Social service should have a definite place in hospital organization. Social service should be the agent of the Commanding Officer for dealing with; (a) the relationships of the hospital to other groups in the community; (b) the relation of the patients to their families and their community; and (c) in the relation of those matters which affect the social conditions which are involved.
Of course everything in the Social Service Department as in any other department of the hospital must be under the absolute control of the Commanding Officer. It has a relation to the administration of the hospital, and to the patients’ treatment. In its relation to the hospital the Social Service Department may:
In the Navy the funds for our entertainment program are primarily provided from allotment made by the Morale Division of the Navy Department and from ships shore or canteen profits. The Red Cross supplements our endeavors and assigns at certain hospitals other personnel than Home Service or Social Service Workers, to assist in recreational measures.
The Social Service Department’s relation to the patient’s treatment:
Then there is the After Care of the patient and one the Social Service Department should be competent to handle:
Lastly there is the Information service which this Department may provide:
The Social Service Department of the hospital irrespective of the source of supply of the personnel must be considered as an integral part of the hospital, subject to the inspections, rules and regulations of the hospital.
The Red Cross at present provides the personnel for social service endeavors and I cannot conceive how any other agency could undertake to provide this service without providing the cobweb like organization spread out over the United States with thousands of Home Service sections as the Red Cross maintains, prepared to furnish information to the government officials. Until the government can provide a similar, and an adequate service, I know of no other civilian organization which enjoys the semi-official recognition imposed by the Congress and to which we in the government can turn for assistance, than the American Red Cross.
The social service problem is one of helping the doctor, the man, the family, and to represent the community.
We as medical men must remember that treatment, if successfully instituted, must embrace rehabilitation of the mind to a like degree that it does the body. A cure cannot be affected by the simple administration of drugs or a stroke of the scalpel. Something just as important, and in many instances more so, is the attention to the mental state of the patient. All the medicine, all the most skilled surgery will not cure unless careful attention is paid to the mental frame of mind of the patient. The whole social service effort is one to help bring back the patient to the world of reality and to maintain morale at a high level.
We must always be conscious that in caring for patients there is a basic distinction due to the mental depressions resultant from illness, helplessness and dependency, and protracted convalescence. Sick men have distorted judgment, reason illogically, magnify trifles, and acquire a certain degree of negativeness. Their spirit of discipline is stunted. They resent correction and restriction. They must be retrained to think logically and coherently. Each patient must be treated separately, prescribing for his individualism when he is abed and while still unable to attempt a return to group action. The morale of the patient is just as important as the administration of drugs or surgical relief. In fact, I do not believe it too broad a statement to say more so, for every patient must be treated from a morale standpoint. While some patients need medical, others surgical treatment, a great many need neither medical nor surgical attention, but only mental rehabilitation. The last class are not necessarily pathological cases nor psychiatric cases, but a peculiar class demanding careful study and definite prescription usually of arecreationalform.
We must not overdo the social service for the good of the man himself, his family and his community. The greatest service we can render the disabled ex-service man is to reinstall in him self-reliance. We must keep his morale high, for morale is the perpetual ability to come back.”
COL. EDWIN P. WOLFE gave the following discussion on “Hospital Supplies”.
“Mr. Spangler has given us a very complete description of the general method of procurement, storage and issue of supplies required in the management of hospitals. It may be permissible, however, to elaborate a few of the details and to call attention to certain common errors on the part of hospital personnel using these supplies.
It is a well established principle for the efficient distribution of supplies that the final “break-up” be made as near the ultimate destination of the supplies as is practicable. This requires, of course, a sufficient number of supply depots located in suitable sections of the country from which the individual hospitals can secure their supplies withthe least practicable delay. The question of size and location as well as rental cost of warehouses is ofttimes the determining factor in the number of depots from which supplies are to be distributed. From the standpoint of economy in operation, fewer depots of larger size are the more desirable; from the standpoint of prompt distribution, the larger number, more widely distributed are the more desirable. It requires a great deal of study of transportation lines and traffic conditions to decide upon the happy mean between these two.
