1 GO3 RM 00031-01 SITE VISIT REPORT METROPOLITAN WASHINGTON, D.C. REGIONAL MEDICAL PROGRAM February 7~8, 1968 SITE VISITORS; George E. Miller, M.D., Director, Office of Research in Medical Education, _ College of Medicine, University of Illinois, Chicago, Illinois Leonidas H. Berry, M.D., Professor, Cook County Graduate School of Medicine, Michael Reese Hospital, Chicago, Illinois Mieczyslaw Peszczynski, M.D., Chairman, Department of Physical Medicine, Emory University School of Medicine, Atlanta, Georgia. DRMP STAFF; Mrs. Martha L. Phillips, Chief, Grants Review Branch, DRMP Mrs. Patricia McDonald, Public Health Advisor Dr. Thomas Bodenheimer, Clinical Program Section, Health Services Branch METROPOLITAN WASHINGTON, D.C. RMP STAFF; Thomas W. Mattingly, M.D., Program Coordinator Mr. Mal Xavier, Administrative Assistant John R. Heller, M.D., Primary Project Director - Cancer Warren V. Huber, M.D., Primary Project Director ~ Stroke Jesse B. Barber, M.D., Project Director - Stroke - Howard Juan Calatayud, M.D., Project Director - Heart ~ George Washington John F. Potter, M.D., Project Director - Cancer ~ Georgetown John F. Stapleton, M.D., Project Director ~ Heart - Georgetown METROPOLITAN WASHINGTON, D.C. RMP EXECUTIVE COMMITTEE OF THE REGIONAL ADVISORY GROUP: Clayton B. Ethridge, M.D., Chairman, Advisory Group - George Washington Francis C. Mayle, M.D., 2nd Vice-Chairman, Advisory Group - Montgomery County Medical Society Patrick J. Doyle, M.D., Georgetown Medical Center Daniel L. Finucane, M. D., Prince George’ s County Department of Health Charles S. Ireland, M.D., Howard Medical Center G. Gordon Kay, M.D., Fairfax Cancer Society John A. Kenney, Jr., M.D., Medico-Chirurgical Society Roy P. Lindgren, M.D., Montgomery County Department of Health Stanley P. Mayers, Jr., M.D., Arlington County Department of Health Robert R. Montgomery, M.D., Montgomery County Heart Association John C. Watson, M.D., Alexandria Medical Society MEDICAL SOCIETY OF METROPOLITAN WASHINGTON, D.C. William S. McCune, M.D., President, Medical Society of the District of Columbia Desmond S. O'Doherty, M.D., Chairman, Program Committee of the Grantee Mr. George W. Cooley, Secretary, Program Committee of the Grantee CATEGORICAL REVIEW COMMITTEE CHAIRMEN Donald P. Conwell, M.D., Stroke Review Committee Jack Kleh, M.D., Heart Review Committee PROJECT PERSONNEL: Washington Metropolitan Region Cerebrovascular Disease Follow-up and Survellance System, Georgetown University - Leonard Chiazze, Jr., Sc.D. - Project Manager Patrick J. Doyle, M.D., Member Advisory Group Executive Committee Desmond S. O'Doherty, M.D., Chairman, Program Committee Home Telecasts of Medical-Surgical Cardiovascular Conferences, Georgetown University Mr. William J. McCarter, Vice President and General Manager - WETA-T-V Mr. Robert D. Smith, Program Director ~ WETA-T-V John F. Stapleton, M.D. ~ Project Director Training Program for Cardiovascular Technicians, Washington Hospital Center James M. Bacos, M.D. - Project Manager Mr. Michael R. Boivin - Technician Mr. Richard M. Loughery ~- Washington Hospital Center Administrator Mrs. Joan Williams, R.N. - Chief Nurse Freedmen's Hospital Stroke Station for the Diagnosis, Treatment and Investigatic of Cardiovascular Disease Jesse B. Barber, Jr., M.D. - Project Manager Anna B. Cole, R.N., Ph.D. ~ Chief Nursing Service Mr. Russell Davis, Physiotherapist Alicia Hastings, M.D. - Head, Department of Physical Medicine Charles S. Ireland, M.D. - Assistant Medical Director, Howard DRAFT SITE VISIT REPORT METROPOLITAN WASHINGTON, D.C. REGIONAL MEDICAL PROGRAM February 7-8, 1968 GENERAL: The site visit team concluded from its visit that substantial progress has been made in the Metropolitan Washington, D.C. Region. This progress is especially striking when viewed in perspective of the inherent complexities of the D.C. Metropolitan area. The purposes for the program have been established; all that remains is their fulfillment. A wide range of individuals and groups have been contacted about the program. The practicing physicians in particular appear to be actively interested, as shown by the number who attended and participated in the opening session of the visit. The D.C. Medical Society is committed to the regional system. Thus far, the only allied health group represented on the Regional Advisory Group is the nursing profession, and this does not extend to the crucial Steering Committee. The Region has had difficulty getting-individuals who are not in medically-related fields to participate in the program. The site visitors commended the active involvement of the Regional Advisory Group and the extensive guidance and review it has given to development of the program. The decision was made recently to expand the membership to include