REPORT OF COMMITTEE 
 
 Hospital Efficiency, 
 Hospital 
 
 Finance and Economics 
 of Administration. 
 
 A. S. KAVANAGH, D.D., 
 
 Superintendent of The Methodist Episcopal Hospital, 
 BROOKLYN, NEW YORK CITY. 
 
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 REPORT OF COMMITTEE ON HOSPITAL EFFICI¬ 
 ENCY, HOSPITAL FINANCE AND ECONO¬ 
 MICS OF ADMINISTRATION. 
 
 By A. S. Kavanagh, D.D., 
 
 Superintendent of The Methodist Episcopal Hospital, 
 Brooklyn, New York City. 
 
 Article 2 of the Constitution of the Hospital Associa¬ 
 tion reads: “The object of this Association shall be the pro¬ 
 motion of economy and efficiency in Hospital management. 
 
 The program of this and previous conferences has been 
 built around economy and efficiency. “The Foundation of 
 Hospital Efficiency” is one of the specific objects treated at 
 this conference, while all the papers and addresses have dis¬ 
 cussed some phase of economy and efficiency, I am quite 
 sure it would be difficult to find a more exact definition of 
 efficiency than that which Dr. Chas. P. Emerson gives in 
 his article in “Hospital Management,” when he says: “Size 
 is a poor standard by which to judge a hospital. The only 
 correct standard would be that of efficiency in giving each 
 patient the individual care which has case requires. 
 
 It is my duty now, by appointment of our President, to 
 survey as far as possible the whoL field and make such sug¬ 
 gestions as I may deem wise in regard to economy and effi¬ 
 ciency. I cannot claim any special fitness for this task, 
 but “such as I have” it is yours for the work sake. 
 
 As I began the task assigned me I was very soon im¬ 
 pressed by the largeness of my subject, and wished for a 
 broader and more exact knowledge of the interests involved. 
 The hospitals embraced in the membership of this organiza¬ 
 tion are suggestive of the wide field which we must con¬ 
 sider Here are general hospitals for medical and surgical 
 diseases; hospitals for throat and nose; for eye and ear; 
 orthopedic; contagious diseases; city hospitals; and private 
 
 hospitals. 
 
 B 
 
Some of the particularly noteworthy movements which 
 perhaps are worthy of special mention are the battle against 
 the white plague, and the increasing provision which is be¬ 
 ing made for those thus afflicted. The movement on foot 
 at Bellevue for the training of midwives. The growth of 
 Social Service work. 
 
 Psychopathic clinics are now conducted in connection 
 with the Long Island State Hospital, which makes it pos¬ 
 sible for a patient to secure the best advice before becoming 
 actually insane. Dr. Doran says that if these clinics had 
 been started long ago thousands of cases of insanity might 
 have been prevented. In Syracuse the City Council has 
 established a Psychopathic Hospital of seven beds for treat¬ 
 ment of incipient cases. 
 
 New York State has authorized work for inebriates, and 
 the mayor of New York City has appointed a commission 
 to consider this problem. 
 
 We must also note with satisfaction the increasing inter¬ 
 est that is being taken in the welfare of babies. Much of 
 this is being done in connection with our general hospitals, 
 the greater part by other organizations, or by private enter¬ 
 prise. Perhaps it will not be inappropriate in this connec¬ 
 tion to mention the work of the Floating Hospitals of the 
 St. John’s Guild, N.Y., the new Seaside Hospital, the Bos¬ 
 ton Floating Hospital, and the hospital work conducted by 
 the New York Association for Improving the Condition of 
 the Poor. 
 
 In my judgment, there is scarcely any line of work that 
 is worthy of more serious consideration than that of crippled 
 children. I wish to give emphasis to this work by a quota¬ 
 tion from a letter received from Miss C. A. Aikens. She 
 writes: “I would think worthy of note the establishment in 
 Minnesota and Massachusetts state hospitals for cripped 
 children, thus making it possible for every crippled child 
 to be put into the best condition for life, however poor he 
 
 V 
 
 4 
 
may be. New York led the way some year's ago, and Penn¬ 
 sylvania and Maryland are pretty well provided for, but 
 there is a very great need that many other states should deal 
 as generously with the crippled child as with the deaf and 
 dumb, or blind child. You cannot realize this need if you 
 have not come up aaginst it as I did in Des Moines where we 
 had not an orthopedic surgeon in the state, ancl where, if 
 expert work was to be done, a surgeon had to be brought 
 from Chicago at great cost.” 
 
