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Chapter XV

Contents

CHAPTER XV

Improvements in the Internal Organization and Administration of Hospitals in the United States

In the latter half of the war, reductions in the staffs of hospitals and changes in their make-up made more imperative than formerly the improvement of hospital organization and administration. It will be recalled that the Wadhams Committee had recommended such action as early as November 1942 and as a result The Surgeon General had brought into his Office in the spring of 1943 an experienced hospital administrator, Lt. Col. Basil C. MacLean. In his opinion preliminary studies confirmed the need for improvement.1 Moreover, as the Army's manpower shortage became serious in the fall of 1943, ASF headquarters began a general program for the more efficient use of personnel. Extending to all technical and supply services, including the Medical Department, it comprehended the standardization of organization, the elimination of nonessential activities and records, the simplification of work methods, and the improvement of administrative procedures.2 As a part of this program and of efforts to shorten periods of patient-stay in hospitals, the ASF Control Division and the Surgeon General's Office began work in the fall of 1943 on the simplification and standardization of the disability-discharge procedure, already discussed. By the following January, General Somervell informed Surgeon General Kirk that he considered improvement of hospital administration one of the Medical Department's major problems. 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 laid during the spring of 1944. Work on the disability-discharge procedure had already demonstrated the value of simplification and standardization and about a week before the Dallas conference the Surgeon General's Hospital Division had asked his Control Division to review hospital administrative procedures generally. The latter Division called for assistance upon the ASF Control Division, which had had experience and which had personnel qualified in such matters. In April 1944 these Divisions, assisted by service command control divisions, surveyed records and procedures used at Schick, O'Reilly, and Halloran 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, information office procedures, and hospital dispositions. To prevent swamping hospitals with revised but imperfect procedures, the Hospital and Control Divisions of the Surgeon General's Office insisted that each revised procedure should be approved by professional consultants of that Office and tested in selected hospitals before general adoption. To avoid unnecessary delays in their use, procedures were to be studied separately and, when revised and tested, were to be issued as parts of a loose-leaf manual on hospital administration.4

Several difficulties were encountered in carrying out this program. Short of personnel because it had reduced its own staff as an example to others, the Surgeon General's Control Division had only one officer who could devote his full time to that work. The Division also lacked personnel qualified by training and experience to make procedural studies and to draft procedural manuals in the form desired by ASF headquarters. Furthermore, its director was absent on special overseas missions during much of 1944 and work on the program suffered from his absence. To overcome some of these difficulties, the Surgeon General's Office temporarily borrowed personnel from the ASF Control Division, from Army hospitals, and from other installations. Even so, the ASF Control Division considered progress on the program unsatisfactory and threatened, early in 1945, to take over its completion. The Surgeon General prevented such action, but friction between his Office and the ASF Control Division continued.5 As 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 them for general use, only one chapter of the projected manual-that on hospital admissions-was published before the peak patient load was reached in the United States. Other revised procedures-those for linen control, disability discharges, and disability retirements-were published in separate manuals or circulars before that date.

The hospital admissions procedure can be used to illustrate both the manner in which new procedures were developed and the methods used to simplify hospital paper work. The Control Division of the Surgeon General's Office, in consultation with the Hospital Division, developed a tentative procedure for the admission of patients, and, along with it, the forms to be used. Before these forms were published, they were approved by the ASF Control Division, the Air Surgeon's Office, the Surgeon General's Control, Professional Services, Hospital, and Medical Statistics Divisions, and the Adjutant General's Methods Management Branch.6 The new procedure was then given a preliminary trial in three hospitals-two of the Service Forces and one of the Air Forces.7 After they had commented on its advantages and disadvantages, it was revised and published in a tentative manual of hospital procedures.8 Soon afterward, the Surgeon General's Office called a conference in Washington to explain the new procedure to representatives of various hospitals.9 Selected hospitals, serving as pilot installations, then began to use the procedure and to teach representatives from other hospitals how to employ it.10 Finally, early in 1945, the new procedure was published in final form as a chapter of the new manual on hospital administration (TM 8-262), and by the middle of that year almost all hospitals with as many as ten admissions a day had begun to adopt it.11

