CHAPTER XV
Improvements in the Internal Organization andAdministration of Hospitals in the UnitedStates
In the latter half of the war, reductions in the staffs ofhospitals and changes in their make-up made more imperative than formerly theimprovement of hospital organization and administration. It will be recalledthat the Wadhams Committee had recommended such action as early as November 1942and as a result The Surgeon General had brought into his Office in the spring of1943 an experienced hospital administrator, Lt. Col. Basil C. MacLean. In hisopinion preliminary studies confirmed the need for improvement.1Moreover, as the Army's manpower shortage became serious in the fall of1943, ASF headquarters began a general program for the more efficient use ofpersonnel. Extending to all technical and supply services, including the MedicalDepartment, it comprehended the standardization of organization, the eliminationof nonessential activities and records, the simplification of work methods, andthe improvement of administrative procedures.2As a part of this program and of efforts to shorten periods ofpatient-stay in hospitals, the ASF Control Division and the Surgeon General'sOffice began work in the fall of 1943 on the simplification and standardizationof the disability-discharge procedure, already discussed. By the followingJanuary, General Somervell informed Surgeon General Kirk that he consideredimprovement of hospital administration one of the Medical Department's majorproblems. About a month later, at a service command conference in Dallas, Tex.,he directed the chief of the Surgeon General's Operations Service, Brig. Gen.Raymond W. Bliss, to "undertake to be the lead-off man in a study of
1(1) Memo, Lt Col Basil C. MacLean, SGO, for Brig Gen Raymond W. Bliss thru Col A[lbert] H. Schwichtenberg, 6 Nov 43, sub: Observations Based on Recent Visits . . . to Nine Gen Hosps. Off files, Gen Bliss' Off SGO, "Util of MCs in ZI" (19)#1. (2) Memo, MacLean for Bliss thru Schwichtenberg, 2 Feb 44, sub: More Efficient Util of Army Hosp Fac. Off files, Gen Bliss' Off SGO, "Util of Army Hosp Fac."
2History of Control Division, ASF, 1942-45, pp. 31-55, 160-66, 182-83. HD.
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the simplification of this Medical Department paper-work."3
Simplification of Administrative Procedures
A basis for the study directed by General Somervell was laidduring the spring of 1944. Work on the disability-discharge procedure hadalready demonstrated the value of simplification and standardization and about aweek before the Dallas conference the Surgeon General's Hospital Division hadasked his Control Division to review hospital administrative proceduresgenerally. The latter Division called for assistance upon the ASF ControlDivision, which had had experience and which had personnel qualified in suchmatters. In April 1944 these Divisions, assisted by service command controldivisions, surveyed records and procedures used at Schick, O'Reilly, andHalloran General Hospitals and outlined a broad program for succeeding months.Studies were to be made to simplify hospital organization, hospital admissions,ward administration, fiscal procedures, mess management, hospital statistics,nursing administration procedures, personnel office procedures, informationoffice procedures, and hospital dispositions. To prevent swamping hospitals withrevised but imperfect procedures, the Hospital and Control Divisions of theSurgeon General's Office insisted that each revised procedure should beapproved by professional consultants of that Office and tested in selectedhospitals before general adoption. To avoid unnecessary delays in their use,procedures were to be studied separately and, when revised and tested, were tobe issued as parts of a loose-leaf manual on hospital administration.4
Several difficulties were encountered in carrying out this program. Short ofpersonnel because it had reduced its own staff as an example to others, theSurgeon General's Control Division had only one officer who could devote hisfull time to that work. The Division also lacked personnel qualified by trainingand experience to make procedural studies and to draft procedural manuals in theform desired by ASF headquarters. Furthermore, its director was absent onspecial overseas missions during much of 1944 and work on the program sufferedfrom his absence. To overcome some of these difficulties, the Surgeon General'sOffice temporarily borrowed personnel from the ASF Control Division, from Armyhospitals, and from other installations. Even so, the ASF Control Divisionconsidered progress on the program unsatisfactory and threatened, early in 1945,to take over its completion. The Surgeon General prevented such action, butfriction between his Office and the ASF Control Division continued.5As a result of these difficulties, and of delays
3(1) Memo, Lt Gen Brehon B. Somervell, CG ASF for SG, 18 Jan 44. HRS: Hq ASF Somervell files, "SG 1944." (2) Mins, ASF Conf of CGs of SvCs, Dallas, Tex., 17-19 Feb 44. HD: 337.
4(1) Memo, Act Dir Control Div SGO for Dir Control Div ASF, 10 Feb 44, sub: Proposed Study of Admin Procedures and Records Used in Gen Hosps. SG: 323.7-5 (Gen Hosp). (2) Memo, Dep SG for CG ASF attn Dir Control Div ASF, 14 Mar 45, sub: Improvement of Hosp Admin Procedures. SG: 300.7. (3) History of Control Division, ASF, 1942-45, App, pp. 357-59. HD.