 Perhaps the finest achievement of the year has been the 
 splendid and successful fight of Dr. A. H. Doty and his 
 assistants against cholera, which a few months ago threat¬ 
 ened this city. Every citizen has read this story with a sense 
 of pride; and also with a sense of shame, when they remem¬ 
 ber the humiliating investigation to which the doctor was 
 subjected in his hour of triumph. Investigations there must 
 be for the public good, but reckless, semi-political attacks 
 upon the good name of a public servant should not be toler¬ 
 ated. 
 
 Now this brief survey indicates the vastness of the hos¬ 
 pital and kindred fields. The Superintendent should, in a 
 measure at least, be conversant with the entire field. This 
 leads me to emphasize the importance of the literature of 
 the year as an aid to efficiency. 
 
 The time was when, according to the acknowledgement 
 of our most experienced Superintendents, they had to blun¬ 
 der along for years while mastering the numerous duties of 
 their offices. While that day has not quite passed for many 
 of us, there is not the same excuse now that there once was 
 for this condition of things. 
 
 One book has come from the press during the past year 
 which is indispensable for the young superintendent, and 
 not altogether devoid of profit for the oldest. I refer to 
 “Hospital Management” brought out under the direction of 
 
 5 
 
that suggestive and sane writer upon all hospital matters, 
 Miss Charlotte A. Aikens, and published by W. B. Saunders 
 & Co. The subjects treated, and the names of the writers, 
 suggest the value of the book. 
 
 “The American Hospital Field” is treated by Dr. Chas. 
 P. Emerson; “The Board of Managers and their Responsi¬ 
 bilities,” by E. S. Gilmore; “The Superintendent,” by Geo. 
 P. Ludlum; “The Medical Service of a Hospital,” by Dr. 
 Henry M. Hurd; etc. 
 
 Then there are other indispensable publications such as 
 “The International Hospital Record;” “The Trained Nurse 
 and Hospital Review;” and “The Canadian Nurse and Hos¬ 
 pital Review;” while the annual proceedings of the Ameri¬ 
 can Hospital Association cover practically every phase of 
 hospital work. 
 
 Scarcely second to these would I place carefully written 
 reports. I do not mean reports which are chiefly statistical 
 tables, containing only the diseases that the “flesh is heir 
 to.” I mean reports which in addition to the various tables 
 give the actual history of the year,—the improvements; the 
 work done; administration, medical, surgical and nursing. 
 
 I am glad to acknowledge my indebtedness to such re¬ 
 ports in trying to form and realize correct ideals in my own 
 work. 
 
 In the next place I wish to say there can be no economy 
 or efficiency worth while without careful and exact business 
 methods. It is well known that the public is sceptical of the 
 business methods of charitable institutions, both public and 
 private. 
 
 When Hon. Bird S. Coler became die first comptroller 
 of the united cities which form Greater New York, he 
 changed the unbusinesslike graft cultivating method of giv¬ 
 ing lump sums to private institutions, to the per capita meth- 
 
 
 6 
 
od,—a change which put some institutions out of commis¬ 
 sion at once. To-day the city authorities are scrutinizing 
 every dollar expended for charitable purposes. To this no 
 honorable institution should object. 
 
 As to business methods, our private institutions, if pos¬ 
 sible, should be in advance, rather than behind, public insti¬ 
 tutions. They are supported by the voluntary gifts of the 
 public, and must by their business method, as well as scien¬ 
 tific work, command the respect and confidence of the pub¬ 
 lic. 
 
 It was this ambition that led this organization some few 
 years ago to adopt the uniform method of accounting, which 
 originated with four of our largest hospitals in this city. 
 Now the best thing about this method of accounting is not 
 that it aids one in making a comparison between hospitals 
 engaged in the same sort of work, or between their own and 
 some other hospital. Sometimes these comparisons have but 
 little meaning, because conditions are not the same. The best 
 thing about the system is that it enables one to make a com¬ 
 parison between their own hospital of a few years ago and 
 now; between their income and expense account of any 
 month, or any year; with the present month, or the present 
 year. 
 