While the revised procedure covered in somewhat greater detail than did the old one the various steps taken in the admission of patients, its greatest significance lay in changes in hospital admission records and their preparation. Two basic forms were prepared for the admission of patients to hospitals: the clinical record brief and the medical report card. In addition, other records such as deposit slips for patients' funds and locator cards for use by interested groups in hospitals were prepared to meet local needs 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 in separate 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 records had to be made up separately also, many by offices needing information found either on the clinical record brief or on the hospital's daily admission and disposition sheet. Under the revised procedure, all forms containing common information were blocked off alike and a mimeograph duplicator was used to transfer that information to as many copies as needed throughout the hospital. Thus one typing replaced fifteen or twenty under the old system. The chapter on the new admissions procedure illustrated each of these forms and gave detailed instructions for their preparation and distribution. In the opinion of the Surgeon General's Office, the new procedure speeded up the admission of patients, eliminated the duplication of records, supplied operating units of hospitals with information they had not formerly received, and saved in the hospitals where adopted a total of about 3,333 man-days of work per week.12 Hospital commanders encountered only minor difficulties in installing the new procedure and, with few exceptions, considered it an improvement over the old one.13

As in the development of the admissions procedure which saved work for administrative officers, the Surgeon General's Office was equally interested in procedures that would relieve ward officers of administrative details in order to permit them to devote more time to professional work. One of the procedures developed during 1944, that for the control and distribution of hospital linens, was designed for this purpose. Developed in a manner similar to the hospital admissions procedure, the linen control procedure was published in December 1944 in an ASF circular rather than as a chapter of the hospital-administration manual.14 Under the old procedure physicians were charged with the linen used in wards and clinics. In order to avoid being "caught short," they required ward personnel to count soiled linen as it left the ward and clean linen as it was returned. Furthermore, they required periodic inventories and some tended to hoard linen unnecessarily. Additional linen-counts were made at intermediate storage points and at hospital laundries. Under the new procedure each hospital had a linen officer who was responsible for all linen used. All counts of linen in wards and intermediate stations were eliminated; and linen officers, rather than ward officers, made periodic inventories. According to some hospitals, a disadvantage of this procedure was an excessive loss of linens. This was compensated for, in the opinion of the Surgeon General's Office and many hospital commanders, by the saving of about 1,250 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 also reported that the new procedure decreased the hoarding of linen and speeded up its distribution to places where needed.15

The use of dictaphones in hospitals was not called for by manuals or circulars, but nevertheless constituted an important change in the method of preparing clinical records. Lack of enough medical stenographers in hospitals, as a result of the civilian labor shortage and of hospital personnel ceilings, made it necessary during 1943 for doctors themselves to prepare clinical records, sometimes in longhand. To relieve them of such a time-consuming process, hospitals began early in 1944 to acquire dictaphones. At convenient times doctors recorded on these machines consultation reports, progress notes, case histories, and final summaries. Clerks organized in central pools then transcribed the information recorded. This system of preparing clinical records permitted doctors to keep more complete and more legible records and to devote more attention to care of patients. It also contributed to the more efficient use of clerical personnel. Finally, by enabling doctors to keep clinical records up to date it helped to speed the disposition of patients and to shorten their period of hospitalization.16

The simplification of other administrative procedures was not completed before the peak patient load was reached, but work on the program continued during the winter of 1944 and the spring of 1945. Beginning in July 1945 chapters in the hospital-administration manual were published on the following subjects: Patients' Funds and Valuables (1 July 1945); Hospital Organization (1 July 1945); Ward Administration (1 October 1945 and 15 February 1946); Accounting Procedures for Hospital Funds (1 October 1945); Mess Administration (15 November 1945); Personnel Administration (28 December 1945 and 15 February 1946); Clinical Procedures (15 February 1946); and Supply Procedures (1 March 1946).17