representa- tives of consumer interests, and several have been brought on to balance the group. The site visitors felt that their inquiries about paramedical repre~- sentatives suggested to the Region the importance of including them in their planning. The D.C. Region is aware of the need to cooperate with surrounding regional medical programs. Visits have been made to the Maryland and Virginia programs and to health officers in these states. The general feeling expressed was that the present loose system is working well. This permits those in peripheral areas to choose to work with one or both programs. The site visit team was concerned that planning is being done for individual projects without interaction among them. The team inferred that this is caused by some administrative shortcomings. Only two staff members are full time, and the rest are 25 percent, which has proved insufficient to provide the necessary coordination. The application for a planning supplement is designed to remedy this situation. During discussion with the directors of the proposed projects, the site visitors sensed their willingness to cooperate with one another althougl this has been arranged by them since each learned of the other's part of the application, rather than as a result of orderly planning. Organized planning for the region, local priority setting, and identification of regional strengths and needs have not yet been approached. However, the site visitors concluded that the D.C. program is moving in the direction of truly regional coordination and that it will continue to be strengthened by the time the program is reviewed at the close of the first grant period. DRAFT . ASSESSMENT OF PROJECTS Project #1 - Stroke Station for the Diagnosis, Treatment, and Investigation of Cerebral Vascular Disease — Freedmen's Hospital. This site visit team was favorable toward this project. The project director demonstrated an impressive understanding of the issues involved and is taking advantage of the resources at the entire University in addition to the medical school, such as speech therapy, social work, and psychology.. The educational elements are not well developed. The representative from the School of Nursing stated that the school's curriculum is currently being revised, and that a plan will be developed for nurses to rotate through the stroke station for training in rehabilitation. The staff for this project does not presently include someone with competence to evaluate the program during its operation. This would seem crucial since a retrospective analysis of such a comprehensive project will be difficult. The problem is well recognized, however, and consultant services of the University's Department of Psychology are being called upon. The project staff recognizes that getting patients to the hospital for rehabilitation may present problems. They have budgeted funds to test the feasibility of various methods of patient transport. Efforts are being made to provide beds in Freedmen's Hospital for rehabilitation patients for demonstration and training and to locate extended care facilities for those who cannot be accepted. A question was raised about the necessity for equipment requested. Dr. Peszczynski advised that it is appropriate. His report of this specific issue is appended. Project #2 - Cerebrovascular Disease Follow-Up and Surveillance System - Georgetown, ~ The site visitors commended the Region for addressing itself to this serious problem. They feel that the proposal is sound and that the project director recognizes that data accumulation in the area of stroke is highly exploratory at this time. A major aspect of this proposal is to design an instrument to record data concerning signs and symptoms of stroke, its evaluation and follow- up. Existing patient charts will be used initially. Data will be recorded only after the charts have been analyzed by physicians. The project is receiving excellent cooperation from the Department of Neurology. Dr. Desmond O'Doherty, Chairman, is personally undertaking-a record review of 175 stroke and suspected stroke cases, the initial identification of reportable characteristics and events. Dr. Patrick Doyle, Department of Community Medicine, is also actively interested in the project. The directors of this proposal and the stroke proposal at Howard University have talked together about the prospects for coordinating their individual projects. No effort will be made to use Standard forms in the region for recording patient data until a valid recording instrument has been established. The site visitors were of the opinion that there is a great need for this type of exploration. and that the present study merits support. DRAFT 3 Project #3 - Training Program for Cardiovascular Technicians - Washington Hospital Center. This project recognizes a major manpower shortage and proposes a solution to the problem. The nursing service at the hospital, the hospital admin- istrator, and the cardiology service support the program, and the National Society of Cardio-Pulmonary Technologists has informally given its approval. Several weaknesses were found in the present application. -However, it might be supported for two years as a pilot study and several possibilities could be explored during this period. For example, other medical institutions in the region might be utilized in providing clinical field work for the trainees. A new junior college in the District of Columbia provides the possibility for academic affiliation. Concurrently, the potential of high school drop outs should not be overlooked. The present intent is to employ the program graduates in the Washington Hospital Center, and plans for enlarging training capacity, either by increasing their own class or helping- other hospitals start similar programs, are very remote. The cost per student seems excessive. Much of the equipment is not understood and apparently not essentialto the training. The application does not include a well-developed curriculum. The site visitors recommended that the course developed by thé Navy, with which the project director is familiar, should be leaned upon until his own is developed. Project #4 - Home Telecasts of Medical - Surgical Cardiovascular Conferences at Georgetown. The site visitors recognized that the conference which this proposal would televise is highly acclaimed and respected by physicians in the D.C. Metropolitan area. This proposal, however, is presented as a “pilot project to evaluate the efficacy of telecasts . . ." and the site visitors believe the methods outlined would not provide this information. The mechanism for evaluating the project is very vague and no educational expertise has been retained for developing such a mechanism. Consideration has been given to televising the conference unscrambled for viewing by the public. Provisions will be made for multiple viewing of the conference in community hospitals with a two-way radio for questioning. No method has been outlined for evaluating either of these aspects of the project. Itwould be difficult to determine from this proposal if the effectiveness of telecast justifies their cost. The site visitors are sympathetic to the aims of the proposal, but they do not believe the present methodology is sufficiently developed to merit support. They suggested that it be returned with strong encouragement for a revised submission. Additional discussion of this project is given in the appended letter of Dr. George Miller. PLANNING SUPPLEMENT: The site visit team was uncertain as to the advisability of the change in administrative structure which this planning supplement would allow. Such a system could cause the program to break into five autonomous subunits with’ no meaningful interaction among them. On the other hand, it was recognized that appointments through the universities provide these positions with additional advantages which will help attract good people to DRAFT the program. The site visitors concluded that the need for additional full time staff 1s obivious and should be funded. In subsequent review of this region, analysis should be made of the extent to which the subunits are cooperating. (Note: the part time positions requested in the planning supplement are already being funded under the continuation award and should no longer be considered part of the present application. The site visitors learned that these people will be phased out when full time staff becomes available.) RECOMMENDATION: The site visit team endorses the readiness of the Region to move into the operational phase of the program. The stroke station (project #1) and cerebrovascular disease follow-up (project #2) merit support as requested. The training program for cardiovascular technicians (project #3) should be funded for two years only with a complete re-review of its accomplishments at that time. The budget should be negotiated downward particularly in the elaborate educational equipment. It is further recommended that the home telecast project (#4) be returned for revision, and that the-applicant be encouraged to re-examine the stated purposes or to clarify the methodology to be employed in meeting the present purposes. The site visit team advises that the planning supplement is needed by the Region and that support for the full time personnel should be funded. 