| / minute new s “ “July 29, 1970 “vel: 2 no: 28 - Nag ons SOME INITIAL PERCEPTIONS oe es" By Harold Margulies, M.D. os Acting Director, Regional Medical Programs | Service _ My perceptions of. the May - 6-8, 1970 Airlie House meeting, written several weeks _ after the event, are greatly | influericed by. events with which you are familiar. “As a reflection-of the tempo of our times, on July | a new Administrator will take “ever the leadership of the Health Services & Mental Health Administration and there has already béen Congressional: confirmation of the appointment of a new Secretary of the Dept.:of Health, Education, and Welfare..:In a tangential way these, and _ a number of less prominent changes fn the organization in which we work, sharpen my comments to you about the uncomfortably short period of time we have i in which 40 perform the tasks which lie before us. Further, at this writing we do not yet have "va new Bill ‘extending the Regional Medical Program legislation, but the form of the . = leatelation ¢ is s becoming clearer i in the actions and deliberations of Congressional com- ee = mittees.: ae re Despite these distractions, some s of my impressions expressed at Airlie House and since “then, remain and are clear and unaltered, Foremost of these was the deeply encour- aging evidence of a lively awareness, willingness and cooperation’! found among the Coordinators reflecting their commitment to make Regional Medical Programs not just successful, but broadly an influential ‘force for constructively altering our health care systems in terms of. their quality and availability of care to all people. a 7 Although I had: been prepared to find at Airlie House a sense of gloom regarding the _ig, almost overwhelming problems which. we face, | found instead a mature perception _ of the character‘of our challenge and a determination to do what has tobe done with’ whatever tools and resources are available. Fiscal strictures were reviewed soberly, ‘and even those who were dismayed by our mutations exhibited no > signs of apathy or unwarranted discouragement. oe _My staff was wise to forewarm me that | would do well to eliminate empty thetoric, : - face reality ar and report the facts. as | saw them. A attempted to do just that. |. / (continued next * poge).. talked about the need to mold Regional Medical Programs into total programs rather than a series of discrete projects; the necessity for Regional Medical Programs to serve as the strong professional ally for Comprehensive Health Planning agencies; the desirability of moving toward the new system of Anniversary Review; andthe = need to revise certain objectives of Regional Medical Programs to achieve what is most necessary to improve the health care of the Regions. they serve separately. and in the country as a whole. | ° In. response, the Coordinators raised all of the issues . they felt were important, de~ scribed their misgivings, and left us with few illusions, Even the uncertainties of © _the new legislation and the question of appropriations y were taken in stride with aq. frankness that matched my own. ~ Perhaps the most complex subject raised centered on the working relationships which are to be established between Regional Medical Programs and Regional Offices of the Dept. of Health, Education, and Welfare. | felt that the answers to this ques- tion were especially difficult to perceive because the Federal-private working ar- rangement Regional Medical Programs and the Regional Medical Programs Service now have is so unique and, at the same time, so delicate. The introduction of another kind of Federal agency was also regarded with: suspicion dnd reasonable mis- givings. Although | left the meeting convinced that doubts and | uncertainties remained, Tre- _ affirmed my opinion that they must be resolved during the. coming months and years. The most sensitive aspect of my ‘role and the role of my staff i is a reflection of two basic elements i in the Regional Medical Programs. One is the strong thrust we are giving toward increased self-determination of each Regional Medical Program. The other is our desire, apparently shared by the Coordinators, for clearer policies and / ‘Tore effective professional leadership on the part of Regional Medical Programs Ser- vice, Certain demands made on Regional Medical Programs Service, including those ‘of better coordination with other Health Services. and Mental Health Administration -. activities,. faster and fuller communications, more professional-ftechnical support, and clearer statements of objectives are all reasonable. «I. promised to meet those demands. 1 am further determined to meet our national. ‘and local commitments by respecting . Bo equally. the advantages ‘of local efforts to meet local needs 7 and the need for clear - _cut Federal policies which will give “coherence to the entire program. | Bey ho Bie More’ than ever, 1 am. “eonvinced that. the character of madical care in this country will _be influenced for generations’ to. come by what we do in the next several years. 