Work-Measurement and Work-Simplification Programs

Delay in completing the manual on hospital administration did not interfere with the simplification of administrative procedures and work methods by hospitals themselves. As part of its program for efficient personnel utilization, early in 1943 ASF headquarters began to require subordinate installations to set up programs of "work simplification" and "work measurement." Work simplification was the process of reducing the jobs of individual workers, or the operations of groups of workers, to their simplest forms and eliminating from them all lost motion. Work measurement was the determination by various standards of the number of employees required for certain jobs or operations.18 During 1944 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 ASF headquarters' emphasis upon management techniques (or administrative engineering) conducted work-measurement and work-simplification studies and proposed changes to save time and personnel in a multiplicity of functions and activities.19 For example, a survey of ward attendants' duties at Walter Reed General Hospital in the spring of 1944 showed that attendants spent 20 percent of their time in off-the-ward errands. To correct that situation a delivery service staffed with twenty people was set up, and forty ward attendants were released.20 Another hospital, Thayer General Hospital, made changes in its system of trash collection that saved 200 man-hours per month. At still another Ashford General Hospital, a reallocation of individual duties and a rearrangement of office and desk space in the registrar's office permitted the completion in 1944 of 4,911 more work-units in 9,600 fewer work-hours than in the year before. Seventeen work-measurement and work-simplification studies made at Newton D. Baker General Hospital during 1944 resulted in the saving of 2,844 man-hours per month. Other hospitals reported similar savings from local changes.21 In this way, hospitals adjusted their operations to performance by reduced staffs and management control became an established function in all large Army hospitals.22

Additional Activities and Their Place in the Organizational Structure of Hospitals

In the latter half of the war new professional and administrative activities were added to Army hospitals. When convalescent reconditioning was established as an Army program, hospital commanders placed that activity in a variety of locations in their organizational structures; but by February 1944 the Surgeon General's Office concluded that reconditioning should be considered as a professional service on a par with medical and surgical services. The next month, with the approval of ASF headquarters, the chief of The Surgeon General's Reconditioning Division announced this decision as policy at a conference of reconditioning officers at Schick General Hospital.23 Two other changes occurred in the professional services during 1943 and 1944. Gradually hospitals began to list nursing as a professional rather than an administrative service and to show neuropsychiatry as an independent service rather 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 came largely as a result of their introduction generally in ASF installations. Revision of the ASF organization manual in December 1943 caused addition of control officers to serve as staff advisers on administrative, procedural, and management problems.25 About the same time authority was granted all ASF installations having a strength of 2,000 or more to appoint special services officers to conduct athletics and recreation programs and orientation officers (later called information and education officers) to conduct information and education programs.26 In February 1944 ASF headquarters directed the establishment on each of its posts of a personal affairs division to assist soldiers in handling their personal affairs.27 In the following December the War Department directed separation centers and many hospitals (those separating from the service one hundred or more persons monthly) to set up classification and counseling units to assist soldiers in planning their return to civilian life.28 General hospitals with few exceptions and regional hospitals in some instances came within the purview of these directives and acted accordingly. These new activities-special services, information and education, personal affairs, and classification and counseling-were to be known later as "welfare services" or as "individual services."

Effect on Hospitals of the ASF Standard Plan for Post Organization

The general program of ASF headquarters to standardize organization throughout the Service Forces continued, as it had earlier, to influence the organization of general hospitals.29 In December 1943 the standard plan for the organization of ASF posts was revised. At that time a control officer and a post inspector general were added to form, along with the existing public relations officer, the commanding officer's immediate staff. Furthermore, the seven functional divisions which previously comprised all post activities were replaced by seven administrative and seven technical staff units. To make this change, the erstwhile Administrative Division, a functional division which had included the adjutant, judge advocate, and fiscal officer, was abolished and its officials were listed among the seven administrative staff units. Certain technical services-quartermaster, ordnance, chemical warfare, signal, and transportation-were relieved from their former subordination to the Supply Division and were established as independent technical staff units. Medical and engineer activities, considered as functional divisions under the old plan, now became technical staff units. All welfare activities continued, under the new post plan, to be grouped under the Personnel Division.30

General hospitals attempted to adjust themselves to the new organizational plan for ASF posts as they had to its predecessor. In each hospital, professional services and some administrative units peculiar to hospitals, such as the registrar's office and the dietetics division, had to be added to the units included in the standard ASF plan. In the administrative field, 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 plan carefully, at least in its organization chart, and only added to the post organization a reconditioning division, a medical supply office, a medical detachment, and a professional division that included the professional services and such administrative units as the registrar's and dietitian's offices. Mayo General Hospital adhered less strictly to the ASF plan. Although it had most of the officers which that plan called for, it placed many who were supposed to be grouped under an intermediate supervisor, such as special services and personal affairs officers, in a direct relationship with the commanding officer.31 (Chart 12) Hospitals that thus multiplied the number of officers reporting directly to the commander violated one of the ASF principles of organization, namely, that the number of such officers should be kept as small as possible.32 Several hospitals on the other hand followed that principle (and incidentally a recommendation made by the Wadhams Committee in the fall of 1942) by combining their administrative services under a single director and their professional services under another.33 In February 1945 the commanding officer of Darnall General Hospital suggested that this grouping of professional and administrative services under separate directors, who in turn were responsible to the commanding officer, might be followed with advantage by all other hospitals.34