 It is the same business spirit that prompted the organi¬ 
 zation of the Central Purchasing Agency in New York, 
 which is of use in standardizing supplies, and which has pos¬ 
 sibly secured better prices for some articles, but which, more 
 than anything else, demonstrated what good terms the hos¬ 
 pitals had secured when acting as their own agent. 
 
 The same spirit should lead to watchfulness against the 
 loss of money through the loss of time (for time is money), 
 or through the lapping of the duties of employees. 
 
 It will be found conducive to the efficiency of each de¬ 
 partment, and of the entire hospital, and good business as 
 well, to keep an accurate time record of every employee of 
 
the hospital. About six months ago we installed a time 
 clock by which each employee, including the superintendent, 
 supervisor of nurses, and everybody down to the scrub¬ 
 woman, is his or her own timekeeper, and practically deter¬ 
 mines the exact wage that he or she will receive. The head 
 of each department also prepares a pay-roll for their depart¬ 
 ment, and if their pay-roll does not agree with the time clock 
 cards, explanations will be in order. Thus the time cards 
 tone up not only each individual employee, but the depart¬ 
 ment heads as well. 
 
 Another thing that will add materially to the economical 
 management of each department is this. The superintendent 
 should so plan his work that he can be his own purchasing 
 agent. Nothing from a box of matches to an operating out¬ 
 fit should be ordered except over his signature. In a large 
 institution this might seem impossible, but not so if he has 
 a good secretary who has the business well in hand; has the 
 prices previously paid; lists of goods purchased, and where. 
 
 Together with the purchasing should be considered the 
 distribution of goods. In my hospital we have requisition 
 slips with blanks for goods desired, and for the goods on 
 hand of the same kind, and for the goods delivered. This 
 requisition slip is signed by the head nurse, O.K.’d by the 
 • supervisor of nurses, and then sent to the storekeeper. When 
 returned to a floor the head nurse signs for the articles re¬ 
 ceived. Then the slip comes to my office, where the ward is 
 credited with the goods received. The pharmacist has a 
 similar method of keeping track of medicines. In this way 
 we know where the supplies are going. 
 
 As to the financial loss which comes through breakage and 
 waste, I can add but little to what we have heard many times. 
 I think the plan adopted by many hospitals of insisting that 
 all broken or worn articles, crockery, furniture, general and 
 treatment utensils, must be returned with requisition for a 
 new supply, is an excellent plan. 
 
 8 
 
In order to keep a close watch over the waste, the plan 
 which we are using is this. We have six receptacles for 
 refuse in our crematory room. Each of these receives the 
 refuse of different parts of the hospital, and is under lock 
 and key. There is a daily inspection of these receptacles, 
 and if anything improper comes down we know where it 
 has come from, and act accordingly. 
 
 Dr. H. T. Summersgill, Superintendent of the New 
 Haven Hospital, writes along the same line. He says: “I 
 have found much waste can be prevented by routine inspec¬ 
 tion of broken crockeryware and other articles which have 
 been condemned or broken. I have a room fixed up. adja¬ 
 cent to the storeroom; in there is placed and labelled one 
 good-sized barrel for each ward and each department. A 
 hole six inches in diameter has been cut in the door so that 
 the contents of these barrels can be observed from the out¬ 
 side. In these barrels are placed the breakage from each 
 ward and each department, the one breaking the article be¬ 
 ing obliged to put label on it with name and date. If a nurse 
 in charge of a ward has an unusual amount of breakage in 
 a month, she is brought to account for poor management. 
 If, on the contrary, a nurse has done very well and been 
 careful in her management, she receives proper credit for it. 
 All our instruments for ward dressings are now sterilized 
 by steam in our operating-room building instead of the cus¬ 
 tom in use in most institutions where they are sterilized by 
 gas in each ward.” 
 
 Knowing the many-sidedness of hospital work, I thought 
 I would like some of my friends to help me; accordingly, I 
 addressed about one hundred members of this Association, 
 asking them to give their fellow-workers the benefit of their 
 experience by writing for this Round Table part of my paper 
 any feature of their work which was particularly successful 
 during the past year. This opened a wide door, as we in- 
 
 9 
 
tended it should, and I received many exceedingly suggestive 
 replies which I now bring to you in this Round Table part 
 of my paper. 
 
