present, 16 individual, inter- that is the goal of the whole Mis- number of MRMP projects draw related-and to some degree in- souri Regional Medical Program. heavily upon the engineering tal- terdependent-projects are in When a patient emerges from this ent available at the University of progress. A brief summary of kind of comprehensive attention, Missouri: for example, the devel- these projects suggests the nature he is ready to return to society as opment of bioengineering elec- and direction of present activities. a productive and adjusted member. tronics for use in early detection MRMP in microcosm. The Smith- Cardtac Hall. Springfield, a city and treatment of heart disease, Ville project represents a microcosm of about 100,000 in southwest Mis- cancer, and stroke. One device al- of the total program activity. The souri, is the site of another kind of ready in operation aids in the re- project at Smithville, a small effort. There, through the efforts of covery of patients suffering from community just north of Greater a number of physicians, several bedsores. These skin ulcers, often Kansas City, centers on the Smith- aspects of a comprehensive cardio- developed by patients confined to Ville Community Hospital, where vascular care program are being bed for long periods of time several aspects of "total medical developed. A model "cardiac hall" stroke victims, for example seem already has been established at to heal faster if a low voltage elec- Vernon E. Wilson, M.D., is program co- one local hospital, with the finan- tric current is maintained through ordinator, Missouri Regional Medical Pro- gram, and executive director for health cial and consultative help of the a wet bandage over the sore. The affairs. University of Missouri, Columbia. MRMP. Although MRMP funds bioengineering project has pro- were not used for physical facili- duced an inexpensive device that (OPPOSITE PAGE) Real hospital and emer- ties, the program did assist with can be used either in the hospital gency procedures or* observed and analyzed planning and training programs or in a patient's home. Should the by Missouri R&glonal Medical Program's oper- that demonstrably have improved current be interrupted by the ations research engineering team. The lnfor. patient care. drying out of the bandage, the nation obtained Is used to make hospital ,4ne simpler and more efflcient. The Springfield project director machine automatically sounds an the faculty of the University of OREGON PROGRAM Missouri School of Journalism, who, with several graduate asso- SPONSORS CONTINUING EDUCATION PROJECT ciates, are studying and scien- tifically measuring the kinds of communications to which people The Oregon Regional Medical Program (ORMP) became opera- i-eact: for example, what motivates tional in April of this year upon receipt of a $221,191 grant for individuals to heed medical advice. on-the-spot education programs to improve care of patients with Studies of the effectiveness of ex- heart disease, cancer, stroke, and related diseases. The Oregon isting brochures on cancer and program, which was 44th of the 54 programs in the nation to be smoking and other diseases mea- funded for planning, is the 13th to become operational. sure communication effectiveness The ORMP will use the grant from the National Institutes of with "Q-scale" techniques. The Health to finance traveling circuit courses for physicians and team also has designed and pro- allied health personnel. The courses, which will be offered three duced brochure covers that score times each year in 18 communities throughout Oregon, Idaho, very high on the Q-scale and is and Montana, are designed to supplement other postgraduate producing poster material designed courses offered by the University of Oregon Medical School. to appeal to various kinds of audi- In addition to the circuit courses, the ORMP is engaged in a ences. Patient Origin Study with hospitals throughout the state in a The Communications Research joint effort to learn the incidence and prevalence of heart disease, Unit also is devising "facilitators" cancer, and stroke, and the points of origin of patients with these to reinforce the patients' desire to diseases in the Oregon area. Hospitals participating in the study follow health instructions. For ex- submit an inpatient discharge statistics form for each patient ample, a provocative set of health- discharged during September, October, and November, 1967. oriented pamphlets is being de- ORMP officials estimate that the study eventually will include signed and written to attract statistics on more than 74,000 patients. recipients not only to read the pamphlets, but to retain them as Data from the Patient Origin Study will be used to evaluate the reference booklets, much as cook- need for ORMP operational projects and-to provide new informa- books are kept and referred to. tion on the incidence and prevalence of heart disease, cancer, Much of this work represents a and stroke, and will provide participating hospitals with descrip- new kind of approach to health- tive