Two other changes were considered desirable to make the ASF post organization applicable to all hospitals. Officers in the Third Service Command headquarters and in the Surgeon General's Office, as well as some hospital commanders, believed that technical service officers with only minor functions in hospitals, such as those of the Chemical Warfare Service, Ordnance Department, and Transportation Corps, should be either eliminated or subordinated-as they had been under the previous ASF post organization-to a director of supply.35 Conversely, because officers concerned with the individual welfare of soldiers (special services, personal affairs, information and education, and classification and counseling officers) assumed more importance in hospitals than in other installations, some hospital commanders and service command surgeons felt that they should be grouped together under a director of individual services rather than under the director of personnel.36

Emergence of Standard Plans for Hospitals

Early in May 1944 the Surgeon General's Office announced that it was planning to publish a standard plan for the organization of general hospitals, but its development was delayed because of shortage of personnel in the 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 GENERAL HOSPITAL, 1944


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sion and priority given to procedures for disability discharges and hospital admissions.37 Meanwhile, the surgeon of the Fourth Service Command worked out a standard plan for the organization of hospitals under his supervision.38 Then, in June and July 1944 the surgeon and the control officer of the Third Service Command, with assistance from the Surgeon General's Office, developed a standard plan for hospitals in that Command. After it had been tested for about six months, The Surgeon General submitted it for comment in February 1945 to other service commands. On the basis of their suggestions, he made minor changes in the Third Service Command plan and adopted it as standard for general, regional, and station hospitals.39 It was published in July 1945 as a chapter of the manual on hospital administration.40 The Surgeon General's Office also worked during this period on the organization of convalescent hospitals and hospital centers. Tentative plans were published in 1944 and 1945. The final plan for convalescent hospitals was published in December 1945, but that for hospital centers remained unpublished because they began to close before it was completed.41

During the movement to standardize hospital organization, the merits of such a step were freely discussed. Hospital commanders generally and service command surgeons in some instances raised arguments against inflexible standardization. One feared that it would crystallize hospital organization, increasing efficiency in the operation of some installations but prohibiting imaginative and capable commanders from making valuable innovations in others.42 Some felt that standardization would prevent hospital commanders from adjusting to local conditions. For example, hospitals giving little outpatient care might not need to establish separate outpatient services. Others believed that commanders needed freedom to fit their organizations to the personalities of officers assigned to them. An eye, ear, nose, and throat specialist of intense individualism and higher rank than a chief of surgical service, for instance, could hardly be successfully subordinated, in an EENT section, to the latter.43 On the other hand, there was some feeling that men should be fitted to jobs, not jobs to men, and that the standardization of organization would help to solve problems raised by clashing personalities. The most telling arguments in favor of standardization were that it was the first step toward the simplification and standardization of administrative procedures, that it facilitated 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 SvC Surg, 16 Feb 45, sub: Standard Orgn Charts of Gen, Regional, and Sta Hosps. Identical letters were sent to all service commands; these letters, with their replies, are on file in HD: 323 "Hosp Orgn." (2) Status of Procedures being 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 Orgn Charts of Gen, Regional, and Sta Hosps. HD: 323 "Hosp Orgn."
43Letters from hospital commanders and service command surgeons expressing these opinions are on file, HD: 323 "Hosp Orgn."


