Part 53

The Veterans’ Bureau as you have been informed relative to the care of ex-service men of foreign allied countries and of American soldiers residing in allied countries has a vital contact with the State Department in addressing their communications to the various foreign countries and in the utilization of the various U. S. Consuls.

The Department of Justice has charge of all suits filed against the U. S. Veterans’ Bureau where suit is brought on an insurance contract. The department of Justice also handles all prosecutions where irregularities are found under the act creating the U. S. Veterans’ Bureau.

Under the Interior Department you know of the use made of the St. Elizabeth’s Hospital and of hospitals under the jurisdiction of the Commissioners of Indian Affairs.

The contact is also quite vital with the Department of the Interior in obtaining various information from the Pension Bureau as a person may be filing an application for compensation and also an application for a pension.

The Department of Agriculture has been of very great assistance to the Bureau in rendering advice relative to the training of disabled ex-service men with a vocational handicap who desire to take up agricultural pursuits, and at the present time the Department of Agriculture is rendering most valuable service in mapping out agricultural courses for the first Vocational School of the Government located at Chillicothe, Ohio.

Many disabled ex-service men taking vocational training have been assisted by the Department of Commerce in mapping out their careers for work incident to that of the Department of Commerce.

The Department of Labor has been of very great assistance in aiding the Bureau to find employment objectives for disabled ex-service men undergoing training or who have been rehabilitated by the U. S. Veterans’ Bureau.

This will give you a general view of the relation of the U. S. Veterans’ Bureau to the Executive Departments of the government. The U. S. Veterans’ Bureau naturally must have a close contact with the Congress. Congress continually calls upon the Bureau for data and information which can only be obtained from the other Executive Departments of the government but which immediately relate to the work of the U. S. Veterans’ Bureau.

Inasmuch as you Gentlemen are essentially interested in hospital administration, I should like to speak briefly on the question of hospital records, and what data the Bureau is required to have when it is called before Congress relative to Appropriations. As you know, Congress makes one appropriation to the U. S. Veterans’ Bureau for Medical and Hospitals Services. Sums from this appropriation are in turn allotted to the U.S. Public Health Service, the War and the Navy Departments, the Interior Department, and the National Homes for Disabled Volunteer’ Soldiers. When the U. S. Veterans’ Bureau is called before Congress for every appropriation it must show specifically how the money has been allotted, for what purposes it has been allotted, and the result accomplished.

It has become imperative for the U. S. Veterans’ Bureau to have available comprehensive records concerning all hospitals in which there are being treated its beneficiaries. It is not sufficient that these records be only those concerning the admission and discharge of patients and the physical examination report in each instance, but equally fundamental data concerning the results of treatment, periodical turn-over of patients, the hospitals’ administration, and of equal importance, but from a different angle, the cost of operation with the resulting per diem cost per patient.

A considerable part of the records on patients, their flow in and out of hospitals and similar data are available or can be made available, the value of these data so derived, of course, will be proportionate to the accuracy or thoroughness with which the records of admission and discharge are prepared and transmitted. The report of admission and discharge of patients and the report of physical examination are at present the only reports common to all Government Hospitals. The necessity for the prompt rendering of accurate admission and discharge reports and physical examination reports in all instances is apparent. Such reports are of very great importance to the U. S. Veterans’ Bureau, for upon them is determined the medical rating of the hospitalized beneficiaries and any delay or omission in the rendering of records of this character reflects upon the administration of the U. S. Veterans’ Bureau.

In regard to the individual hospital operation costs, until very recently the U. S. Veterans’ Bureau has been operating in the dark on unit costs. It is demanded that the U. S. Veterans’ Bureau have complete knowledge of the cost of operating all government hospitals, not merely as a gross item, but classified by purpose of expenditure and by department of hospital for which spent. The reason for this point is made two-fold—First, that the Bureau before it can allot money to the several services for hospital expense, must be in a position to know for what purpose the money should be disbursed; and second, because the Congress of the United States is holding the Bureau accountable for all moneys appropriated to it and unless this Bureau can tell Congress in detail this money has been spent, or is to be disbursed, our hospitalization program will be jeopardized until such information can be secured.

The per diem rates for hospitals of the several services vary materially so far as our estimates are concerned. The degree to which such a variation in rates is only an apparent variation due to the different bases upon which they are calculated is not at present ascertainable, but it should be. Not only should this Bureau know what it costs for its own patients at any one institution, but it should know the per diem cost over a given period for all the patients hospitalized there. The cost to this Bureau affects not only our appropriation; the cost to the service operating the hospital, including this Bureau’s share, but it affects the U. S. Treasury. If the cost of maintenance of certain hospitals is excessive, it would be poor business not to evacuate that hospital, if other conditions made it practicable, or if impracticable to attempt to reduce its operating cost.

Recently the U. S. Public Health Service inaugurated a system of cost accounting by individual hospitals. With the perfection of this procedure the U. S. Veterans’ Bureau will be in a position to talk intelligently about operating costs with these hospitals whether by departments of hospitals, purposes of disbursement, such as salaries, repairs, etc., or by unit costs.

The U. S. Veterans’ Bureau looks forward to the time when similar data are available and regularly submitted by the War Department, the Navy Department and the National Homes for Volunteer Disabled Soldiers, not merely as reimbursements due certain appropriations, but by actual disbursements of detailed purpose of not only for this Bureau’s share, but for total operations.

The U. S. Veterans’ Bureau also maintains contact with the various miscellaneous Departments and institutions of the government. Time will not permit of going into any details or of mentioning these contacts.