information about the patients they serve. oriented activity, and preliminary Other information gathering and dissemination projects spon- results indicate that the techniques sored by ORMP have included a statewide workshop at which and materials devised by the Com- hospital and medical leaders met with representatives of health munications Research Unit will be agencies and voluntary health organizations to explore ways of eff ective. improving the prevention, detection, and treatment of heart dis- Research also is being con- ease, cancer, and stroke in the Oregon region. Additional opera- ducted into the development of tional programs for the training of coronary care unit nurses and multiphasic, automatic laboratory for the prevention, diagnosis, and treatment of patients with screening for early detection of stroke, cancer, and heart disease have been approved by the diseases. Another project concerns Oregon regional advisory board and submitted to the division of an automated and computerized Regional Medical Programs, National Institutes of Health, for method of taking patient histories. approval. It is hoped that this device, or something similar to it, will en- PHYSICIANS FROM Corvallis, Ore., and surrounding communities meet at Good able the patient to contribute more Samaritan Hospital, Corvallis, for a small group discussion of cases presented in the "Polyps and C6ncer of the Colon" course, one of a series of traveling positively to his own care, thus circuit courses sponsored by the Oregon Regional Medical Program. offering a partial solution to the serious shortage of physicians and long waiting periods for patients. SUMMARY After a year of experience, the MRMP staff is discovering the po- tential benefits of coordinating the efforts of many disciplines in the search for solutions to health care problems. Under the aegis of pro- grams like MRMP, the future holds possibilities for this kind of inter- change not only among disciplines on a single campus, but among universities and health-oriented agencies everywhere. In THE CENTRAL Kansas Medical Center in Great Bond is the base of operation for the educational project of the Kansas Regional Medical Program. This project is an attempt to establish an active continuing education program for medical and nursing staffs. CASE STUDY: KANSAS REGIONAL MEDICAL PROGRAM LOCAL ACTION GROUPS INVOLVE COMMUNITIES IN KANSAS PROGRAM by CHARLES E. LEWIS, M.D. The Kansas Regional Medical Pro- ments of this proposal, and on June gram is based on a network of projects 1, 1967, the Kansas Regional Medi- carried out by local action groups, rep- cal Program became operational. resenting a regional approach to the To achieve the objectives set HE DEVELOPMENT of the Kansas improvement of patient care, the author forth in Public Law 89-239, more TRegional Medical Program be- says. He describes projects now under groups must participate in the pro- gan in January 1965 when several way dealing with research, education, gram than just research and teach- faculty members of the University work evaluation, communications, and ing centers. Involvement of local of Kansas Medical Center met to a library network. After one year of communities in the activities of the discuss potential involvement in the operation, the local action approach Regional Medical Program is es- proposed program. Discussions con- appears to be successful and the pro- sential if the program is to develop tinued throughout that year, and in gram holds much promise, he con- roots and thrive. The Kansas Re- November the University of Kan- cludes. gional Medical Program operates sas Medical Center was designated on the philosophy that this pro- by the governor as the agency to National Institutes of Health, re- gram must be made up of a net- act in behalf of the Kansas Region. questing $197,945 for the first year work of projects representing a In April 1966 a planning grant and $223,700 for the second year regional approach to the improve- was submitted to the Division of of planning activities. This applica- ment of patient care. Regional Medical Programs of the tion was approved in June 1966, For a Regional Medical Program and planning began on July 1. A to survive, it must beget a second Charles E. @wis, M.D., is coordinator of grant requesting funds for support generation of projects, and a third the Kansas Regional Medical Program, and of operational activities was sub- generation, and so forth. Unless professor and chairman, department of pre- ventive medicine and community health, mitted in October. In April 1967 additional groups can become in- University of Kansas Medical- Center, Kansas City. approval was given for certain ele- volved, the program is sterile and regional approach to improving patient care. Most of the eff orts of the opera- tions and planning staff of the Kansas Regional Medical Program have been concerned with the pro- motion of local action groups throughout the region. Since the beginning of operational activities, 10 communities or groups of com- munities