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ments, and that it promoted manpower economy.44 At any rate, both the Surgeon General's Office and ASF headquarters were committed to standardization of hospital organization by the winter of 1944. That they did not insist on inflexibility was demonstrated by a proviso that hospital commanders might deviate from the standard plan if their respective service 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 and reflected the experience of hospitals in making adjustments to it. In both plans, the commander's immediate staff included public relations officers, control officers, and inspectors (called inspectors general on posts and medical inspectors in hospitals). General hospitals, according to the standard plan, were to have six of the seven administrative staff divisions of posts. The seventh, training, was to be subordinated to the personnel division. In addition, they were to have four administrative staff units not called for in the post organization plan. These were the station complement (medical detachment), the dietetics division, the veterinarian's office (for food inspection), and the registrar's office. The plan for hospitals had no technical 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 placed on the administrative staff. The welfare services, despite the wishes of hospital commanders, were left subordinated to the personnel division. The plan for hospital organization naturally included professional services. There were nine in general hospitals, including the reconditioning service, the neuropsychiatric service, and the nursing service. In this field hospital commanders were left with more latitude than in the administrative because, the manual stated, the professional services "function solely in a professional manner and are subject to constant variation by reason of changes in types of patients treated." The standard plan for regional and station hospitals resembled that for general hospitals. The chief differences were that administrative and technical units which existed as parts of post and general hospital organizations were eliminated and the neuropsychiatric service was subordinated, as a section, to the medical service.46(Chart 13)

Publication of the standard plan for the organization of general, regional, and station hospitals had little appreciable effect upon their organization.47 The chief reason, perhaps, was that the plan itself reflected experiences of hospitals in conforming with ASF directives on organization.48 Nevertheless, it officially sanctioned their conformity and provided them with a detailed statement of the functions of all major units within hospitals. Undoubtedly its value would have been greater if pub-

44Ltr, SG to CG 1st SvC attn SvC Surg, 16 Feb 45, sub: Standard Orgn 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 the annual reports of 14 general and 19 regional hospitals for 1944 and 1945.
48Interv, MD Historian with Dr. Press, 9 Oct 50. HD: 000.71.


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CHART 13-COMPARISON OF STANDARD PLANS FOR ORGANIZATION OF ASF POSTS AND ASF GENERAL HOSPITALS, 1945


273

lished four years earlier, at a time when new hospitals were beginning to open with staccato rapidity.49

The development of standard organizational plans for convalescent hospitals and hospital centers came even later than for general hospitals and was therefore of less value. Having only limited amounts of personnel and no guides for organization, ASF convalescent hospitals were organized by their commanding officers to fit individual circumstances. Consequently they differed from one another in many respects. Convalescent hospitals that were separate installations attempted generally to organize administrative activities according to the standard ASF post plan.50 Those that operated in conjunction with general hospitals depended upon the latter for some administrative services and organized for the rest as the personnel assigned to them permitted.51 Gradually a common feature began to emerge. It was the establishment of a reconditioning section and the grouping of patients into companies, battalions, and/or regiments for administration and supervision.52 In the winter of 1944, when additional emphasis was placed upon the convalescent program, the Surgeon General's Office developed and published a guide53 which left the organization of administrative activities of convalescent hospitals almost entirely to the discretion of their commanders. The result was that, as they received more patients and operating personnel, some set up administrative offices that duplicated, or at least paralleled, those of the general hospitals located near by.54 The guide showed in more detail the organization of convalescent activities. They were to be grouped in three divisions: a receiving division, an infirmary division, and a reconditioning division. The infirmary division was not to be established in convalescent hospitals located near general hospitals. The reconditioning division was to have a twofold function: it was to exercise command over patients who were to be organized in three battalions (neuropsychiatric, primary reconditioning, and advanced reconditioning), and it was to conduct the convalescent training program. This program was to include occupational therapy, physical reconditioning, educational reconditioning, and classification and counseling. The plan served as a guide to convalescent hospitals that remained separate installations during 1945, and it was used to some extent, particularly for the organization of convalescent activities, by those that became parts of hospital centers in the spring of that year. That hospitals considered it as a guide only is indicated by differences

49The plan of 1945 for general hospitals remained in force for five years. The Surgeon General's Office then published, on 15 September 1950, a new standard plan for their organization. It is of interest that this plan called for fewer major units within a hospital and charged two officers, the executive officer and the deputy commanding officer, with the co-ordination, if not the supervision, of the administrative and professional services respectively. SG Cir 119, 15 Sep 50, sub: Orgn of US Army Hosps Designated 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 reference to 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-Revised Program. 
54An Rpts, 1945, Percy Jones, Wakeman, and Cps Butner and Carson Hosp Ctrs. HD. These reports have discussions of organization of convalescent and general hospitals before they were combined to form centers.