The average person who uses hospital supplies has very little conception of the great amount of storage space which is necessary in order to carry at all times in the warehouses a six months’ stock to the end that requisitions may be filled immediately upon receipt. As an illustration, the Medical Department of the Army had in operation within the territorial limits of the United States on November 1, 1918, ten large distributing depots, with an aggregate floor space of more than 2,000,000 square feet. This area expressed in square feet is so staggering as to convey a very inadequate conception of its size. To those of you who are familiar with the methods of describing land in the central and western states, it may be made intelligible by saying that the area exceeds that of a forty acre tract. In fact, it is approximately 45 acres. If you can conceive of such a tract piled ten feet high with supplies, allowing, of course, for roadways and aisles you will get some conception of the mass of material which had been accumulated for the Army at that date. Then bear in mind that there were thirty-three camps, each with its large general hospital, having three warehouses, approximately 25 × 125 feet more or less completely filled with supplies and you can get an idea of the quantity of supplies required for current use in those hospitals and for dispensary service of the camp. As a further illustration of the quantities of supplies necessary it may be permissible to state that the quantity of gauze of various meshes, from that required in bandages down to the coarsest grade used in surgical dressings, not forgetting, of course, the muslin, that was procured by use between April 6, 1917 and March, 1918, was sufficient to have provided a strip a yard wide around the earth at the equator and a bow knot consisting of several hundred miles in addition. If the yarn which was required in weaving this mass of material had been all made into one single thread, one end of it might have been hooked on the limb of some giant tree on earth with the other end dropped into one of the spots on the sun and still had a few thousand miles to spare. The number of beds actually available for use in the hospitals in the United States on January 1, 1919, if placed end to end would have stretched over a distance in excess of 90 miles. If the mattresses had been placed side by side and end to end to form a square, they would have covered sixteen acres.
Proper warehousing is a very necessary part of the supply service. For efficient warehousing as well as for prompt and satisfactory distribution of supplies, a standard list of articles to be used is necessary.These articles should be grouped in the warehouse in conformity with the class to which they belong,—textiles in one place; drugs, medicines and reagents in another; hospital furniture in another, and so on through the entire list of supplies.
Warehouses should be located on railroad spurs so that supplies may be delivered directly from cars into the warehouse and from the warehouse directly into the cars. Concentration of storage space is desirable on account of the shorter distance to move supplies when unloading and loading. To this end a depot consisting of several stories, one above another, affords the minimum trackage necessary in handling supplies and it is desirable that such a building be selected when practicable.
The decision in the early part of the year 1917 to restrict the number of articles, particularly surgical instruments, which would be manufactured for the use of the hospital services of the Government and for civilian use made it possible to provide the essentials for hospital services with the limited manufacturing facilities which were then available. Such a list had been in use in the Medical Department of the Army for many years and doubtless similar lists obtained in the hospital services of other departments of the Government. This standard list presupposes specifications for the articles enumerated therein; specifications again presuppose personnel qualified to determine what those specifications should be. To write concise and adequate specifications requires familiarity on the part of the personnel writing them with the articles described therein and not only with the articles themselves, but with the process of their manufacture. The prime essential of the efficient supply service therefore is not limited to the funds provided by Congress but embraces as of equal importance a personnel trained in the actual purchase, inspection, storage and issue of the supplies, secured at the cost of the appropriations which have generally been so liberally made by Congress. The actual buying of an article and the placing of the contract therefore, is a comparatively simple matter, but the question of determining whether the articles purchased will satisfactorily accomplish the object for which they were procured is an acquirement which comes only with years of observation and experience, and then in those persons whose inclinations the more readily adapt them to the routine necessary to acquire this experience. Whatever may be the standard of any article which may be selected, the assurance that the article delivered conforms to the article specified rests solely upon the qualifications of the person designated to inspect and accept it.
