Part 14

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 to the 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 the treatment 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.

_Fifth Session_ Thursday, January 19, 1922.

GEN. SAWYER: “I would like to ask if either of our committees are ready to report or whether they have any inquiries to make”. He asked Captain Blackwood for a report.

CAPT. BLACKWOOD reported that the Committee on Forms met yesterday noon and felt they had a task that was going to take months. As they had no copies of the forms in use two of the members of the committee were to get them by noon today.

GEN. SAWYER: urged that the matter be pushed in order that some little understanding at least might be had before the end of the meetings, that perhaps some suggestions could be made that could be carried out after the meetings adjourned. “I am requested to state for the Committee on Resolutions that there is no special report that they have to make now.” He introduced Admiral Stitt, to preside.

ADMIRAL STITT: “The first paper is “Discussion of Disciplinary Regulations of Veterans’ Bureau as they affect the beneficiaries and hospitals,” which someone will read for Colonel Patterson, who is still ill.”

MAJOR R. W. BLISS, U. S. Veterans’ Bureau, took up “Discussion of Disciplinary Regulations of Veterans’ Bureau as they affect the beneficiaries and hospitals”, as follows:

“In a discussion of U. S. Veterans’ Bureau General Orders 27, dated September 9, 1921 and 27–A dated January 14, 1922, covering the Disciplinary regulations governing beneficiaries of the Veterans’ Bureau who are patients in hospital, it is assumed that even before September 1921, all present recognized the advisability and necessity of some lawful method by which the small lawless element, often present in hospitals, as it is in any other community might be effectively dealt with.

It is further assumed that the provisions of the September General Order #27 are generally well known to this audience.

Therefore, this present paper will be limited to a brief statement of fact of the numbers of patients discharged under this order, and to a statement of the essential differences in the September G. O. #27 and the G. O. 27–A, issued yesterday, leaving any comment to the general discussion.

I have here a chart showing the name, location and type of every Government hospital receiving Veterans’ Bureau patients, and giving the total number of patients in each, and the total number of patients discharged from each one, under the provisions of General Order #27, between the dates of the issuance of this order, on September 9, 1921 and January 14, 1922.

This represents 67 Public Health Service Hospitals, 14 Naval Hospitals, 9 hospitals connected with the National Homes for Disabled Volunteer Soldiers, 6 Army hospitals and St. Elizabeths’ Hospital, under the Interior Department, a total of 97 Government hospitals.

The total number of patients, to which I shall refer hereafter, mean Veterans’ Bureau Patients.

Between the dates above mentioned there have been in and admitted to these 97 hospitals, 44,318 patients. Of this number, 474, or a trifle over 1%, have been discharged for disciplinary reasons; 732 or 2% have left against Medical Advice, and 1804 or 4% have been absent without leave for a period of 7 days or over, and have so been dropped from the rolls of the hospital. This is a total of 3010 or 7%.

In the 67 Public Health Service hospitals there have been 33,028 patients, of this number 336, or 1% have been discharged for disciplinary reasons, 520 or 1.5% have left against Medical Advice, and 1233 or 3.5% have been dropped as over 7 days A.W.O.L. This is a total of 2089 or 6%.

In the 14 Naval hospitals, there have been 2571 patients. Of this number, 44, or 1.7% have been discharged for disciplinary reasons, 49 or 1.5% have left against Medical Advice, and 44 or 1.7% have been dropped as AWOL. This is a total of 107 or 4%.

In the 9 soldiers homes there have been 4721 patients. Of this number 56 or 1.2% have been discharged for disciplinary reasons, 111 or 2.3% have left against Medical Advice, and 437 or 9.2% have been dropped as A.W.O.L. This is a total of 604 or 12.7%.

In the six Army hospitals, there have been 3076 patients. Of this number 44 or 1.4% have been discharged for disciplinary reasons, 50, or 1.6% have been discharged against medical advice, and 65 or 2% have been dropped as AWOL. This is a total of 159 or 5%.

St. Elizabeth’s hospital has had 922 patients and our records show that none have been discharged for disciplinary reasons, none left against advice and none have been dropped as A.W.O.L.

In a general way, the large tubercular hospitals show the greatest number and percentage of discharges under this order. One or two hospitals show over 30% discharges, these being mostly against advice and absent without leave.

Since the issuance of the September General Order #27 a great deal of adverse criticism of it has been received from many sources.