have expressed definite interest. These groups range from two small communities of 5000 persons each in Northwest Kansas to nine counties in Southeast Kan- sas that have joined together in their approach to the program. While 10 "communities" already have applied for "action," several others are working on projects for the program. ASSIST LOCAL GROUPS (ABOVE) A TYPICAL planning session of the Having encouraged the forma- Kansas Regional Advisory Council illustrates will become extinct. However, all tion of local action groups, the core the "Kansas method"-roll up your sl;e,es and get down to business. This grou re- offspring of a Regional Medical staff of the Kansas Regional Medi- views new project applications submitted by Program must be related to the cal Program must assist these local action groups. (BELOW) These nurses parent and must represent evidence groups in converting their ideas are receiving training for duty in an inten- sive care unit. This program, one of several of stepwise progress toward the into projects. This action requires demonstration projects under way, also at, ultimate goal of the program-a different approaches, depending tempts to evaluate the newly acquired skills and information gained by the trainees. upon the size and the nature of the that will be installed in community cal library and data link to the local action group. hospitals throughout the state. A University of Kansas Medical Cen- The first groups within the Kan- library network that will make it ter will assist in the creation of a sas region to submit projects for a possible for health professionals tangible manifestation of the uni- supplemental operations grant re- throughout the state to receive on versity's concern for continuing quest generally represented larger request recent bibliographic re- education by extending itself into institutions and metropolitan areas. views, as well as soft copies of the state. If this project is success- It appears that smaller conununi- scientific articles, through their ful, it will be replicated at several ties require considerably more help hospitals or existing public library other centers throughout the re- during the brainstorming period, networks. gion. in which ideas that not only are Several demonstration projects The approach described in de- feasible, but also are acceptable to also are under way. They include veloping a local action program the community, are identified. the development of a work evalua- seems to have been successful. On Thus, the role of the staff varies, tion unit in a community hospital Nov. 18, 1967, the Kansas Regional depending upon the degree of def- in Wichita that is similar to a car- Advisory Council met and consid- inition of the projects proposed by diovascular work evaluation pro- ered 11 new project applications a group at the time it becomes "in- gram now existing at the Univer- resulting from community activi- volved" with the Regional Medical sity of Kansas Medical Center. A ties. Five of these applications Program. cancer detection clinic is being were approved and submitted to It is in the best interests of all studied in a private hospital in the Division of Regional Medical concerned if all local action groups, metropolitan Kansas City to eval- Programs in Washington in the large or small, can discuss poten- uate means of increasing its ef- form of a supplemental operations tial projects with the staff as early ficiency. grant request. If approved, these as possible. The staff assists them A program to train nurses for applications will involve 19 addi- in defining the background need, duty in intensive or coronary care tional hospitals in the Kansas Re- the objectives, the methodology, units involves four hospitals in the gional Medical Program. Judging including means of evaluation and metropolitan area. This program from activity in other communities, the budget for the projects they are already has been oversubscribed it seems probable that supplemen- proposing. Local action groups are for the first year. It includes an tal grant applications will be forth- encouraged to submit or to develop attempt to evaluate trainees, in- coming from the Kansas region on several ideas that might result in cluding their fund of information a quarterly basis for several years. projects that could be carried out and newly acquired skills, and an The ability of the Regional Ad- in their areas. The submission of experimental evaluation program visory Council to function effec- several ideas (potential projects) utilizing actors from the graduate tively suggests that the regional allows the staff to exert some guid- school of the University of Kan- review mechanism can, at least ance over the long-range develop- sas who play the roles of "pro- under certain circumstances, fulfill ment of the program by assisting grammed" patients. Students are its responsibilities. the natural promotion of those able to examine their own be- projects that are obviously more havior by replaying video tapes AN EXPERIMENTAL VEHICLE consistent with