1 G03 RM 00031-01 EMORY UNIVERSITY SCHOOL OF MEDICINE SO BUTLER STREET, S&S. RB. ATLANTA, GEORGIA 30303 DEPARTMENT OF PHYSICAL MEDICINE February 9, 1968 Mrs. Martha L. Phillips Chief, Grants Review Branch Division of Regional Medical Programs National Institutes of Health Bethesda, Maryland 20014 Dear Mrs. Phillips: In connection with Dr. Jesse Barber's proposal, "The Freedmen's Hospital Stroke Station for the Diagnosis, Treatment, and Investigation of Cerebral Vascular Disease,” I consulted with Dr. Stephen Weens, Chairman and Professor of: the Department of Radiology at the Emory School of Medicine and we came to the con- clusion that the request for Biplane Radiographic Unit with stereo tomography aid two rapid cassette changers, as well as “Ekoline 20", and the Head Holder are very reasonable requests to enable The Freedmen's Hospital Stroke Station to make satisfactory diagnostic investigation of their patients. Y yours, n{t ' Mieezyslaw Peszczynski, M.D. Chairman and Professor, Department of Physical Medicine Emory School of Medicine SHYUOOHd W3IG3W IWNOISaY JO NDISTAIG SS,wecn eg 2] 934 QSAIB954 1 GO3 RM 00031-01 College of Medicine UNIVERSITY OF ILLINOIS AT THE MBDICAL CENTER CHICAGO ice of Research tn Medical Education ater for the Study of Medical Education 901 S. Wolcott Avenue « Chicago, [llinvis 60612 + Telephone 6638590 (Area Code ?} February 9, 1968 a rt ao On = wD 25> Nm ere wa =. tz x: ae, rm “Oo Mrs. Martha Phillips nom =e o Division of Regional Medical Programs 2 a National Institutes of Health rv Bethesda, Maryland Dear Mrs. Phillips: In view of the controversy that may be precipitated in the National Advisory Council by the comments which both Review Committee and site visitors have made in con- nection with the Metropolitan Washington Home Telecasts project proposal, let me attempt to summarize the position these groups have taken. The concept embodied in the plan to disseminate more widely a teaching conference that has won such general admiration, and to evaluate its efficacy when telecast into a viewer's home or hospital was very appealing and won the interest of all. The proposal emphasized, and reviewers concurred, that the most critical element in the project was accumulation of data from which general- izations might be drawn about the efficacy of such efforts in the continuing education of practitioners. There was no dissent from the view that such evaluation would be difficult to accomplish, but there was among Review Committee members and site visitors alike, a unanimous feeling that those who proposed the project exhibited such limited understanding of. the nature of these problems,of the information already available which might have been useful in solving them, of the methodology which must be incorpor- ated in a sound evaluation program, and of the personnel oa | ji or “ CLINOIS SS CENTENNIAL YEAR 1967-68 1 GO3 RM 00031-01 Nrs. Martha Phillips _o72~ February 9, 1968 required to carry it out, that support of the program in its present form was not justified. There was, for example, no plan for sampling either of populations or of varieties of terminal learning that were sought, only the most casual and superficial reference to the measurement methods to be employed and no hint of the contemplated form of data analysis. In fact, a review of the proposal and discussion of its nature with project staff in the course of the site visit led to the inescapable conclusion that the pilot effort as proposed requiring an investment of more than $250,000, would produce no more solid evidence about efficacy than the testimonials with which the application was heavily larded. , While the project does not merit support in its present form, it is certainly the hope of all that these glaring deficiencies will be corrected and the proposal resubmitted . for under these circumstances it would surely win our enthusiastic endorsement. Sincerely yours, oy , ( S ' do AAA A George E. Miller, M.D. Director GEM:1lo SITE VISIT REPORT WESTERN NEW YORK STATE REGIONAL MEDICAL PROGRAM February 5-6, 1968 SITE VISITORS Robert J. Slater, M.D., Executive Director, Association for Aid of Crippled Children, New York John $. Hirschboeck, M.D., Wisconsin Regional Program Coordinator , John A. Prior, M.D., Associate Dean, Ohio State University, Columbus, Ohio Jack Hall, M.D., Director of Medical Education, Methodist Hospital, Indianapolis, Indiana - DIVISION OF REGIONAL MEDICAL PROGRAMS STAFF Mrs. Martha L. Phillips, Chief, Grants Review Branch Mrs. Sarah Silsbee, Continuing Education & Training Branch HEALTH ORGANIZATION OF WESTERN NEW YORK ~ Mr. Martin Maier (representing Dr. William Chalecke, Chairman) Herbert E. Joyce, M.D., Chairman of Proposal Committee ~ Douglas M. Surgenor, Ph.D., Provest of Health Sciences - SUNYAB Mr. Mitchell E. Roth, Executive Director of Health Planning Council Ruth T. McGrorey, M.A., Ed.D., Dean, School of Nursing, SUNYAB Albert C. Rekate, M.D., Associate Dean, School of Health Related