 We have been discussing business methods of organiza¬ 
 tion. Several of my correspondents have something of value 
 to say concerning this subject. 
 
 Miss Louise C. Brent, Superintendent of the Hospital 
 for Sick Children, Toronto, writes: “One of the successful 
 features that has aided the efficiency of the hospital adminis¬ 
 tration, is that each department has a head, who is respon¬ 
 sible to the superintendent for the work of his, or her de¬ 
 partment, from the superintendent of nurses to the caretaker 
 of the building. This may not be exactly a new feature, but 
 we have found it an entirely satisfactory one. 
 
 Dr. Clarence E. Skinner, of the Elm City Private Hospi¬ 
 tal, also gives emphasis to the same fact which, he says, 
 “conduces very greatly to the efficiency of service and econ¬ 
 omy of financial management.” 
 
 Mrs. A. M. Lawson, Superintendent of the General 
 Memorial Hospital, writes: “The fact that heads of our 
 departments report to the superintendent, and not to com¬ 
 mittees, or sub-committees, makes the executive work run 
 more smoothly.” 
 
 Miss Nancy E. Cadmus, Superintendent of the Manhat¬ 
 tan Maternity and Dispensary, speaking of the employment 
 of a resident physician and his duties, says: “He is simply 
 a head of a department the same as the principal of nurses, 
 housekeeper, or engineer.” 
 
 These quotations are sufficient, I think, to make clear the 
 position of the superintendent in any efficient plan of hospi¬ 
 tal organization. He is the connecting link between the 
 board of managers and each department of the hospital. If 
 the board of managers treats him with the consideration 
 that his position should have, he will be their representative 
 in all details of administrative work. 
 
 10 
 
From many letters it is evident that the nursing question 
 is still open for discussion. 
 
 Dr. Renwick R. Ross, Superintendent of the Buffalo 
 General Hospital, requests that we discuss the “special nurs¬ 
 ing of private patients twelve or twenty-four hour system.” 
 I suppose by right that should go to the question box, but 
 I will say this. In my hospital we have no difficulty with the 
 matter. When nurses are on private duty outside the hospi¬ 
 tal they frequently take twenty-four hour cases; whether 
 in the majority or minority of cases, I do not know. 
 
 Now it is easier to nurse in the hospital than outside. 
 The attending physician and supervisor of nurses determine 
 whether the patient should be a twelve or twenty-four hour 
 case. The nurse that will not take a twenty-four hour case 
 under these condition will not be permitted to come in and 
 take a twelve-hour case. 
 
 Others write concerning the scarcity of nurses, intimating 
 that herein is a great hindrance to hospital efficiency, and 
 these reports come from all parts of the country. Here in 
 New York the difficulty is felt with very great keenness. The 
 desire to improve the quality of nursing by securing for our 
 training schools reasonably well-educated young women is 
 appreciated by every one who has had occasion to have a 
 trained nurse in his own family. 
 
 But the Board of Education in New York State, which 
 has practically unlimited powers under a loosely-drawn State 
 law, has pushed matters so far that the greater part of the 
 hospitals in Greater New York City have memorialized the 
 Board of Regents of the State protesting against the present 
 methods of the Education Department in dealing with the 
 hospitals of the city. 
 
 If other states are pressing matters as New York State 
 is, it is easy to understand the reason for the shortage of 
 nurses. The course in this State is legally two years, but 
 those who prepare the curriculum believe in three years, 
 
and in three years only, and prepare the curriculum accord¬ 
 ing. Now it is perfectly evident that many a girl falls out 
 in the midst of her course because of the crowding which is 
 necessary in order to master the various studies, even though 
 she had three years to complete them. 
 
 Then again the demand which requires one year of high 
 school, or its equivalent, places a premium upon the intel¬ 
 lectually and physically unfit. Girls who are unable to pur¬ 
 sue their studies beyond one year in high school fail for phy¬ 
 sical or intellectual reasons. As a rule, the grammar school 
 graduate is the equal, and in some cases superior to the girl 
 with one year of high school to her credit. 
 