5(1) Memo, Maj J. B. Joynt, Control Div ASF for Col A. G. Erpf, Control Div ASF, 18 Dec 44, sub: Problems on Hosp Manual. (2) Memo, Col A. G. Erpf, Control Div ASF for Col O. A. Gottschalk, Control Div ASF, 18 Dec 44, sub: Control Div SGO. (3) Memo SPMCQ 300.7, Dep SG for CG ASF attn Dir Control Div ASF, 14 Mar 45, sub: Improvement in Hosp Admin Procedures. (4) Memo, Col A. G. Erpf for Col O. A. Gottschalk, 17 Mar 45. All in HRS: Hq ASF Control Div file, "SGO." (5) Memo, Act Dir Control Div ASF for Act CofS ASF, 5 Apr 45, sub: Status of Hosp Admin Procedures. SG: 323.3 (Hosp). (6) Memo, CG ASF for SG, 7 Apr 45, same sub. Same file. (7) Memo, SG for Act CofS ASF, 12 Apr 45, same sub. Same file. (8) Memo, Dir Control Div [SGO] for Dir HD [SGO], 23 Jun 45, sub: An Rpt of Control Div for FY 1945. HD: 319.l-2-(Control Div, SGO) FY 1945. The reason that Colonel MacLean took little or no part in the development of simplified administrative procedures, and left the Surgeon General's Office in the fall of 1944, is not clear to the writer.
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inherent in testing revised procedures before adopting themfor general use, only one chapter of the projected manual-that on hospitaladmissions-was published before the peak patient load was reached in theUnited States. Other revised procedures-those for linen control, disabilitydischarges, and disability retirements-were published in separate manuals orcirculars before that date.
The hospital admissions procedure can be used to illustrateboth the manner in which new procedures were developed and the methods used tosimplify hospital paper work. The Control Division of the Surgeon General'sOffice, in consultation with the Hospital Division, developed a tentativeprocedure for the admission of patients, and, along with it, the forms to beused. Before these forms were published, they were approved by the ASF ControlDivision, the Air Surgeon's Office, the Surgeon General's Control,Professional Services, Hospital, and Medical Statistics Divisions, and theAdjutant General's Methods Management Branch.6The new procedure was then given a preliminary trial in three hospitals-two ofthe Service Forces and one of the Air Forces.7After they had commented on its advantages and disadvantages, it wasrevised and published in a tentative manual of hospital procedures.8Soon afterward, the Surgeon General's Office called a conference inWashington to explain the new procedure to representatives of various hospitals.9Selected hospitals, serving as pilot installations, then began to use theprocedure and to teach representatives from other hospitals how to employ it.10Finally, early in 1945, the new procedure was published in final form as achapter of the new manual on hospital administration (TM 8-262), and by themiddle of that year almost all hospitals with as many as ten admissions a dayhad begun to adopt it.11
While the revised procedure covered in somewhat greaterdetail than did the old one the various steps taken in the admission ofpatients, its greatest significance lay in changes in hospital admission recordsand their preparation. Two basic forms were prepared for the admission ofpatients to hospitals: the clinical record brief and the medical report card. Inaddition, other records such as deposit slips for patients' funds and locatorcards for use by interested groups in hospitals were prepared to meet localneeds only. Under
6(1) Diary, Hosp Div SGO, 12 and 14 Jun 44. HD: 024.7-3. (2) Ltrs, SG to Chief Forms Design and Standardization Sec Methods Management Br Control Div ASF, 13 Jul 44, sub: Revision of MD Form 52 and Revision of WD MD Form 55A. SG: 315.
7(1) Memo, Capt H. S. Press, SGO for Mr W. A. Archibald, SGO, 30 Jun 44, sub: Progress of Hosp Procedures Simplification Project. SG: 323.7-5 (Gen Hosp).
8Manual of Hosp Procedures (Tentative), prepared by SGO Control Div, 1 Sep 44. HD.
9Ltr, CO Regional Hosp Cp Swift to CG 8th SvC attn SvC Surg, 1 Oct 44, sub: Rpt of Hosp Admin Procedure Conf Held in Washington, 25 Sep 44. SG: 337.-1.
10For example, see: An Rpts, 1944, Schick Gen Hosp, and Ft Jackson and Cp Swift Regional Hosps. HD.
11(1) Memo SPMCQ 300.7, SG for CG ASF, 14 Mar 45, sub: Improvement in Hosp Admission Procedures. HRS: Hq ASF Control Div file, "SGO." (2) An Rpt, FY 1945, Control Div SGO. HD. (3) TM 8-262, Admin of Fixed Hosps, ZI, Ch II, Hosp Admissions, 1 Feb 45.