Sciences, SUNYAB Robert Patterson, M.D., (representing Dr. Robert K. Ausman, Director) Roswell Park Memorial Inst. oe David CG. Dean, M.D., Heart Association of Western New York William E. Mosher, M.D., Health Commissioner, Erie County, New York WESTERN NEW YORK REGIONAL MEDICAL PROGRAM STAFF John R. F. Ingall, M.D., Program Coordinator Mr. Spero Moutsatsos Patricia Shine, R.N. Mr. Anthony Zerbo Mrs. Marian Sumer,Aésistatt to the Vice President for Finance, SUNYAB PROJECT REPRESENTATIVES - Pulmonary Model: John W. Vance, M.D., Millard Fillmore Hospital Frederick Beerel, M.D., Millard Fillmore Hospital Jerome Maurizi, M.D., E.J. Meyer Memorial Hospital Theodore Noehren, M.D., Buffalo General Hospital Mr. William Salleck, Western New York Tuberculosis & Health Association Coronary Care: Mrs. Betty N. Lawson, R.N. Albert C. Rekate, M.D. Lewis J. Young, Cardiologist, Sisters of Charity Hospital Communications: Harry J. Alvis, M.D., Director, Postgraduate Education, School of Medicine, SUNYAB Mr. Gordon R. Evans, American Telephone and Telegraph Company Mr. William H. Siemering, WBFO Radio Projects in Planning: Sumer J. Yaffe, M.D., Buffalo Children‘s Hospital Edward L. Wallace, Ph.D., Department of Management Science, SUNYAB Harry J. Sultz, D.D.S. REPRESENTATIVES OF COUNTY COMMITTEES ADVISORY TO HOWNY Mr. Martin Maier, Chautauqua County Robert Wettingfeld, M.D., Chautauqua County Cedric Mather, M.D., Cattaraugus County Father Cosmas Girard, P.F.M., Cattaraugus County Paul Welsh, M.D., Genesee County John Hartman, M.D., Erie County, Pa. David Harrington, M.D., Genesee County DRAFT 3 GENERAL COMMENTS This inter-state, eight county area appears to be a natural region and the concept of regionalization is recognized and accepted by representatives of all of the counties, including the Buffalo metropolitan areas. Official representation on the Regional Advisory Group and its special committees is well balanced, but at this early stage in regional development the major program emphasis is in the areas outside the metropolitan area (Buffalo, Lackawanna, Niagra Falls and Tonawanda). , Administrative arrangements for planning and program are beginning to be well developed and are, up to the present, based largely on the coordinator's personal contacts. Central office support is being strengthened and the necessary further broadening of professional capability will be achieved by supplementing the core staff (request pending). The arrangements for fiscal management of the grant via SUNYAB and the Research Foundation of the State University of New York in Albany, are working well. ° In the time since the application was submitted, a more formalized arrangement for administrative-advisory relationships and for handling of program pro- posals has been established. This was explained to the group and has been submitted in writing to DRMP by the Coordinator. Cooperative arrangements are excellent, especially among the practitioner groups and educational institutions (community colleges, major hospitals, etc.) Only two problems are encountered: 1) The Regional Medical Program is not producing tangible results fast enough to meet the expectations of the physicians, particularly those in peripheral counties: and 2) The predictable "conflicts of interest" between two major, well-established centers, such as the SUNY School & Medicine and Roswell Park Memorial Institute. Planning, beyond these projects, which are a natural outgrowth of the co- operative efforts, appears to be largely happenstance at this stage. With the exception of a recently completed manpower survey (which is organized as a computerized "perpetuat inventory") there is little evidence of a unified approach to priority setting or identification of regional resources and needs. This deficiency is recognized, and among the approaches to its eventual solution are the addition of more professional staff and increasing assistance from the SUNYAB Department of Management Services under Dr. Edward Wallace. The site visitors were very favorably impressed by this man, especially in his explana- tion of the approach to the region's blood banking problems (done with RMP cooperation but without RMP funds) and his general approach to systems ap-~ plication to medical programs. DRAFT COMMUNICATIONS NETWORK This project plans to link by two-way telephone communication 48 hospitals in the region with the Regional Medical Program facilities in Buffalo. (Four community hospitals will not be included since their medical staffs also serve other hospitals in the same communities.) Initially the network will be utilized for professional and lay education, but later it will be used for data collection, transmission, storage and analysis, and services such as EKG transmission, - The SUNYAB