1 have no. illusions about the difficulties which lie ahead, Even before’! assumed my . present position, | had known the Regional Medical Programs well enough to have be-. come confident that they would, if prudently developed, realize their. great potential. At Airlie House | learned that my-confidence was well placed. The coming g year will moke all the difference... At will be. difficult.but. thoroughly. engaging... mee -CCRMP.... . | at its quarterly meeting Joly 8 in “Jan Francisco, approved for for- ~ warding to Washington six new op~ ~ erational proposals. Results of the | balloting on priority are shown in brackets beside each project, low- > @st score indicating the, greatest : -ptlority: Continuing | Education (2. 0) by Area VII, San Diego; Family Practice (I. 9) and Medical Oncology. (2.7) by Area I, San Francisco; Perinatal Crisis (2, 1) and Continuing Educa- _ | tion (2.5) by Area IV, UCLA; Renal Program (2.6) Area vill, Arvine; The Progress Report and ‘Continuation Application for Califomia was ap- proved. A total of $9,700,000 was | requested for the eight Areas and the - Watts-Willowbrook District RMP. The Organization and Procedures . Subcommittee reaffirmed the current — . yystem of Technical Review for pro- posals. Final right of approval is reserved for CCRMP but its primary. function is. to assign priorities. * * xk * a ee a . October 7 i in Los Angeles. ee ket Eee ee A The Ad Hoc Conference. Committee : a announces that the date of the "has been changed to Oct. 28-30," | . | The use of carryover funds from Area » ~ -V core program budget to implement — _ five special studies has been OK'd . by CCRMP as follows: ” ae Ce Pree. Clinte Liaison Program - $22,800; San Femando Valley Health Consortium - $10, 000; Respiratory S Training Institute - $22, 400; Summer a “Experience for Allied Health Students - $1,800; Comprehensive Health Care.’ for Senior Citizens in ELA - $40, 000. . The studiés were approved by Area V Advisory Group on May 19 and will be reported in detail ina forthcoming __issue of V-Minvte News. tee WELCOME ABOARD » Cardiac ‘Committee - Byron E. Mork, M.D., to represent. Nogational:. Rehabilitation. a ae Library Services - Mrs. Myrtle: Humphrey, Librarian with Charles — R. Drew Postgraduate Schoolof : : . : hedicine, = . ‘Changes i in the Secretarial Stoff at . -.., Area Vio The newcomers are Miss ( Jate of the next meeting of CCRMP 7 oda be Cindy. Gates and Mrs. Ruth Smith. has been rescheduled to Wednesdey, : eo aoe : a ee Horovitz, former. Executive Dir- ~“ eetor of L. A. County Heart Assn., _ who has been associated with Area V , Cardiac Committee as consultant, . "$s Joining Califomia RMP as Asso- © Regional Conference at Asilomar =.’ fate (Coordinator of Area IV: (UCLA) vo teen we Lo yet SRS AREA V REGIONAL MEDICAL PROGRAMS ~——CALENDAR . August 1970 Monday, August 3 cs AREA V Free Clinic Liaison 10 a.m. - 12 noon Program RMP Conference Room Wednesday , August 5 AREA V Staff Meeting 9:30 a.m. Conference Roon. Thursday, August 6 . CCRMP - Staff Consultants 2-5p.m. Vintage Rm. Ot . Hilton Inn, S.F. Airport Tuesday, August.tI ‘ AREAV Cardiac Coordinating 11:30 a.m, . . RMP Conference: Room Wednesday, August 12... AREA V _ Staff Meeting _ 9:30 a.m. Conference Room Thursday, August i3 | COMP. -L. A, Health Manpower 12 noon Los Angeles Friday, August 14. | AREA V Committee Chairmen 11:30 a.m, RMP Conference Room AREA ADVISORY GROUP MEETINGS FOR 1970 - September 8 November 10 | COMMITTEE CHAIRMEN'S MEETINGS - AUGUST, SEPTEMBER = August 14 September II | NOTICE bet a During the summer months, the Calendar will cover two-week periods and V-Minute News will be published once every two weeks. ANNIVERSARY REVIEW, AND THE DEVELOPMENTAL COMPONENT . soles were explained at the July 14 meeting of the Area V Advisory Group by Paul D. Ward, Executive Director of the California RMP, Over 40 AAG members, committee chair- “meni; core staff and guests were present to hear Mr. Ward, considered one of the most effective spokesmen for RMP on the national scene, : : Mr. Ward traced the origin of the Anniversary Review and | Developmental ‘Compon-_ ent to long-standing efforts to decentralize federal goverment programs and to move . ‘ some of the decision making to regional levels. The annual or anniversary review-- “instead of the three or four site visits currently being made--has been adopted by the Administration and the National Advisory Council as a ‘solution to an increas~ ~~ ingly heavy work load. The Developmental Component provides a degree of fund- ing about which RMP's may make their own decisions, The amount is not to exceed — 10% of the total amount granted to a Region for its core program and its use rust give first recognition to national priorities, although the focus may be local. The method differs from the usual RMP practice in that it permits experimental testing of projects on a very small scale providing there is reasonable assurance of continued funding once the development has proved worthwhile. "This is a legal delegation by the National Advisory Council of its review process to local Regional Advisory Groups,”" Mr. Ward said. "Once given the right to use these funds, we will be reviewed on a yearly basis as to whether or not th2 money has been spent wisely or unwisely and whether the greatest amount of benefit has been obtained for each dollar spent. Each yearly review will determine whether the original amount is increased or decreased. We have to produce results that are measureable, tangible, and meaningful to the delivery of medical care services." . “A study of RMP's relation to current HEW priorities, Mr. Ward related, had resulted in a consensus that first