the needs of the made in an effort to evaluate the The Kansas Regional Medical region (as seen by the Kansas Re- effective domain of nursing care in Program might be described as an gional Advisory Council) and that the program. experimental vehicle for develop- will represent successive steps in The research project is providing ing methods for regionalization of the development of a truly regional base line data and follow-up eval- health care (for persons with cer- program. uation of all projects. One of its tain diseases) within the state. major endeavors has been a con- There is some danger that with a VARIETY OF EFFORTS sumer study in three counties in program of this type, individuals The original operational grant Kansas with various problems re- will ask, "What can the program supports a variety of efforts. A garding the health service system. do for me?" instead of "What can computer project is concerned with This study will provide base line the program do for our commu- studying the feasibility of install- data to measure the efforts of treat- nity?" ing hospital information systems in ment with Regional Medical Pro- In addition, there is a risk of hospitals involved in the educa- grams. overselling the program in terms tional project, as well as with pro- The largest project in the region of leading the public to believe that viding computation and data anal- is the educational project being a flurry of activities under the ysis services for staff offices and carried out at the Central Kansas name of "Regional Medical Pro- other projects within the program. Medical Center in Great Bend. This grams" will result in the ability to A communications group is exam- program represents an attempt to prevent or even cure patients with ining the feasibility of construct- introduce a program of active con- heart disease, cancer, or stroke. It ing two-way audio-visual commu- tinuing education based upon needs would be unfortunate if impatience nications between various centers determined by local health profes- and expectations for immediate throughout the state. This group sionals and members of the project payoff lead to disillusionment and also is concerned with utilizing staff. Full-time faculty in medicine defeat before the design intentions television and other media in self- and nursing will be located at this of Regional Medical Programs can instructional learning laboratories hospital. In addition, a local medi- become a reality. REGIONAL MEDICAL PROGRAMS: THE VIEW FROM THE HOSPITAL Two respected IN THE early days of the life Eugene Sibery, executive director, Of the organization created by Greater Detroit Area Hospital Public Law 89-239-the Regional Council, and acting coordinator of ketittk professionals, Medical Programs-one often the Michigan Regional Medical heard the expression 1 4 regional Program during its organizational medical complexes." Those charged period, and still active in the Re- with administering the law, espe- gional Medical Programs at the closely related cially those from the hospital state, regional, and national levels. world working to spread the Both agreed on two things. Potential good tidings of the Re- First, there was, at the outset, an to both hospitals gional Medical Programs, cringed understandable emphasis of the whenever they heard this phrase. medical school as the statutory Rightly so, because the phrase center of the programs and, sec- "regional medical complex" car- ond, that without the deep in- and tke ried with it a connotation of ever volvement of the community hos- larger complexes of laboratories, pital on a widespread basis, the Re institutes, classrooms, and hospi- Regional Medical Programs could ,qional Medical tals clustered about the great not begin to attain their potential medical centers in various regions for improvement of health care of our country. in this country. Program concept The primary aim of the legisla- lip A NEW RELATIONSHIP tion was not to reduce the "gap" between the laboratory bench and Dr. Howell, who has committed and operations the hospital bedside or clinic. To much of his personal time and most Americans, the hospital bed- energy to the successful inaugura- side is in their own community tion of the RMP concept, sees it a,qree on tke hospital and not in the large medi- as a first-time mobilization of hos- cal center. Furthermore, the gap pitals, the practicing physician, between laboratory bench and hos- and the school of medicine and koc,,nitat's position pital bedside in the medical center research facility. He said that it often is small. It was a reduction has brought unusual problems and in the time lag and the distance that these were to be expected. f - One of them, Dr. Howell said, is oCal Pont gap between the university medi as cal center and the community hos- the fact that the dean of the school pital, at least in the categorical of medicine must now develop a area of heart disease, cancer, and relationship that he has never had of RMP effectiveness stroke, that was sought in the law. before