Schools of Medicine, Dentistry, Nursing and Health-Related Sciences are committed to providing program substance. Dr. Harry J. Alvis, Director of Postgraduate Education, School of Medicine, is providing overall SUNYAB coordination. The key technical staff are not named although Dr. Ingall in- dicated specific individuals had been identified and interested in the project once funds were assured. Preliminary programming has developed but specific long-range programming is awaiting assurance of support. - The site visit team felt that an overall understanding of the neéd and potential of the RMP network was evident both within SUNYAB and in the_outlying hospitals. Problems of implementing the communications system encountered in similar programs elsewhere, assuring technical excellence, processing questions and answers from on-line, preparing hospitals, etc., do not appear to have been approached with the same clarity. The site visit team is concerned about the capability to mount the whole program to all 46 hospitals simultaneously as is planned. Widespread support for the establishment of the communications program was evident from both practitioners and hospitals, as was discontent at the delays in getting started. A trial run of 16 outlets is scheduled to start in April 1968 to forestall the mounting impatience of doctors in the periphery, amd to test out technical capabilities. The trial run will utilize commerical lines. Once grant funds are available, it is planned to install multiplex, multiple channel "long lines" Linkage, to increase utilization of the system and to avoid problems of signal distortion inherent in the varying cycles of the different telephone companies operating within the region. Because the region crosses state boundaries, cheaper inter-state rates will be possible. Conference-type consultations are a planned use of the network. Later, use of EKG diagnostic assistance will previde an opportunity to test usefulness in improving the quality and speed in managing illness. Other planned uses are for diagnostic assistance and data collection on poison control and establishing a more efficient distribution and control of blood among the in- stitutions in the region. Review of evaluation techniques revealed plans to utilize direct observations on degree of motivation and involvement in hospitals, as well as information on number of questions asked from each center and the number of questions that were not asked due to time limitations. A more specific evaluation design awaits employment of an evaluation director, probably a doctoral can- didate from the College of Education. DRAFT an The site visit team is convinced that the communication network is essential to the development of this Regional Medical Program, and that further delay will jeopardize relationships with the peripheral hospitals and physicians. The team is concerned about the ability of this group to mount such a large and complex program simultaneously to 48 hospitals with inadequate staff, lack of technical experience, and lack of administrative experience in a highly specialized area. Therefore, the site visit team recommends: (1) That the concept of a‘total Regional Telephone Communications Network be approved in principle as an operational activity and that the entire amount requested for the three-year period be encumbered immediately. This will permit the Regional Medical Program to make final financial: arrangements with the telephone company. : (2) That the entire operation not be mounted simultaneously, but be phased upward after some experience with the 16 outlet- study which will start April 15. (3) That the Division of Regional Medical Programs establish a team involving both program and technologic experts to provide the judgment on readiness of this region to enter the full programmed phase. It is suggested further that the Division of Regional Medical Programs provide this same type of expertise to other regions planning similar programs. CORONARY CARE PROGRAM This proposal was presented by Mrs.. Betty Lawson, who is the Director of the Program. She impressed the visitors as a very capable person with experience _4n nursing education, and with the obvious enthusiastic support of the School of Nursing of the University, the program advisory boards (both physicians and nurses), and the staff of the participating hospitals. Dr. Albert Rekate has been the principal physician-planner for this project and will continue to serve it as Chairman of the Medical Advisory Board on Curriculum. The site visitors were shown a newly established demonstration coronary care unit and classroom facility which will serve as the central focus for the didactic portion of the training. The space has been provided by the University, the teaching equipment is on long-term.loan by the Heart Association of Western New York. In addition to Mrs. Lawson, Dr. Ingall and Dr. Rekate, Dr. Lewis Young (Sisters» Hospital), and Dr.