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the old procedure the two basic forms had to be typed inseparate operations, for even though much information was common to them both,such as the patient's name, rank, serial number, organization, age, race,length of service, etc., those forms were blocked off differently. Other recordshad to be made up separately also, many by offices needing information foundeither on the clinical record brief or on the hospital's daily admission anddisposition sheet. Under the revised procedure, all forms containing commoninformation were blocked off alike and a mimeograph duplicator was used totransfer that information to as many copies as needed throughout the hospital.Thus one typing replaced fifteen or twenty under the old system. The chapter onthe new admissions procedure illustrated each of these forms and gave detailedinstructions for their preparation and distribution. In the opinion of theSurgeon General's Office, the new procedure speeded up the admission ofpatients, eliminated the duplication of records, supplied operating units ofhospitals with information they had not formerly received, and saved in thehospitals where adopted a total of about 3,333 man-days of work per week.12Hospital commanders encountered only minor difficulties in installing the newprocedure and, with few exceptions, considered it an improvement over the oldone.13
As in the development of the admissions procedure which savedwork for administrative officers, the Surgeon General's Office was equallyinterested in procedures that would relieve ward officers of administrativedetails in order to permit them to devote more time to professional work. One ofthe procedures developed during 1944, that for the control and distribution ofhospital linens, was designed for this purpose. Developed in a manner similar tothe hospital admissions procedure, the linen control procedure was published inDecember 1944 in an ASF circular rather than as a chapter of thehospital-administration manual.14 Under the old procedure physicianswere charged with the linen used in wards and clinics. In order to avoid being"caught short," they required ward personnel to count soiled linen asit left the ward and clean linen as it was returned. Furthermore, they requiredperiodic inventories and some tended to hoard linen unnecessarily. Additionallinen-counts were made at intermediate storage points and at hospital laundries.Under the new procedure each hospital had a linen officer who was responsiblefor all linen used. All counts of linen in wards and intermediate stations wereeliminated; and linen officers, rather than ward officers, made periodicinventories. According to some hospitals, a disadvantage of this procedure wasan excessive loss of linens. This was compensated for, in the opinion of theSurgeon General's Office and many hospital commanders, by the saving of about1,250 man-days of work per month and
12(1) TM 8-262, Admin of Fixed Hosp, ZI, Ch II, Hosp Admissions, 1 Feb 45. (2) An Rpt, FY 1945, Control Div SGO; and An Rpt, FY 1945, Hosp and Dom Oprs SGO. HD.
13For example see: An Rpts, 1944, Baxter and Fitzsimons Gen Hosps; An Rpt, 1945, Birmingham Gen Hosp; An Rpts, 1944, Cps Crowder and Swift, and Ft Jackson Regional Hosps; An Rpts, 1945, Cp Wolters and Ft Bragg Regional Hosps. HD.
14(1) ASF Memo for Record, 11 Nov 44. AG: 427 (11 Nov 44) (2). (2) Ltr SPMCH 300.5 (ASF Cir), SG to AG, 30 Nov 44, sub: Proposed ASF Cir on Linen Control and Distribution Systems. Same file. (3) Rpt of Economies Effected through Procedures Studies Made by or jointly with Control Div ASF, 13 Apr 45. HRS: Hq ASF Control Div file, "Est Admin Savings Resulting from Procedural Revisions." (4) ASF Cir 395, 2 Dec 44.
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the relief of doctors of administrative details. It was alsoreported that the new procedure decreased the hoarding of linen and speeded upits distribution to places where needed.15
The use of dictaphones in hospitals was not called for bymanuals or circulars, but nevertheless constituted an important change in themethod of preparing clinical records. Lack of enough medical stenographers inhospitals, as a result of the civilian labor shortage and of hospital personnelceilings, made it necessary during 1943 for doctors themselves to prepareclinical records, sometimes in longhand. To relieve them of such atime-consuming process, hospitals began early in 1944 to acquire dictaphones. Atconvenient times doctors recorded on these machines consultation reports,progress notes, case histories, and final summaries. Clerks organized in centralpools then transcribed the information recorded. This system of preparingclinical records permitted doctors to keep more complete and more legiblerecords and to devote more attention to care of patients. It also contributed tothe more efficient use of clerical personnel. Finally, by enabling doctors tokeep clinical records up to date it helped to speed the disposition of patientsand to shorten their period of hospitalization.16
The simplification of other administrative procedures was notcompleted before the peak patient load was reached, but work on the programcontinued during the winter of 1944 and the spring of 1945. Beginning in July1945 chapters in the hospital-administration manual were published on thefollowing subjects: Patients' Funds and Valuables (1 July 1945); HospitalOrganization (1 July 1945); Ward Administration (1 October 1945 and 15 February1946); Accounting Procedures for Hospital Funds (1 October 1945); MessAdministration (15 November 1945); Personnel Administration (28 December 1945and 15 February 1946); Clinical Procedures (15 February 1946); and SupplyProcedures (1 March 1946).17
Work-Measurement and Work-Simplification Programs
Delay in completing the manual on hospital administration didnot interfere with the simplification of administrative procedures and workmethods by hospitals themselves. As part of its program for efficient personnelutilization, early in 1943 ASF headquarters began to require subordinateinstallations to set up programs of "work simplification" and"work measurement." Work simplification was the process of reducingthe jobs of individual workers, or the operations of groups of workers, to theirsimplest forms and eliminating from them all lost motion. Work measurement wasthe determination by various standards of the number of employees required forcertain jobs or operations.18 During1944 and 1945 hos-
15(1) An Rpt, FY 1945, Hosp and Dom Oprs SGO; An Rpts, 1944, Lawson, Thayer, Oliver, and Ashburn Gen Hosps, and AAF Regional Hosp Keesler Fld; An Rpts, 1945, Birmingham and Lovell Gen Hosps, and Surg 7th SvC. HD. (2) Mins, Hosp Comdrs Conf, 7th SvC, 22 Aug 45. HD: 337.
16(1) Excerpts from rpts of various hosps on the use of dictaphones, Jun-Jul 44. SG: 413.51. (2) An Rpts, 1944, Ashburn, Deshon, Beaumont, Baxter, and Birmingham Gen Hosps, and Regional Hosps at Fts McClellan and Meade, Maxwell and Scott Flds, and Cps Shelby, Barkeley, Swift, and Crowder. HD.