 It was natural that superintendents should write concern¬ 
 ing material improvements. 
 
 Mr. Asa Bacon, Superintendent of the Presbyterian Hos¬ 
 pital, Chicago, tells of the expenditure of nearly $800,000 in 
 improvements, and no deficiency for four years. 
 
 Dr. W. T. Graham, Superintendent of the Methodist 
 Hospital in Indianapolis, tells of the expenditure of $125,000 
 in new buildings, and of plate glass partitions between each 
 crib. 
 
 The Beth-El Hospital, of Colorado Springs, Miss Flor¬ 
 ence E. Standish, Superintendent, has expended $35,000 in 
 the erection of new buildings. The money was raised by 
 issuing six per cent, bonds. Then an agent was put in the 
 field to raise the money who is meeting with success. I no¬ 
 tice she mentions a paid ansethetist. 
 
 Mrs. Jennie E. Bassett, Superintendent of New Britain 
 General Hospital, writes of a new operating building costing 
 $25,000, and of plans for a new private building. She asks: 
 “Will some one kindly tell me the best finish for hospital 
 floors; and how to prevent the awful waste of food from 
 patients’ trays ?” I have read Mrs. Bassett’s question chiefly 
 because it illustrates for all of us the first essentials to ef¬ 
 ficiency—to detect and feel keenly the need of improvement. 
 
 12 
 
The New York Hospital, Dr. Thos. Howell, Superintend¬ 
 ent; The New York Society for the Relief of the Ruptured 
 and Crippled, Mr. Oliver H. Bartine, Superintendent; The 
 Presbyterian Hospital, are about to change their locations, 
 and are planning for even larger things in the future than 
 in the past. 
 
 The New York Post-Graduate School and Hospital, Dr. 
 Fred Brush, Superintendent, is bringing to completion build¬ 
 ings which will increase their bed capacity from 200 to 400. 
 
 The Methodist Episcopal Hospital, in Brooklyn, N.Y., 
 has recently spent $100,000 in improvements. 
 
 The Indianapolis City Hospital, Dr. J. L. Freeland, Su¬ 
 perintendent, is rejoicing over Si 10,000 received from the 
 city for new buildings. He also reports a legacy of $225,- 
 000, and confesses to inside information as to $700,000 mbre 
 coming from a living donor. 
 
 There are only two things better than legacies—a gift 
 during one’s lifetime, so that he can have the pleasure of 
 seeing it at wo^k; or a gift upon which the hospital may pay 
 a moderate annuity during the life time of the donor. 
 Either of these methods will defeat the purpose of the legacy 
 chaser—for there are legacy chasers as well as ambulance 
 chasers. 
 
 The Rev. Geo. F. Clover, Superintendent of St. Luke’s 
 Hospital, this city, tells us of the appointment ot nurses as 
 anaesthetists at his hospital, and he adds: “We have gone 
 far enough to feel that it is a step in the right direction.” 
 
 They have also set apart a special building for the hous¬ 
 ing of the help in which each person has a small room. This 
 arrangement gives satisfaction to a majority of the servants. 
 “But,” he states, “we have found, however, a few servants 
 who felt so lonely and fearful over going to single rooms 
 that they put in a request that they might be allowed to re¬ 
 turn to club rooms with several other servants.” 
 
 13 
 
Concerning floors he writes, and this may be of interest 
 to Mrs. Bassett and others: “A combination tile and linol¬ 
 eum floor which I laid nearly a year ago has proven to be 
 quite excellent, and it appeals to me as rather the best thing 
 yet done' in the way of flooring.” 
 
 Dr. Wm. O. Mann, Superintendent of Massachusetts 
 Homoepathic Hospital^ Boston, tells of a new $150,000 build¬ 
 ing for Clinical Research and Preventive Medicine. In this 
 building there will be an auditorium for public lectures along 
 the lines of preventive medicine. This, perhaps, might be 
 considered unique in hospital work. 
 
 Miss Mary H. Riddle, Superintendent of Newton Hos¬ 
 pital, Newton, Mass., writes: “This is one of the hospitals 
 in which both schools of medicine practice without friction.” 
 Perhaps that might be a good cure for hospital friction.” 
 