From years of experience in presenting the needs of the hospital service of the Army to Congress, I am convinced of the urgent necessity for economy along all lines of expenditure and activities. Economy does not necessarily mean the elimination of activities nor the discontinuance of the use of various articles in order to bring the gross expenditure within the sums appropriated. It does mean, however, that no greater quantity of any article, however insignificant, which may be issued tothe user, shall be used for that purpose than is actually necessary to accomplish the results desired. It means that the services of employees shall be fully and efficiently used. It means that the articles which are not consumable in character shall be handled with such care and regard to their future usefulness as will continue them in efficient service for the greatest length of time. As an illustration, it is common practice among many physicians when writing prescriptions for various ailments to prescribe a four ounce mixture and to dismiss the patient. The same practice has obtained very largely in the hospital services of the Government. If, instead of issuing the usual four ounce mixture a two ounce, or a one ounce mixture had been prescribed, equally good results would have been obtained, since the patient in many instances actually takes only a quarter, a third or a half of the four ounce mixture, recovers from the ailment for which it was prescribed and throws the medicine away. This is particularly true in military practice. If the lesser quantity be prescribed and further medication be found necessary, the patient for whom it is prescribed will return to the doctor, giving him an opportunity for another and more complete physical examination and consideration of the remedy, of the result obtained and of any other more suitable, or have the prescription refilled if it be necessary. A dozen tablets should be dispensed in place of customary two or three dozen. In other words, in the hospitals and dispensary services of the Government the medicines issued should be in quantities not to exceed the retirements of three days. This will result not only in the saving of drugs themselves, as well as of bandages and surgical dressings issued, but will result in material saving in the cost of the containers in which they are issued. We too infrequently consider the sum which the aggregate saving of the few cents here and the few cents there will reach at the end of a year in the larger hospital services. With supplies abundant and seemingly easy to secure everyone who uses them is prone to become prodigal in their use and I cannot emphasize too strongly the need for economy along these lines. The application of the old saying, “take care of the pennies and the dollars will take care of themselves” to the every day use of supplies in hospitals would result in enormous savings at the end of the year.
I was very much impressed with the remarks of Dr. Lavinder on specialization of medical practice and the tendency in governmental institutions to carry it to extremes. This is no where more pronounced than in the demand for hospital supplies. What our patients need is plenty of attention and simplicity in equipment and treatment. Efficiency, yes, but simplicity especially. How often it happens that a medical officer at a governmental institution becomes imbued with the idea that he requires certain special apparatus which must be obtained at considerable cost to the procuring agents to carry out his theories of treatment. In a few months, or a couple of years at the longest, he is relieved from those duties, at that hospital and goes elsewhere. The officer who follows him conceives that an entirely different set of instruments and equipment is necessary for thetreatment of the same class of patients than those used by the former medical officer. The instruments and equipment of the former officer are returned to the store rooms where they take up valuable space and new equipment is secured by the incoming officer to take their place.
The elimination of these personal peculiarities and requirements will do much to reduce the enormous expenditure which is everywhere being made for hospital supplies and equipment.
In closing, permit me again to stress the need for economy in the use of all supplies required by governmental hospitals, for an earnest effort to use the equipment provided to its utmost efficiency and an honest effort to get the most out of all the expendable supplies used in the treatment of the patients committed to our care. If we are honest in these efforts we will have no difficulty in convincing both Houses of Congress of the justness of our requests for funds to carry out the purpose committed to us.”
COLONEL JAMES A. MATTISON, Chief, Surgeon, N.H.D.V.S.
“Of the various papers which have been read this afternoon on the medical side, nursing side, diet and supplies, the two words which seem to have been the key-note of each of these papers have been ‘standardization’ and ‘cooperation’. It seems to me that the matter of standardization on the subject that I am to talk on is one of the most important factors that we can consider.” He stated that standardization could be carried not only through the individual hospital, but through every government agency which does this type of work. He continued, reading the following article—“Hospital Supplies”.
“Almost every group of hospitals follows a different system in the business management, especially from the standpoint of procuring, conserving, and issuing of supplies. It is believed that a decided step forward for U. S. Veterans’ Hospitals would be a standardization in the method of procuring, handling, and issuing of all supplies. At the present time most of our agencies have different laws regulating the methods by which supplies are to be purchased and handled.
In some branches of the service practically everything has to be procured on competitive bids. In some, greater leeway is allowed and certain articles may be purchased by circular letter, while others give still greater leeway in allowing the purchase of a large quantity of supplies in open market. There are advantages in all of these methods and at the same time there are opportunities, at least in some cases of some of the methods being greatly abused. This, however, depends almost wholly upon the personnel responsible for the transactions.
The property officer or employee, whether he is represented by the same person as the purchasing officer or not, is inseparably connected with the subject of supplies, and the weaknesses connected with hospital supplies, provided such an officer is not too greatly handicapped, depends to a very large extent upon this individual.
The per capita cost of supplies in general is dependent not so much upon the quantity actually used as upon the waste which takes place, and the waste depends wholly upon the personnel handling the supplies. It is therefore, highly important that the personnel in charge of the supplies must of necessity be thoroughly trained and conversant with the needs and requirements of the service and at the same time have authority to question requisitions and demands which are in excess of apparent needs. This is a fact which I am sure we all recognize.