with the administrator of Regardless, in the early stages the community hospital. The in- of the program hospital involve- evitable choice of the medical ment at the local level was ex- school as the primary participant tremely limited, and even today it in the RMP planning process at is a matter of considerable con- the outset did produce a sense of cern. Two persons who are close outsideness-of nonparticipation- to both hospitals and the Regional on the part of the local hospital Medical Programs discussed this and the local physician. problem recently. They are James However, although the medical T. Howell, M.D., executive direc- school was at the heart of things tor of Henry Ford Hospital in at the beginning, the real target in Detroit and a member of the Na- Dr. Howell's opinion is "out there tional Advisory Council to Re- in the community." Dr. Howell gional Medical Programs, and Dr. believes that the good of pro- grams will come from community is on a silver platter, concept. The community's focal point and we involvement; he also is' sure that community hospital must reach are going to work with the medi- the real control over the future of out. It, and this obviously means cal staff and the Regional Medical RMP's is in fact going to be at the the hospital administrator, is to a Program organization to identify local community level. very large measure the master of our communities' needs. "What the region is going to his own fate in this program. The do," Dr. Howell said, "must be hospital administrator, with his INITIATORS, NOT REACTORS derived at the local level. A phy- managerial talent, has an unprec- "Let's face facts! The medical sician and the hospital have the edented opportunity to improve center is often remote from tlle right to make their own decisions patient care not only in his own actual practice of medicine, often and then work through the re- hospital but throughout the na- remote from the practicing physi- gional advisory board to bring tion." cian. Fancy schemes of communi- their own programs to fruition. IFOCUS IN HOSPITALS cating the latest in medical knowl- 4 iThe state medical societies, the edge to the practitioners on the state hospital associations, the state Mr. Sibery agrees that at the firing line may die a-borning sim- nurses' association-all sorts of outset the Regional Medical Pro- ply because the doctor doesn't have groups-must be involved in the grams were medical-center-ori- any more hours in his busy day. It creation of the planning body. In ented. Some of the medical schools may be, and he's the one who can every one of the regions, the state perceived the programs, he said, as tell you, that the way to improve hospital association has been in- simply a method of expanding his practice is to have someone volved. The degree of activity their own continuing education ef- work with him in his actual prac- varies, as one would expect, but forts. The medical schools were tice, with his actual patients. where the hospital group has been the ones that were going to deter- "Much has been said and much the most active, there we are go- mine the needs and then do their concern expressed about the fact ing to have the best results. utmost to meet those needs. He be- that in most cases the medical lieves that this was the wrong ap- school was the applicant for the INITIATIVE IS LOCAL proach and that, if it had prevailed, RMP grant. To me, while I happen "What hospitals and their or- RMP's may well have foundered. to prefer the method of an inde- ganizations must understand is As originally contemplated, he pendent agency that we've used in that this program is not designed pointed out, the Michigan Regional Michigan to avoid identification to produce something from the top Medical Program would have had with an individual school, it doesn't down. RMP simply says, 'Send us a direct effect on just 12 per cent really make all that much differ- a proposition.' RMP doesn't tell of the hospitals: the hospitals ence. What does make a difference the physician or the hospital what that, in Mr. Sibery's opinion, least is the involvement of the local they should want or what they needed improvement. community hospital in the identifi- should do. There are no standard Mr. Sibery was instrumental in cation of needs. The thing that forms. The local group can put it turning the program around. matters is that the definition of together in any way it sees fit. "What we had to do," he said, need must not be made by remote "RMP headquarters in Bethesda was to devise programs that control, either in a planning agency isn't telling Fargo, North Dakota, would have input at the grass or in a medical school. or Albany, New York, what they roots, that would determine the "There are some glaring exam- think is good for them. It has cre- needs at that level. Then we could ples of the hospitals being ignored ated a very flexible organization, identify the role that medical and others of hospitals ignoring an organization that is a vote of schools and other centers of excel- the whole