priority had to be for development of health manpower; a second priority was given to organization and the delivery of health services (asso- ciated with preventive measures, prepaid group practice, use of subprofessional and _ paraprofessional personnel, ambulatory care, and the creation of any kind of model or method which provides needed health services where none previously existed,. (particularly 1 in disadvantaged areas), A third priority was found in the target groups~~ children under five years of oge, migrant farm workers and their families, and the American Indian, LE a op eh PEE hl eee 3 All 55 RMP's will-go on Anniversary. Review during the next twelve months but only four or five Regions are considered sufficiently developed to get a Developmental | Component. Mr. Ward estimated that California might expect to receive a quarter ’ million of the two million dollars set aside for Developmental ‘Component for the. Sook next t fiscal | year for the whole of the United States, : : K* * * we . w 3 © ~ : B ot © . i @ 3 *: 3 2 E- * deny! WV im CALIFORNIA REGIONAL MEDICAL PROGRAMS AREA V i UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF MEDICINE AREA OFFICE 1 West Bay State Street Alhambra, Calif, 91801 Telephone (213) 576-1626 - Editor - Elsie McGuff. Area ¥ Staff Donald W. Petit, M.D. ~ William A. Markey, MS. ~ Russell D. Tyler, M. D. Area Coordinator —_ ‘Deputy ‘Coordinator - Operations Division ~ Frank E ‘Aguilera, ¥. P, A | * Community Programs ~ Ghaiys Asctum, Or. Pe fH. - Kay D. Fuller, R.N. Leon C: Hauck, M.P.H. John $. Lloyd, Ph.D. Elsie uw McGuff “Coronary Care Program © “Dofathy E.” Anderson, MLPA. Conminity Programs (~~~ See Norsing Health Data oe Evaluation _ Communications Clyde E. Madden, ACS. Social Work Toni ‘Moors, B.A. * Robert E- Randle, M.D. - Luis A. Pingarton. “ye Vivien E. Warr, RAN! eget Community Programs Continuing Education East L Los Angeles . Coronary Care Prograns _aipenmite Cimon Area Advisory Grup Cancer “Chronic Disease oe “Cardiac ~ Continuing Education . “Hospital Administrators _ Libraty Services - Nursing Stroke Systems & Computers ~ Social Workers - Chester A. Rude 7 * Lewis W. “Guiss, ‘MD. "© Russell D. Tyler, M.D. George C. Griffith, M.D. "Phil R. Manning, M.D. “<-Henry'B, Dunlap, M. Par John M. Connor, M.A. = Fotine ‘0°Conner, RN. Rober H. Pudenz, wD. Lee D. Cady, MD. i ae * Betnice W. H. Harper, AC.S.W. Reprinted from: TRUSTE Journal for Hospitol Governing Roords VOLUME 73, NUMBER 6; JUNE 1970 Published monthly by the American Hospital Association Personality Factors, Poor Communication Blamed for Poor Trustee- CONCERNED and serious inquiry into the hidden “core” problems that obstruct good working rela- tionships among members of ‘the medical staff, governing board, and administration characterized the activities of 250 physicians, trus- tees, and administrators attending the medical staff leadership confer- ence at Monte Corona Conference Center, Twin Peaks, Calif., late in April. : The conference, sponsored by the postgraduate division of the 6 Medical Staff-Administrator. Relationship University of Southern California School of Medicine and Area 5 of the California Regional Medical Programs, marked the first time that hospital medical staff members, trustees, and administrators in that area had assembled for the express purpose of discussing how they might best work together in the pa- tients’ behalf. Under the guidance of Andre L. Delbecq, Ph.D., associate professor of business, Graduate School of Business, University of Wisconsin, Trustee the conference participants, work- ing in small groups, were asked to decide “in the silence of their own minds” what they believed to be the “problems behind the problems” in their working relationships and to list them in order on a small score card. Although an indepth evaluation of the results of this particular “class exercise’—and. of others in which other questions were asked —was patently impossible within the short time span of the two-day June 1970 meeting, a swift tally of the replies indicated that personality problems —tendencies to dominate, differ- ences in basic philosophy and value systems—plus ineffective commv-.. nication were serious obstructior ta good working relations in many hospitals. It was suggested that resolution of personality conflicts egald be an important prerequisite to constructive handling of the marty complex problems facing hos- pitals today. COORDINATION NEEDED At the formal presentations, which alternated with informal group sessions at the conference, attention focused on the particular challenges that medical staffs, gov- erning boards, and administrative personnel must face as their hospi- tals move deeper into the 1970s. Thomas E. Tonkin, president of the California Hospital Association, said that the demands of a mor’ sophisticated public are makin, greater coordination of effort among trustees, physicians, and ad- ministrators imperative. He sug- gested that effective coordination would require a greater sharing by staff doctors of the responsibility for the business development of the hospital. He stressed that in certain crisis situations, such as those that arise during employee strikes when extensive work’ stoppage is life- threatening to the patients—the 7 medical staff's advice and assistance are essential to a successful resolu- tion of the problems. Kenneth