17(1) TM 8-262, Admin of Fixed Hosps, ZI, dates listed. (2) An Rpt, FY 1945, Hosp and Dom Oprs SGO. HD.
18(1) History of Control Division, ASF, 1942-45, pp. 160-63; App, pp. 141-44 and 151-53. HD. (2) Memo, CG SOS for Dir Staff Divs, Cs of Sup and Admin Servs, CGs all SvCs, 1 Mar 43, sub: Work Simplification. SG: 024.-1.
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pital control officers appointed as a result of ASFheadquarters' emphasis upon management techniques (or administrativeengineering) conducted work-measurement and work-simplification studies andproposed changes to save time and personnel in a multiplicity of functions andactivities.19 For example, a surveyof ward attendants' duties at Walter Reed General Hospital in the spring of1944 showed that attendants spent 20 percent of their time in off-the-warderrands. To correct that situation a delivery service staffed with twenty peoplewas set up, and forty ward attendants were released.20Another hospital, Thayer General Hospital, made changes in its system of trashcollection that saved 200 man-hours per month. At still another Ashford GeneralHospital, a reallocation of individual duties and a rearrangement of office anddesk space in the registrar's office permitted the completion in 1944 of 4,911more work-units in 9,600 fewer work-hours than in the year before. Seventeenwork-measurement and work-simplification studies made at Newton D. Baker GeneralHospital during 1944 resulted in the saving of 2,844 man-hours per month. Otherhospitals reported similar savings from local changes.21In this way, hospitals adjusted their operations to performance by reducedstaffs and management control became an established function in all large Armyhospitals.22
Additional Activities and Their Place in theOrganizational Structure of Hospitals
In the latter half of the war new professional andadministrative activities were added to Army hospitals. When convalescentreconditioning was established as an Army program, hospital commanders placedthat activity in a variety of locations in their organizational structures; butby February 1944 the Surgeon General's Office concluded that reconditioningshould be considered as a professional service on a par with medical andsurgical services. The next month, with the approval of ASF headquarters, thechief of The Surgeon General's Reconditioning Division announced this decisionas policy at a conference of reconditioning officers at Schick General Hospital.23Two other changes occurred in the professional services during 1943 and 1944.Gradually hospitals began to list nursing as a professional rather than anadministrative service and to show neuropsychiatry as an independent servicerather than as a section of the medical service.24
19In an interview on 20 November 1951 General Kirk stated that he thought too much emphasis had been placed upon the "workload business." In his opinion workload studies were expensive and "did not pay more than ten cents on the dollar." HD: 314 (Correspondence MS)V.
20Work Simplification Rpt, 8 Apr 44, sub: Delivery Serv, Walter Reed Gen Hosp. SG: 323.7-5 (Walter Reed GH)K.
21An Rpts, 1944, Thayer, Ashford, Newton D. Baker, O'Reilly, Kennedy, Baxter, Schick, and Birmingham Gen Hosps; An Rpts, 1945, Crile and Battey Gen Hosps. HD.
22(1) Memo, Dir Control Div SGO for Dir HD SGO, 23 Jun 45, sub: An Rpt of Control Div for FY 1945. HD: 319.1-2 (Control Div, SGO) FY 1945. (2) SG Cir 119, 15 Sep 50, sub: Orgn of US Army Hosps Designated as Class II Instls or Activities, provided for a management office in each Army hospital designated as a Class II installation or activity (that is, general hospitals operating in 1950 under the direct control of SGO).
23(1) An Rpts, 1944, Baxter, Finney, Crile, Lawson, Vaughan, and Fletcher Gen Hosps. HD. (2) Ltr, Act SG to CG ASF, 15 Mar 44, sub: Orgn Chart, Reconditioning Program, with 1st ind, CG ASF to SG, 17 Mar 44. Off file, Physical Med Consultants Div SGO, "Reconditioning, Gen (Policy)." (3) An Rpt, Reconditioning Conf, Schick Gen Hosp, 21-22 Mar 44, p. 17. HD: 353.9 Schick Gen Hosp.
24See annual reports of hospitals on file in HD.
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Additional administrative activities in hospitals camelargely as a result of their introduction generally in ASF installations.Revision of the ASF organization manual in December 1943 caused addition ofcontrol officers to serve as staff advisers on administrative, procedural, andmanagement problems.25 About the same timeauthority was granted all ASF installations having a strength of 2,000 or moreto appoint special services officers to conduct athletics and recreationprograms and orientation officers (later called information and educationofficers) to conduct information and education programs.26In February 1944 ASF headquarters directed the establishment on each ofits posts of a personal affairs division to assist soldiers in handling theirpersonal affairs.27 In the followingDecember the War Department directed separation centers and many hospitals(those separating from the service one hundred or more persons monthly) to setup classification and counseling units to assist soldiers in planning theirreturn to civilian life.28 Generalhospitals with few exceptions and regional hospitals in some instances camewithin the purview of these directives and acted accordingly. These newactivities-special services, information and education, personal affairs, andclassification and counseling-were to be known later as "welfareservices" or as "individual services."