program. I think the confidence in us at the local level. lence should play in meeting these hospitals and their organizations I think that it is up to the hospitals needs. The hospital is evolving as must become the initiators of ac- to accept this vote of confidence. the focal point for health within tion rather than the reactors to it. "RMP has given the community the community; therefore it is go- We in hospitals and hospital groups hospital a chance to come closer ing to become a comprehensive must understand this legislation to the center of medical progress. community health center. and its intent and be among the The community hospital must "Not that every hospital is going chief architects of its development. move. It must respond. I now sense to become a university teaching We must go out and knock on a much greater awareness on the hospital, but every hospital must doors wherever they are and insist part of hospitals than at the be- be concerned with a full range of that we be heard. I believe that we ginning of the programs. This, of services. If this is true, and I sin- have the expertise. I know that the course, is due largely to the ap- cerely believe it, then the hospital community hospital is the level at pointment of full-time staffs in the is the best place to start identify- which the Regional Medical Pro- various regions. Now that these ing local needs. It is the primary gram must be made to work. It is staffs are busy in the various re- organizational level at which the logical, therefore, that we should gions, I think that communications members of the medical staff start get into the act all the way. are improving every single day. relating in some 'meaningful and "Like Dr. Howell, I think that "I'd like to emphasize that the organizational way. I think it is up this program offers every hospital whole design of the Regional Med- to the hospital to recognize this, to a unique opportunity to tie into, ical Programs is to take away any proclaim it, and then to say that to tap the great resources of our 'this is good for you' or 'here it we, the hospital, do represent the medical center." 0 INTRODUCING THE AUTHORS Frank M. Woolsey Jr., M.D., co- director for health affairs at the ordinator of the Albany Regional University of Missouri, Columbia, Medical Program, describes some is a graduate of the University of activities being developed by that Illinois Medical School. Dr. Wilson program in an article beginning on is chairman of the Commission on page 52. Health Professions of the National Dr. Woolsey also serves as asso- Association of State Universities ciate dean of the Albany (N.Y.) and Land Grant Colleges, a con- Medical College of Union Univer- sultant for health education and sity, and as professor and chair- construction to the United States man of the department of post- Public Health Service, a member graduate medicine at the college. of the American Association of Medical Colleges-Veterans Admin- istration liaison committee, and a member of the Advisory Council on Health Research Facilities of the National Institutes of Health. DR. WOOLSEY DR. CASTLE C. Hilmon Castle, M.D., coordi- nator of the Intermountain Re- gional Medical Program, discusses DR. WILSON DR. LEWIS pilot projects sponsored by the Intermountain program in an ar- Charles E. Lewis, M.D., director ticle beginning on page 48. of the Kansas Regional Medical Dr. Castle also is associate pro- Program, discusses several pilot fessor of medicine and professor projects sponsored by the Kansas and chairman of the division of program in an article beginning on postgraduate medical education at page 60. the University of Utah College of Dr. Lewis, who also serves as Medicine, Salt Lake City, where professor and chairman of the de- he also serves as associate dean of partment of preventive medicine the medical college. He is a fellow at the Ulaiversity of Kansas Medi- of the American College of Cardi- cal School, Kansas City, took his ology and of the American Heart medical degree at Harvard Uni- Association Council on Cardiology, versity and a doctor of science de- a fellow of the American College gree at the University of Cincin- of Physicians, a past president of nati, where he was a fellow in the the Association of Medical Tele- Kettering Laboratory Department vision Broadcasters, and a member of Preventive Medicine. He has of the American Medical Associa- served as a resident in occupa- tion committee on national plan tional medicine at Eastman Kodak for continuation education for phy- Company, Rochester, N.Y., and as sicians. an associate editor of the Jour- nal of Occupational Medicine. Dr. Lewis is a member of the Ameri- Vernon E. Wilson, M.D., program can Public Health Association, the coordinator of the Missouri Re- American College of Preventive gional Medical Program, describes Medicine, and the New York Acad- current activities in the program emy of Science, and is a fellow of in an article beginning on page 56. the American Academy of Occu- Dr. Wilson, who also is executive pational Medicine. m