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CHART 14-STANDARD PLAN FOR ORGANIZATION OF ASF CONVALESCENT HOSPITALS, 1945


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that continued to exist in the organization of different installations.55

At the end of 1945 a second plan for the organization of convalescent hospitals was developed by the Surgeon General's Office and published by ASF headquarters.56 A combination of the old plan for convalescent hospitals and the new standard plan for general hospitals, it showed the administrative organization of convalescent hospitals in more detail than did the old one. The immediate staff of the commanding officer and the administrative staff units of convalescent hospitals were to be essentially the same as those prescribed for general hospitals. The convalescent services were to be similar to those called for by the 1944 guide for convalescent hospitals. The most important change was the separation of the reconditioning, or convalescent training, program from the administration of companies of patients. The chief of the reconditioning service was to have charge of the former, while the hospital commander was to supervise directly the commanders of the 1st convalescent regiment (neuropsychiatric), 2d convalescent regiment (medical), and 3d convalescent regiment (surgical). Publication of this plan after convalescent hospitals had already begun to close undoubtedly limited its effect upon the organization of such installations. (Chart 14)

The establishment of hospital centers in the spring of 1945 was expected to eliminate duplication of administrative activities involved in the operation at the same location of both convalescent and general hospitals. The Surgeon General's Office expected that administrative functions common to both would be centralized under center headquarters, but a guide for the organization of hospital centers published in April 1945 was sufficiently general to leave to local commanders the decision as to how much centralization there would be.57 For that reason, and because of differences among hospital centers-some being located on posts with other activities and some constituting posts in themselves-centers varied in organization from one to another.58 Two extremes were represented by the Percy Jones Hospital Center and the Wakeman Hospital Center. (Chart 15) The former, a post itself, had operating as well as supervisory functions, and administrative activities common to both the general and convalescent hospitals assigned to it were performed by center headquarters.59 Wakeman, on the other hand, was located on a post with other Army activities that were nonmedical in character. Post headquarters furnished some administrative services for both the general and convalescent hospitals; each hospital performed the others itself; and center headquarters served in a supervisory, not an operational, capacity.60

In the hope of achieving a measure of uniformity in the organization of hospital centers, the Surgeon General's Office in July 1945 sent 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 Functional Charts, 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, Cp Carson Hosp Ctr, 31 Jul 45. HD: 323 "Hosp Orgn."
56ASF Cir 445, 14 Dec 45, Pt II-Conv Hosp-Revised Program.
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 attn SvC Surg, 9 July 45, sub: Standard Orgn Charts for Hosps. SG: 323.3 (5th SvC)AA.


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CHART 15-ORGANIZATION OF PERCY JONES HOSPITAL CENTER, 1945


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CHART 16-STANDARD PLAN FOR ORGANIZATION OF A HOSPITAL CENTER (ZI), 1945


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and service command surgeons.61 Following receipt of their replies, that Office by the beginning of 1946 developed a standard plan for the organization of hospital centers. Although never published, it was significant because it represented The Surgeon General's idea of what the organization of a hospital center should be. Of prime importance was the fact that center headquarters was to be operational and was to perform for general and convalescent hospitals the administrative services that were common to both. Hence, the center commander's immediate staff and the administrative staff divisions of hospital centers were to be essentially the same as those found in both general and convalescent hospital organization charts. To assist a center commander in supervising and co-ordinating the professional activities of hospitals under his control, his immediate staff was to contain a director of dental services, a director of professional services, and a director of nursing services. General and convalescent hospitals, minus the staff and administrative divisions of center headquarters, were to be under separate commanders, each of whom reported directly to the center commander and had an administrative assistant to provide the few administrative activities that could not be concentrated under center headquarters.62 (See Charts 15, 16.)

A significant feature of the hospital organization plans just discussed was their attempted conformity with the standard plan for the organization of ASF posts. While there were perhaps enough similarities between the functions of posts and those of hospitals to warrant such conformity, one may question whether it was altogether desirable or would have been required if standard plans emphasizing the peculiar functions of medical installations had been issued earlier. Certainly the Medical Department would have benefited from having such plans available when the hospital expansion program first began. Moreover, they would have made easier the task of simplifying and standardizing hospital administrative procedures. While accomplishments in this field were substantial, it was unfortunate that they came so late in the war. Offsetting this delay, perhaps, was the fact that management control became an established function 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. Similar letters were sent to other service commands.
62Morgan and Wagner, op. cit., pp, 156-64.

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