Effect on Hospitals of the ASF Standard Plan for Post Organization
The general program of ASF headquarters to standardizeorganization throughout the Service Forces continued, as it had earlier, toinfluence the organization of general hospitals.29In December 1943 the standard plan for the organization of ASF posts wasrevised. At that time a control officer and a post inspector general were addedto form, along with the existing public relations officer, the commandingofficer's immediate staff. Furthermore, the seven functional divisions whichpreviously comprised all post activities were replaced by seven administrativeand seven technical staff units. To make this change, the erstwhileAdministrative Division, a functional division which had included the adjutant,judge advocate, and fiscal officer, was abolished and its officials were listedamong the seven administrative staff units. Certain technical services-quartermaster,ordnance, chemical warfare, signal, and transportation-were relieved fromtheir former subordination to the Supply Division and were established asindependent technical staff units. Medical and engineer activities, consideredas functional divisions under the old plan, now became technical staff units.All welfare activities continued, under the new post plan, to be grouped underthe Personnel Division.30
General hospitals attempted to adjust themselves to the neworganizational plan for ASF posts as they had to its predecessor. In eachhospital, professional services and some administrative units peculiar tohospitals, such as the registrar's office and the dietetics division, had tobe added to the units included in the standard ASF plan. In the administrativefield, hospitals made adjustments in various ways. Baxter
25For example, see An Rpts, 1944, Baxter, Woodrow Wilson, Schick, and Mayo Gen Hosp. HD.
26(1) ASF Cir 127, 20 Nov 43. (2) WD Cir 360, 5 Sep 44.
27ASF Cir 31, 7 Feb 44.
28WD Cir 486, 29 Dec 44.
29See above, p. 123.
30ASF Manual M 301, Pt IV, Rev 2, 15 Dec 43. Also see above, Chart 13.
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General Hospital, for example, followed the ASF plancarefully, at least in its organization chart, and only added to the postorganization a reconditioning division, a medical supply office, a medicaldetachment, and a professional division that included the professional servicesand such administrative units as the registrar's and dietitian's offices.Mayo General Hospital adhered less strictly to the ASF plan. Although it hadmost of the officers which that plan called for, it placed many who weresupposed to be grouped under an intermediate supervisor, such as specialservices and personal affairs officers, in a direct relationship with thecommanding officer.31 (Chart 12) Hospitalsthat thus multiplied the number of officers reporting directly to the commanderviolated one of the ASF principles of organization, namely, that the number ofsuch officers should be kept as small as possible.32Several hospitals on the other hand followed that principle (and incidentally arecommendation made by the Wadhams Committee in the fall of 1942) by combiningtheir administrative services under a single director and their professionalservices under another.33 In February 1945 thecommanding officer of Darnall General Hospital suggested that this grouping ofprofessional and administrative services under separate directors, who in turnwere responsible to the commanding officer, might be followed with advantage byall other hospitals.34
Two other changes were considered desirable to make the ASFpost organization applicable to all hospitals. Officers in the Third ServiceCommand headquarters and in the Surgeon General's Office, as well as somehospital commanders, believed that technical service officers with only minorfunctions in hospitals, such as those of the Chemical Warfare Service, OrdnanceDepartment, and Transportation Corps, should be either eliminated orsubordinated-as they had been under the previous ASF post organization-to adirector of supply.35 Conversely,because officers concerned with the individual welfare of soldiers (specialservices, personal affairs, information and education, and classification andcounseling officers) assumed more importance in hospitals than in otherinstallations, some hospital commanders and service command surgeons felt thatthey should be grouped together under a director of individual services ratherthan under the director of personnel.36
Emergence of Standard Plans for Hospitals
Early in May 1944 the Surgeon General's Office announcedthat it was planning to publish a standard plan for the organization of generalhospitals, but its development was delayed because of shortage of personnel inthe Control Divi-
31See annual reports of hospitals named. HD
32ASF Manual M 301, 15 Aug 44, Pt I, Sec 103.02, sub: Principles of Orgn.
33(1) An Rpts, 1944, Cp Barkeley and Scott Fld Regional Hosps. HD. (2) 1st ind, CO Staten Island Area Sta Hosp to CG 2d SvC attn SvC Surg, 3 Mar 45, on Ltr, CG 2d SvC (Surg) to CO Staten Island Area Sta Hosp, 24 Feb 45, sub: Orgn Chart. HD: 323 "Hosp Orgn."
34Ltr, CO Darnall Gen Hosp to CG 5th SvC attn SvC Surg, 22 Feb 45, sub: Standard Orgn Charts of Gen, Regional, and Sta Hosps, with incl. HD: 323 "Hosp Orgn."
35(1) Orgn Chart prepared by 3d SvC Hq, [1944]. HD: 323 "Hosp Orgn." (2) Interv, MD Historian with Dr. H. A. Press, formerly of SGO Control Div, 1944-45, 9 Oct 50. HD: 000.71. (3) An Rpts, 1944, Mayo, Valley Forge, Ashburn, and Baker Gen Hosp. HD.
36Ltrs from 4th and 5th SvC Surgs, and COs of Darnall, Nichols, O'Reilly, and Schick Gen Hosps. HD: 323 "Hosp Orgn."