It is not the policy of the Government in any branches of the service to furnish inferior quality of supplies. However, the experience of Government hospitals in general is, that it is quite difficult in many cases to get the grade of goods delivered that is specified, regardless of what method is followed in making purchases. This is particularly true with certain firms who regard U. S. Government agencies as legitimate prey and have no scruples in unloading undesirable goods or goods of an inferior quality, provided they are able to get away with it. I daresay that every branch of the service has to contend with this condition and it is believed that here again there should be some means by which other branches of the service may be apprised of information regarding unreliable firms which has been obtained by them through actual experience.”
MR. M. SANGER, of St. Elizabeths’ Hospital, gave a further discussion of “Hospital Supplies”, as follows:
“Mr. Spangler, in a presentation of the question of Hospital Supplies, has covered in a general way the method of deciding the class of supplies required, how to procure these supplies, how to decide upon the quantities needed, and the general scope of standardizing supplies so as to serve the best interests of the Government, to supply the needs of the patients, and to procure and conserve the supplies in the most economic and efficient. manner.
In reference to the supplies themselves, as has been stated, the first thing is to decide what is needed. The second, as to the best method by which these supplies may be purchased. Third, the amount of warehouse space available for storing these supplies. Fourth, as to the best grade of supplies to secure for the particular purpose for which they may be required. Fifth, considering warehouse space and the non-perishable class of supplies, what are the most economic quantities in which they may be purchased.
There are one or two matters pertaining to the question of supplies, however, that it seems he has not touched upon, and which I will discuss for a few minutes. The first is in relation to those which may be considered the non-expendibles, or more specifically those supplies which are necessary in connection with machines of various classes; whether it be automobiles, refrigerating machines, boilers, large tools, or what not. As soon as a machine of this sort is secured, an entry should be made showing date of order, date of receipt, cost, name of make, from whom purchased, and any other information of a similar nature. This information will be needed in order to purchase repair parts, and when needed, as in case of a breakdown, it will be needed in a hurry. Parts may have to be purchased by telegraph. The same information would be needed in case of inventory, or, if a cost system were in effect, to show depreciation, wear and tear, or give other information in order to secure accurate cost figures.
The second item which I would speak of is the manner or method in which you keep record of your general supplies. To a great extent, your success or failure will depend upon the extent to which you are able to keep up a continuity of certain supplies. For illustration, in running a power plant one must at all times have an ample supply of fuels, oils, packings, and repair parts. If you are furnishing food, you must at all times have an ample supply of certain articles of diet. Your dietitian prepares your menu and lists certain articles. These articles are required for certain periods. Failure to have these items of supplies when required upsets the menus. Substitutes must be utilized, which ofttimes bring duplication of items on succeeding days or meals. This will often lead to complaints on the part of the patient or student, who desires a change and who believes his rights are being interfered with.
I would suggest, in order to minimize such occurrences, that a form of perpetual inventory be installed, with labels in the form of cards or records attached to each item. On such records, there should be marked the minimum mount of each item that should be carried before a new requisition is to be placed for replenishing the supply on hand. The amount of the minimum of each item will have to be decided upon data based upon experience covering, (first) quantities used, and (second) time required for a new supply to be received after the order has been placed, (third) whether supplies are to be obtained direct from the contractor or if purchase must be made on the open market, whether supplies come from the vicinity of the place where required or must be shipped from a distance.
These things, though they seem small in themselves, as your experience will doubtless demonstrate, are of such importance that I cannot place too much weight upon them; and I think that a very early and close study of these questions will assist you to a material extent in meeting the problems that will confront you, and enable you to overcome many of your difficulties.”
MISS RUTH EMERSON, of the American Red Cross, taking Mr. Pearson’s place on the program, stated that it was because the Surgeon General of the Public Health Service turned to the Red Cross that they came into being in this particular connection.
She stated that certain fundamental principles had been written down between the Public Health Service and the Red Cross, which had been abided by, and that it had been a great problem which was taken up with the Commanding Officer to keep out the things that were undesirable and to bring to each hospital the best things for that hospital, not only for the patients but for the personnel. She stated further that on the information side the Red Cross had been a great aid in bringing to the patients knowledge about various government regulations, but that now as more and more attempts are made by the various departments to get this information to the man the need for the Red Cross in this regard becomes less. Another important function of the social service worker is to find out the home conditions to which a man with tuberculosis is going when discharged from the hospital.
CAPT. BLACKWOOD: stated that as the hour was late he moved that the discussion of this important subject be postponed until tomorrow morning.
The motion was carried and the meeting adjourned at 4:45 P.M.