J, Williams, M.D., di- rector of medical affairs of the _Catholic Hospital Association, echoed Mr. Tonkin’s comments re- garding society’s demands for greater coordination among trus- tees, physicians, and ,administra- tors. This can be achieved, he said, only if there is competent manage- ment that correlates all of the in- hospital professions and skills. Traditionally, Dr. Willams said, hospital managements have main- tained a “hands off” policy toward the medical staff and its function while the physicians, in turn, have had nothing to do with the hospi- tal’s business operation. Because the medical staff influences the quality, quantity, and cost of medi- cal care, it represents, in a sense, the only control mechanism the public has with respect to these fac- tors, Dr. Williams said. Bringing the medical staff into the management of the institution, Dr. Williams explained, would re- quire recognizing certain long- standing barriers, among them, the physicians’ fear that strong manage- ment would operate asa threat to clinical freedom; election of staff leadership on the basis of popu- larity rather than leadership skills; the absence of job descriptions for -department chiefs;.rotation policies for heads of clinical departments that prevent the development of 8 strong leadership because of limited tenure. te To overcome these barriers, Dr. Williams said, physicians must first become deeply aware of the de- mands society is placing upon them and then realize that their partici- pation in the hospital’s management actually will afford them greater opportunity to exercise their influ- ence within the hospital. A NEW SPECIALTY PREDICTED Problems in the field of emer- gency care were discussed by Rals- ton R. Hannas Jr., M.D., who pre- dicted that from this department would come the next recognized specialty in medical practice. - The tremendous utilization. of emergency departments, Dr. Han- nas said, is turning them into outpa- tient departments in many hospitals, Because of the need for physi- cians of broad capabilities to care for the wide variety of ills, disor- ders, and accidents that continually flow into the emergency depart- ment, the establishment of a spe- cialty in this area is becoming necessary. He identified several ex- isting specialties that could con- tribute to the type of training that would be needed for board certifi- cation of physicians specializing in emergency care. These included in- ternal medicine, for training in epi- sodic care; psychiatry, for treatment of acute nervous disorders, over- doses of drugs, etc.; pediatrics, for infections and poisoning cases; and _ Trustee radiology, for diagnosis of signs and symptoms, LEGAL PROBLEMS San Francisco attorney, David E. Willett, in discussing legal trends affecting hospitals, identified three situations in which medical staffs and governing boards should exer- cise extreme care in their decision making in order to avoid litigious action, These were the rejection of an applicant for medical staff mem- bership; dismissal of a member al- ready on the staff; and adequate staffing of the emergency depart- ment. With respect to both the applica- tion for staff membership and dis- missal from the staff, the courts are especially concerned, he said, that the physicians be afforded the pro- tection of civil liberties provisions under the U.S. Constitution. There- fore, credential committees and medical staff executive committees must make sure that their decisions are not capricious but are based on accurate information, and that their motivation for rejection of an appli- cant for staff membership, or dis- missal of a staff member is in no way questionable. Attorney Joseph A. Saunders of Los Angeles, speaking at the same session, listed 10 prerequisites for affording “due process” for a re- jected applicant tothe medical staff. Among these were the right to a hearing with proper notice as to the time of the hearing and notification June 1970 of the matters that would be in con- troversy (the reasons for the rejec- tion); the opportunity to present documentary facts in support of his application; entitlement to a hear- ing by an impartial panel; and no- tification of the basis on which the decision to reject was made. Regarding dismissal of a member already on the staff, the obligation to prove dereliction becomes even stricter, with the burden of proof resting on the committee rather than on the physician, Mr. Saunders said, To avoid a possible taint of malice or slander, information ac- quired in investigation and evalua- tion of an applicant for staff mem- bership, or of a physician facing dismissal, must be used only within the bounds of committee proceed- ings. Both attorneys warmed that if procedures for dismissal of a physi- cian are faulty, the court may have to decide on matters that properly should be decided by physicians and not by a judge. The two attorneys also pointed out that, unfortunately, no dis- missed physician ever sues merely for reinstatement; he invariably sues for damages ds well, on the basis of loss. of income, malice, etc.,—liti- gation that can be very costly for the hospital. They added, however, that even though a hospital might be unable to prevent a dismissed physician from bringing suit, it could, by following carefully the proper procedures for dismissal, avoid the payment of damages. ® 9