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CHART 12-ORGANIZATION OF MAYO GENERALHOSPITAL, 1944
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sion and priority given to procedures for disabilitydischarges and hospital admissions.37 Meanwhile,the surgeon of the Fourth Service Command worked out a standard plan for theorganization of hospitals under his supervision.38Then, in June and July 1944 the surgeon and the control officer of theThird Service Command, with assistance from the Surgeon General's Office,developed a standard plan for hospitals in that Command. After it had beentested for about six months, The Surgeon General submitted it for comment inFebruary 1945 to other service commands. On the basis of their suggestions, hemade minor changes in the Third Service Command plan and adopted it as standardfor general, regional, and station hospitals.39 It was published inJuly 1945 as a chapter of the manual on hospital administration.40 TheSurgeon General's Office also worked during this period on the organization ofconvalescent hospitals and hospital centers. Tentative plans were published in1944 and 1945. The final plan for convalescent hospitals was published inDecember 1945, but that for hospital centers remained unpublished because theybegan to close before it was completed.41
During the movement to standardize hospital organization, themerits of such a step were freely discussed. Hospital commanders generally andservice command surgeons in some instances raised arguments against inflexiblestandardization. One feared that it would crystallize hospital organization,increasing efficiency in the operation of some installations but prohibitingimaginative and capable commanders from making valuable innovations in others.42Some felt that standardization would prevent hospital commanders fromadjusting to local conditions. For example, hospitals giving little outpatient care might notneed to establish separate outpatient services. Others believed that commandersneeded freedom to fit their organizations to the personalities of officersassigned to them. An eye, ear, nose, and throat specialist of intenseindividualism and higher rank than a chief of surgical service, for instance,could hardly be successfully subordinated, in an EENT section, to the latter.43On the other hand, there was some feeling that men should be fitted tojobs, not jobs to men, and that the standardization of organization would helpto solve problems raised by clashing personalities. The most telling argumentsin favor of standardization were that it was the first step toward thesimplification and standardization of administrative procedures, that itfacilitated the measurement of work and of personnel require-
37(1) Rad, SG to CG 4th SvC attn SvC Surg, 3 Mar 44. SG: 323.7-5(4th SvC)AA. (2) Edward J. Morgan and Donald O. Wagner, The Organization of the Medical Department in the Zone of the Interior (1946), p. 145. HD. (3) Interv, MD Historian with Dr. Press, 9 Oct 50. HD: 000.71.
38(1) Rad, SG to CG 4th SvC attn SvC Surg, 3 Mar 44. SG: 323.7-5(4th CA)AA. (2) 1st ind, CG 4th SvC (Surg) to SG, 9 Mar 45, on Ltr SPMCH 323.3 (4th SvC)AA, SG to CG 4th SvC attn SvC Surg, 16 Feb 45, sub: Standard Orgn Charts of Gen, Regional, and Sta Hosps. HD: 323 "Hosp Orgn."
39(1) Ltr 323.3 (1st SvC)AA, SG to CG 1st SvC attn SvCSurg, 16 Feb 45, sub: Standard Orgn Charts of Gen, Regional, and Sta Hosps.Identical letters were sent to all service commands; these letters, with theirreplies, are on file in HD: 323 "Hosp Orgn." (2) Status of Proceduresbeing Developed in SGO, [Apr 45] HD.
40TM 8-262, Ch. I, Hosp Orgn, 1 Jul 45.
41(1) ASF Cirs 419, 22 Dec 44; 135, 16 Apr 45; and 445, 14 Dec 45. (2) Morgan and Wagner, op. cit., p. 162.
421st ind, CG 7th SvC (Surg) to SG, 8 Mar 45, on Ltr 323.3(7th SvC)AA, SG to CG 7th SvC attn SvC Surg, 16 Feb 45, sub: Standard OrgnCharts of Gen, Regional, and Sta Hosps. HD: 323 "Hosp Orgn."
43Letters from hospital commanders and service commandsurgeons expressing these opinions are on file, HD: 323 "Hosp Orgn."
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ments, and that it promoted manpower economy.44 Atany rate, both the Surgeon General's Office and ASF headquarters werecommitted to standardization of hospital organization by the winter of 1944.That they did not insist on inflexibility was demonstrated by a proviso thathospital commanders might deviate from the standard plan if their respectiveservice commanders approved.45
Details of the Medical Department's Standard Plans
The standard plan for the organization of general hospitals,published in July 1945, resembled the ASF plan for post organization andreflected the experience of hospitals in making adjustments to it. In bothplans, the commander's immediate staff included public relations officers,control officers, and inspectors (called inspectors general on posts and medicalinspectors in hospitals). General hospitals, according to the standard plan,were to have six of the seven administrative staff divisions of posts. Theseventh, training, was to be subordinated to the personnel division. Inaddition, they were to have four administrative staff units not called for inthe post organization plan. These were the station complement (medicaldetachment), the dietetics division, the veterinarian's office (for foodinspection), and the registrar's office. The plan for hospitals had notechnical staff divisions as such. Some, such as ordnance and chemical warfare,were eliminated completely; others, such as quartermaster and transportation,were subordinated to the supply division; and another, the engineer, was placedon the administrative staff. The welfare services, despite the wishes of hospital commanders, were left subordinated to the personneldivision. The plan for hospital organization naturally included professionalservices. There were nine in general hospitals, including the reconditioningservice, the neuropsychiatric service, and the nursing service. In this fieldhospital commanders were left with more latitude than in the administrativebecause, the manual stated, the professional services "function solely in aprofessional manner and are subject to constant variation by reason of changesin types of patients treated." The standard plan for regional and stationhospitals resembled that for general hospitals. The chief differences were thatadministrative and technical units which existed as parts of post and generalhospital organizations were eliminated and the neuropsychiatric service wassubordinated, as a section, to the medical service.46(Chart 13)
Publication of the standard plan for the organization ofgeneral, regional, and station hospitals had little appreciable effect upontheir organization.47 The chief reason, perhaps, was that the planitself reflected experiences of hospitals in conforming with ASF directives onorganization.48 Nevertheless, it officially sanctioned theirconformity and provided them with a detailed statement of the functions of allmajor units within hospitals. Undoubtedly its value would have been greater ifpub-
44Ltr, SG to CG 1st SvC attn SvC Surg, 16 Feb 45, sub: StandardOrgn Charts of Gen, Regional, and Sta Hosps, with 1st ind and incl. HD: 323"Hosp Orgn."