-Jules Constant (Buffalo General Hospital), there will be a rotating assignment of cooperating lecturers, representative physicians, nurses and allied health professionals. The lecturers will be selected from a large pool of representatives from SUNYAB and the entire region. The staff of clinical nurse instructors directly under the supervision of Mrs. Lawson are already trained nurse supervisors and staff nurses in the five cooperating hospitals. The students will receive the practical portion of their training from either Sisters Hospital, E.J. Meyer Memorial Hospital, Buffalo General Hospital, South Buffalo Mercy Hospital or the Veterans Administration Hospital. DRAFT 6 The site visit team had the opportunity to tour the coronary care facilities at Sisters Hospital, which are under the direction of Dr. Lewis Young and which will serve as the principle practical training unit. This is most certainly an impressive model to which all hospitals in the region can and do look to in the planning and staffing of their own units. The interest of Dr. Young and his staff in this entire program was clearly illustrated. It was the consensus of the site visit team that this is not only an excellent program in and of itself, but that it is an essential instrument of cooperation for the region. It seeks to fulfill what the practicing physicians see as the region's most pressing immediate need. PROPOSAL FOR A REGIONAL MODEL COMPREHENSIVE PULMONARY CARE FACILITY The principle presentation was made by Dr. John W. Vance and Dr. Federick R. Beerel, principal physicians on the chest service at Millard Fillmore Hospital. Although the meeting was held in this institution, Dr. Maurizi (the E. J. Meyer General Hospital) and Dr. Noehren (Buffalo General Hospital) were also present, and the cooperation among the representatives of the three institutions was very evident. Although the project -under review requests only a small amount of funds for further planning, this group is moving delib- erately into an integrated and full-blown project for comprehensive management of acute obstructive pulmonary disease, first in the metropolitan area and then in the entire region. Tied in, to a greater or lesser degree are: (1) the case-finding activities which have been ongoing for a number of years under the Tuberculosis & Health Association in cooperation with the County Health Department; (2) an out-patient facility that has existed for a number of years and is now very adequately housed at the Millard Fillmore Hospital: (3) general hospital and intensive care facilities in all three of the cooperating hospitals: and (4) a number of educational facilities in the city including the Erie County Technical Institute at which a program for inhalation therapy is being planned, the School of Health-Related Sciences at the SUNYAB which will add a postgraduate course in respiratory physical therapy, and at least one or two of the nurse training programs in the city hospitals which are planning training for acute care of pulmonary patients and for home care and after-care. The physician education activities will be outgrowths of their experience with an annual conference, jointly sponsored by the various chest services in cooperation with the Tuberculosis & Health Association and through the continuing education activities of the various hoepital staffs. In summary, the site visitors were impressed with the degree of cooperative planning accomplished by these private practitioners representing three separate hospitals, and between these hospitals and the various educational efforts throughout the city. It was recommended that this small planning grant be approved with the awareness that a full-blown proposal will be reaching the Division shortly. DRAFT RECOMMENDATIONS The site visit team endorses the Council's approval of the three-part application designated 3 G02 RM00013-02S1 and, in recognition of the degree of regional development and operational capability, recommends further that an operational grant be made to include the coronary care program and the communications network (see specific conditions concern- ing the latter); and that the six month request for planning a pulmonary care facility be awarded as a planning supplement. — ~ In a separate consideration, the site visitors recommend to the Review Committee and to the National Advisory Council approval of the applica- tion designated 3 G02 RM00013-02S2 with the condition that the part- time salaries for physicians be recalculated to be in keeping with local and national Regional Medical Program policies.