 Under the by-laws of the Methodist Hospital in Brooklyn 
 all schools can treat their patients in our private beds. To 
 treat surgical cases, it is necessary that outside physicians 
 must be on the surgical staff of some reputable hospital. 
 
 Dr. A. W. Smith, Superintendent of Hartford Hospital, 
 Hartford, Conn., writes: “We allow our staff or any le- 
 putable physician to send in cases to private rooms and take 
 care of them.” 
 
 Mr. Reuben O’Brien, Superintendent of the Manhattan 
 Eye and Ear Hospital, says that nothing adds to hospital ef¬ 
 ficiency like an experienced woman in charge of the kitchen. 
 
 Miss Margaret Moran, Superintendent of the Macon 
 Hospital, Macon, Ga., writes concerning the success of the 
 newly installed signal light system. ^\ny system that will 
 do away with noisy call bells will soon find its way into all 
 of our hospitals. 
 
 Dr. C. I. Fisher, Superintendent of the Presbyterian Hos¬ 
 pital in this city, writes a most valuable letter concerning the 
 relation of the Superintendent to the House Staff in regard 
 to their relations to patients outside strictly professional mat- 
 
 14 
 
ters. He says: “For many years I have taken note of the 
 various incidents, accidents, etc., which have brought dis¬ 
 credit to the hospital through the attitude and behavior of 
 the House Physician and Surgeons. As soon as we have 
 graduated our House Physicians and Surgeons and the 
 seniors come to take their places, I get these men together 
 and tell them about these things which have happened, how 
 they discredit the hospital, and how they could and should 
 have been handled differently. 
 
 The ambulance men have, through ignorance and some¬ 
 times over-confidence and lack of tact, caused us consider¬ 
 able trouble. I get these men together of an evening and 
 tell them all the things that have happened, what surprises 
 are likely to come to them, and show them how tliey can 
 handle these and bring credit rather than discredit to the 
 hospital. 
 
 The men who examine patients for admission to the 
 hospital, have in themselves great possibilities for good or 
 evil, particularly evil. I have an evening with these men, 
 and tell them the' things that have happened, and along 
 what ilnes there are peculiar dangers in admitting or not ad¬ 
 mitting certain classes of cases. We have a good talk to¬ 
 gether, perfectly informal, and they ask me questions. I am 
 sure that in these talks, I have saved the hospital a great 
 deal, and prevented things happening which would have 
 been exceedingly unpleasant. 
 
 I endeavor to accomplish similar things with our nurses, 
 though not in quite the same way. 
 
 There is another question to which I would invite your 
 attention. Dr. Fisher presented a paper on a very practical 
 subject last year at St. Louis, and it seems to me we should 
 not allow it to be forgotten. He made a plea for more ample 
 provision for the great middle class who are neither rich 
 nor poor. They do not wish charity, neither can they afford 
 luxurious accommodation, nor large surgical fees 
 
Here, however, is a danger: v/hile the hospital may plan 
 for this class of patients even at a loss, yet the surgeons’ 
 fee may be just as large as if the patient was cared for in 
 a private room with a single bed. Indeed the fee may be 
 larger because of reduced hospital charges. 
 
 Dr. Fisher well said that “it will be necessary to place 
 about it such regulations as will safeguard it from any ef¬ 
 fort of the parsimonious rich to obtain use of these rooms, 
 or of attending physicians or surgeons to put into them those 
 wealthy patients who should pay the price of the more ex¬ 
 pensive service.” The fees for these rooms should be very 
 moderate and definitely fixed. 
 
 I think there has been no more practical deliverance than 
 this for some time. And it seems to me that the matter 
 should not be allowed to stop there. I wish that it might 
 be taken up by our hospital journals and discussed, and 
 that our superintendents might be prevailed upon to report 
 through these journals their plans for the care of this class 
 of patients, rates, fees, etc. 
 
 In bringing this paper to a conclusion permit me to con¬ 
 gratulate the committee on the non-commercial hospital ex¬ 
 hibit, on the excellent display which they have made, which 
 I am quite sure will be conducive to economy and efficiency 
 of hospital administration. 
 
 President: I am sure we are all very grateful to Dr. 
 Kavanagh for his excellent resume of the work of the year 
 in the different hospitals of the country. To me it has been 
 very illuminating. 
 
 16