45TM 8-262, Ch. I, Sec I, 1 Jul 45.
46TM 8-262, Ch. I, 1 Jul 45.
47Morgan and Wagner, op. cit., pp. 147-51,arrive at this conclusion after examining the data on organization given in theannual reports of 14 general and 19 regional hospitals for 1944 and 1945.
48Interv, MD Historian with Dr. Press, 9 Oct 50. HD:000.71.
272
CHART 13-COMPARISON OF STANDARD PLANS FORORGANIZATION OF ASF POSTS AND ASF GENERAL HOSPITALS, 1945
273
lished four years earlier, at a time when new hospitals werebeginning to open with staccato rapidity.49
The development of standard organizational plans forconvalescent hospitals and hospital centers came even later than for generalhospitals and was therefore of less value. Having only limited amounts ofpersonnel and no guides for organization, ASF convalescent hospitals wereorganized by their commanding officers to fit individual circumstances.Consequently they differed from one another in many respects. Convalescenthospitals that were separate installations attempted generally to organizeadministrative activities according to the standard ASF post plan.50 Thosethat operated in conjunction with general hospitals depended upon the latter forsome administrative services and organized for the rest as the personnelassigned to them permitted.51 Gradually a common feature began to emerge. Itwas the establishment of a reconditioning section and the grouping of patientsinto companies, battalions, and/or regiments for administration andsupervision.52 In the winter of 1944, when additional emphasis was placedupon the convalescent program, the Surgeon General's Office developed andpublished a guide53 which left the organization of administrativeactivities of convalescent hospitals almost entirely to the discretion of theircommanders. The result was that, as they received more patients and operatingpersonnel, some set up administrative offices that duplicated, or at leastparalleled, those of the general hospitals located near by.54Theguide showed in more detail the organization of convalescent activities. Theywere to be grouped in three divisions: a receiving division, an infirmary division, and a reconditioning division. The infirmarydivision was not to be established in convalescent hospitals located neargeneral hospitals. The reconditioning division was to have a twofold function:it was to exercise command over patients who were to be organized in threebattalions (neuropsychiatric, primary reconditioning, and advancedreconditioning), and it was to conduct the convalescent training program. Thisprogram was to include occupational therapy, physical reconditioning,educational reconditioning, and classification and counseling. The plan servedas a guide to convalescent hospitals that remained separate installations during1945, and it was used to some extent, particularly for the organization ofconvalescent activities, by those that became parts of hospital centers in thespring of that year. That hospitals considered it as a guide only is indicatedby differences
49The plan of 1945 for general hospitals remained inforce for five years. The Surgeon General's Office then published, on 15September 1950, a new standard plan for their organization. It is of interestthat this plan called for fewer major units within a hospital and charged twoofficers, the executive officer and the deputy commanding officer, with theco-ordination, if not the supervision, of the administrative and professionalservices respectively. SG Cir 119, 15 Sep 50, sub: Orgn of US Army HospsDesignated as Class II Instls or Activities.
50An Rpts, 1944, Mitchell Conv Hosp and Surg 4th SvC. HD.
51(1) An Rpts, 1944, Madigan and Percy Jones Gen and Conv Hosps. HD. (2) An Rpts, 1945, Brooke and Wakeman Hosp Ctrs, have referenceto 1944 orgn. HD.
52An Rpts, 1944, Wakeman and Lovell Gen and Conv Hosps,and Cp Carson Conv Hosp. HD.
53ASF Cir 419, 22 Dec 44, Pt II, Conv Hosp-RevisedProgram.
54An Rpts, 1945, Percy Jones, Wakeman, and Cps Butner andCarson Hosp Ctrs. HD. These reports have discussions of organization ofconvalescent and general hospitals before they were combined to form centers.