The U. S. Veterans’ Bureau when viewed from its huge task of running an insurance company with over three and one-half billions of insurance in force, of making payments on 149,000 insurance claims each month, making payment on 204,000 compensation claims each month, with approximately 29,000 ex-service men and women undergoing hospitalization, and having caused to be made over 1,000,000 medical examinations and responsible for 104,000 disabled ex-service men undergoing vocational training, representing a task which calls for the closest cooperation and assistance from every department of the government and only by having the closest cooperation possible will the government, through the U. S. Veterans’ Bureau, be able to discharge its obligations to the host of disabled ex-service men and women of this country.

The Bureau has always enjoyed the fullest cooperation from the various departments of the government and knows that the same cooperation will be extended with unstinted measure in the future, to the end that every pledge will be redeemed concerning the care and treatment of the defenders of this Republic, and to the end that this administration will go down in history as an administration that did not forget its sick and wounded soldiers, and brought peace and contentment to every fireside where assistance on the part of the government was requested and was due.”

COLONEL JAMES A. MATTISON, N. H. D. V. S, gave the following discussion of “Economy of Administration in U. S. Veterans’ Hospitals”:

“The subject is so broad that we can only consider certain phases of it within the time allotted for this paper. We all recognize that there are certain fundamental essentials which must of necessity be provided in every hospital regardless of the number of patients cared for. This necessarily means that overhead expenses of an institution hospitalizing small numbers of patients will be out of proportion to those of a hospital caring for a large number.

The general business management, the purchasing of supplies and equipment, the conservation and dispensing of the same, the elimination of waste, etc,. will be considered only casually for the purpose of emphasizing the importance of adhering as closely to strict business methods as is done in the case of every successful business man, whether he be a hospital executive, a merchant, or a man in any other line of business.

In this connection, it might be said that a mistake which is made in many government institutions, and one which is not made by the most successful business men, is to attempt to start on economy at a place where one can least afford to economize, that is in the pay and allowances of the personnel immediately responsible for the management of the institution, the responsible heads of departments, etc. In other words, we are not always willing to pay for brains, a price commensurate with the business responsibility involved. Again when we have been fortunate enough to secure the right man the right place, we do not always recognize his value by paying him a price commensurate with the value of his work. Furthermore, when we have made the mistake of getting the wrong man, who in reality is receiving a greater compensation than his services are worth, and one who, in reality, is a very expensive employee, we oftentimes make the mistake of not recognizing inefficiency and promptly correcting it,

In case there is any decided handicap along the lines of inefficiency in the responsible personnel in the administrative, utility, service or professional departments, it should be promptly corrected, as it is to those in such petitions to whom we constantly look to be on the alert in recognizing the short comings of all subordinate personnel.

In visiting our own or other hospitals we promptly recognize the presence or absence of evidence of the proper vigilance or efficiency in every department. In case of a tour of inspection of one of these institutions there should be found spurting steam valves, leaking water faucets, extravagant use of electric lights, overheated buildings, garbage and swill tanks running over with waste food supplies, evidence of lack of organization and co-operation on the part of the personnel, professional or otherwise, we should immediately recognize the fact that there was inefficiency existing in the personnel of such an institution, and as a result of this, a decided lack of economical and efficient administration. Finding such conditions in other departments, we should expect to find unsatisfactory conditions when the patient population was reached. We should expect to find histories poorly written or not written at all, patients waiting over-time for special examinations or special treatments, lack of accurate laboratory and X-ray records, etc. The matter of such inefficiency and consequent poor administration on the part of the personnel in any institution would naturally lead to great dissatisfaction on the part of the patients of such an institution and to the greatest lack of economy on the part of the administration, of the hospital.

In connection with the professional department proper, again the attainment of the most satisfactory results from the standpoint, both of economy and efficiency, is dependent upon the capacity and co-operation of the responsible personnel. There has been much discussion in regard to the number of professional personnel doctors, nurses, attendants, etc., and on this subject there has been apparently wide differences of opinion. However, these differences have been based upon differences of viewpoints of what the actual conditions to be met were.

A definite agreement has been reached in regard to the required personnel, nurses, doctors, attendants, social service, workers, etc., to each two hundred patients in a hospital caring for all acute patients, whether they be major surgical, acute active neuro-psychiatric, active tuberculosis, or other type of acute condition requiring active, constructive treatment.

As a matter of fact, however, we all know that in none of our Veterans’ Hospitals, especially the larger ones of 500 to 1000 or more beds, are all the patients or even a majority of them represented by this type of patients, on the contrary we have a large group of convalescent patients who require professionally very much less attention from the standpoint of active constructive treatment, dietetic attention, etc., and hence require vastly less personnel, and the expense of their maintenance in the hospital will be very greatly reduced from that of the acute type. Again, we have another group which represents the semi-domiciliary type, many of whom require very slight constructive treatment, and yet they belong to a type of patients who are capable of being finally rehabilitated and restored to an earning status in life. This group requires still less care than the former, and naturally less personnel and proportionately less per capita cost to the institution caring for them. Lastly, we pass to a purely domiciliary group who are to a large measure permanently disabled and are, therefore, many of them, to be permanent charges oh the Veterans’ Hospitals. The great majority of the latter group will require little or no special treatment, but will require only general care and maintenance. In this group we are dealing with a type who will represent the minimum per capita cost.

As time goes on we shall realize, especially in our larger hospitals, that the above condition will exist to a larger and larger measure and the necessity of a very close checking system and a very careful classification of the patients along the lines indicated above will be a matter of the very highest importance.