274
CHART 14-STANDARD PLAN FOR ORGANIZATION OF ASFCONVALESCENT HOSPITALS, 1945
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that continued to exist in the organization of differentinstallations.55
At the end of 1945 a second plan for the organization ofconvalescent hospitals was developed by the Surgeon General's Office andpublished by ASF headquarters.56 A combination of the old plan forconvalescent hospitals and the new standard plan for general hospitals, itshowed the administrative organization of convalescent hospitals in more detailthan did the old one. The immediate staff of the commanding officer and theadministrative staff units of convalescent hospitals were to be essentially thesame as those prescribed for general hospitals. The convalescent services wereto be similar to those called for by the 1944 guide for convalescent hospitals.The most important change was the separation of the reconditioning, orconvalescent training, program from the administration of companies of patients.The chief of the reconditioning service was to have charge of the former, whilethe hospital commander was to supervise directly the commanders of the 1stconvalescent regiment (neuropsychiatric), 2d convalescent regiment (medical),and 3d convalescent regiment (surgical). Publication of this plan afterconvalescent hospitals had already begun to close undoubtedly limited its effectupon the organization of such installations. (Chart 14)
The establishment of hospital centers in the spring of 1945was expected to eliminate duplication of administrative activities involved inthe operation at the same location of both convalescent and general hospitals.The Surgeon General's Office expected that administrative functions common toboth would be centralized under center headquarters, but a guide for theorganization of hospital centers published in April 1945 was sufficiently general to leave to local commanders the decision as to howmuch centralization there would be.57 For that reason, and because ofdifferences among hospital centers-some being located on posts with otheractivities and some constituting posts in themselves-centers varied inorganization from one to another.58 Two extremes were representedby the Percy Jones Hospital Center and the Wakeman Hospital Center. (Chart15) The former, a post itself, had operating as well as supervisoryfunctions, and administrative activities common to both the general andconvalescent hospitals assigned to it were performed by center headquarters.59Wakeman, on the other hand, was located on a post with other Armyactivities that were nonmedical in character. Post headquarters furnished someadministrative services for both the general and convalescent hospitals; eachhospital performed the others itself; and center headquarters served in asupervisory, not an operational, capacity.60
In the hope of achieving a measure of uniformity in theorganization of hospital centers, the Surgeon General's Office in July 1945sent out the Percy Jones plan for comment by hospital center commanders
55(1) An Rpts, 1945, Welch and Cp Upton Conv Hosps. HD. (2)Orgn and Functional Charts, Percy Jones Hosp Ctr, 24 Apr 45; Orgn and FunctionalCharts, Brooke Hosp Ctr, 16 Aug 45; Orgn and Functions, Cp Edwards, Mass,Embracing the Post and the Hosp Ctr, 20 Aug 45; Orgn and Functional Manual, CpCarson Hosp Ctr, 31 Jul 45. HD: 323 "Hosp Orgn."
56ASF Cir 445, 14 Dec 45, Pt II-Conv Hosp-RevisedProgram.
57(1) See above, pp. 198-99. (2) WD Cir 105, 4 Apr 45. (3)ASF Cir 135, 16 Apr 45.
58Morgan and Wagner, op. cit., pp. 163-64.
59An Rpt, 1945, Percy Jones Hosp Ctr. HD.
602d ind, CO Wakeman Hosp Ctr to CG 5th SvC attn SvC Surg,18 Jul 45, and 3d ind, Surg 5th SvC to SG, 9 Aug 45, on Ltr, SG to CG 5th SvC attnSvC Surg, 9 July 45, sub: Standard Orgn Charts for Hosps. SG: 323.3 (5th SvC)AA.
276
CHART 15-ORGANIZATION OF PERCY JONES HOSPITAL CENTER,1945
277
CHART 16-STANDARD PLAN FOR ORGANIZATION OF A HOSPITAL CENTER(ZI), 1945
278
and service command surgeons.61 Following receiptof their replies, that Office by the beginning of 1946 developed a standard planfor the organization of hospital centers. Although never published, it wassignificant because it represented The Surgeon General's idea of what theorganization of a hospital center should be. Of prime importance was the factthat center headquarters was to be operational and was to perform for generaland convalescent hospitals the administrative services that were common to both.Hence, the center commander's immediate staff and the administrative staffdivisions of hospital centers were to be essentially the same as those found inboth general and convalescent hospital organization charts. To assist a centercommander in supervising and co-ordinating the professional activities ofhospitals under his control, his immediate staff was to contain a director ofdental services, a director of professional services, and a director of nursingservices. General and convalescent hospitals, minus the staff and administrativedivisions of center headquarters, were to be under separate commanders, each ofwhom reported directly to the center commander and had an administrativeassistant to provide the few administrative activities that could not be concentrated under centerheadquarters.62 (SeeCharts 15, 16.)
A significant feature of the hospital organization plans justdiscussed was their attempted conformity with the standard plan for theorganization of ASF posts. While there were perhaps enough similarities betweenthe functions of posts and those of hospitals to warrant such conformity, onemay question whether it was altogether desirable or would have been required ifstandard plans emphasizing the peculiar functions of medical installations hadbeen issued earlier. Certainly the Medical Department would have benefited fromhaving such plans available when the hospital expansion program first began.Moreover, they would have made easier the task of simplifying and standardizinghospital administrative procedures. While accomplishments in this field weresubstantial, it was unfortunate that they came so late in the war. Offsettingthis delay, perhaps, was the fact that management control became an establishedfunction in all large Army hospitals by the end of the war.
61For example, see: Ltr, SG to CG 9th SvC attn SvC Surg, 9 Jul 45, sub: Standard Orgn Charts for Hosps. SG: 323.3 (9th SvC)AA. Similarletters were sent to other service commands.
62Morgan and Wagner, op. cit., pp, 156-64.
