should be constructed to bring present facilities up to a proper level. Further, the State plan must order proposed construction projects by priority before granting funds which insures that local applications in each State will receive attention on the basis of priority of need rather than on the basis of political pressures.

The act insures that the Federal administrator will not act in an arbitrary manner, as it requires regulations and other administrative actions be approved by the Federal hospital council. Backing of the Federal council also permits the Federal administrator to administer the act in an objective manner.

The requirement for surveys is one of the most important features of the act. For the first time, the act provided for an actual inventory of all of the hospital resources within a State, whether governmental, nonprofit, or privately owned even though funds for construction go only to governmental or nonprofit agencies.

These studies and the ideal plan for hospitals which each State must prepare provided a guide for all construction, whether federally aided or not. The plan avoids duplication and insures adequate facilities for all of the people within a State.

Much more could be said of the consistent and thoughtful study given to the preparation of this legislation. The association participated in this study and has contributed to the very best of its ability not only in the preparation of the initial legislation, and later amendments, but in its administration. We believe this is a proper function of our association.

We are, of course, proud of the accomplishments under the act in bettering hospital care for the people of this country.

We are sure this committee knows that this act has been described as a model of local, State, and Federal partnership in meeting an important national need.

We have endeavored, not only at the Federal level, but in States and localities to stimulate and insure continuing participation in the successful accomplishment of these important objectives.

Shortly after the enactment of this legislation in the spring of 1948, the association with the approval of the Public Health Service held working conferences countrywide with representatives from official State agencies and hospital administrators representing State and local hospital associations. These conferences had as their objectives: 1. To accomplish an exchange of information on the hospital-construction program between representatives of hospitals and State planning agencies;

2. To identify required activities and possible developments under Public Law 725;

3. To establish suggested priorities of action to accomplish a constructive State hospital planning program;

4. To define responsibilities of hospitals and State agencies for the various necessary and desirable activities under Public Law 725;

5. To suggest basic principles which should underlie the future hospital-expansion program;

6. To outline ways in which full public understanding and support of the hospital program might be accomplished;

7. To stimulate interest in the conduct of similar conferences within each State.

The working conferences referred to were not inconsequential in promoting the successful operation of the program.

We have a copy of the report of these conferences should the committee wish to examine it.

Senator HILL. Excuse me. How lengthy is that report, Mr. Bugbee?

Mr. BUGBEE. It is about a hundred pages, Senator Hill.

Senator HILL. Certainly I hope you will file a copy here. In fact, you might file enough copies so that each member of this subcommittee may have a copy.

Do you have sufficient numbers for each man on this subcommittee? Mr. BUGBEE. It is some time back, and I do not. I have one copy. Senator HILL. Will you file that one copy?

Mr. BUGBEE. I shall do it.

Annually, the American Hospital Association has cooperated with the association of directors of the State agencies administering this act in providing opportunity for them to meet and discuss not only the day-to-day problems of operation under the Hospital Survey and Construction Act, but all aspects of hospital care which might affect administration of this program to insure adequate hospital facilities countrywide.

In the past 2 years, in spite of very limited association personnel, 2 members of the staff made visits to every newly operating hospital in 4 States which had received Federal aid under this act to study the success with which these hospitals were providing community service. These studies involved inquiry as to the demand for hospital service, the number of new physicians attracted to the community, the adequacy of the supply of technical personnel such as nurses, laboratory technicians, and so forth, the effect on occupancy of nearby hospitals, and the success which each hospital was enjoying in balancing its budget.

Reports from these studies are briefed in an article in the March 1953 issue of Hospitals, the journal of the American Hospital Association.

A third member of the staff recently surveyed a number of health centers being constructed in the Southern States. The history of the services rendered by these important units, over 400 of which have been built countrywide, is described in an article appearing in the November 1953 issue of our journal.

Last year, with legislation proposed in the Congress for an extension in the expiration date for the Hospital Survey and Construction Act, the association determined again to secure grassroots opinion about the act. Conferences were organized nationwide to which were invited representatives of State administrative agencies and State hospital associations.

These 4 regional groups each met for 2 days. As an agenda, they first listed all possible criticisms of the act, both favorable and unfavorable. Then they, by actual vote, gave their opinion as to the validity of both favorable and unfavorable criticisms.

We have here for the committee copies of the report of these workshops.

Senator PURTELL. Have you a sufficient number for all members of the committee?

Mr. BUGBEE. I have four copies and can supply others, Mr. Chair

man.

Senator PURTELL. If you would supply four or five more, we would like very much to have them.

Mr. BUGBEE. I shall do so.

Senator PURTELL. That is for the files.

Mr. BUGBEE. Yes, sir.

Senator PURTELL. Rather than for incorportation in the record at this time.

Thank you.

Mr. BUGBEE. I think the unanimity of approval as to accomplishments and the small number of criticisms which were accepted as valid is remarkable.

It was the finding of these workshops and the advised opinion of members of the association's board of trustees and house of delegates which led the association to recommend that the act be extended.

It is not the purpose of this testimony to delineate all of the efforts of the association to insure the success of the program under the Hospital Survey and Construction Act. We are, however, endeavoring to establish for the committee the responsible position that the association has taken in order that our comments on the amendments may be evaluated in proper perspective.

Senate bill 2758 we recognize as a companion bill to H. R. 7341.

H. R. 8149, which was passed by the House of Representatives on Tuesday, March 9, is very similar to S. 2758. However, it appears to us to incorporate some improvements in language. Our comments in general apply to it as well as to S. 2758.

The broad purposes, as stated in S. 2758, are substantially the purposes as stated in title VI, section 601 (a) and (b) covering the survey and construction of hospitals. We presume that the amendments are suggested for two purposes:

(a) To provide for survey and construction of facilities not now covered under present legislation, or

(b) To provide a higher priority in the construction of certain types of facilities, even though they may be provided for under present provisions of the act.

Our comments will be first directed to the examination of the 4 classifications of facilities outlined in the proposed section 651, page 4, and defined in the amendments proposed for section 631, on page 12 of S. 2578.

In general, there has been difficulty in the field from the standpoint of classifying hospitals because hospitals generally were not constructed on the basis of any overall planning. They grew up to meet local needs. Individual hospitals were developed to utilize the medical manpower available and to facilitate the type of practice being carried on in a community.

Generally, there is no clear-cut line of demarcation between the physical plants of different types of hospitals, whether they be the typical community general hospital or for the care of mental illness, tuberculosis, or other chronic illnesses.

The type of patient to be treated, whether requiring long-term or short-term care and, among other factors, the size community, have all affected the gathering together of facilities in the individual hospital.

We find some hospitals primarily classified for the care of chronic illness with laboratory, X-ray, and all the facilities which would be present in the usual general hospital. On the other hand, we find some general hospitals with no more in the way of diagnostic equipment than might be expected to be found in some units for the care of chronic illness or even a nursing home.

The American Hospital Association, concerned with the lack of standardization of definition of hospitals and related institutions in January of 1953, called together 29 individuals experienced in hospital operations, hospital statistics, prepayment for hospital care, and hospital licensure, in both this country and Canada, including representatives of the Public Health Service and of the Census Bureau of the Federal Government. These individuals were invited because of their experience with the problems created by lack of definition of a type of hospital.

I have here a copy of the report of this hospital classification conference outlining the deliberations of this group during 3 days.

The significant findings of the conferences were the following definitions:

HOSPITALS AND RELATED INSTITUTIONS

A hospital or related institution is any establishment offering services, facilities, and beds for use beyond 24 hours by 2 or more nonrelated individuals requiring diagnosis, treatment or care for illness, injury, deformity, infirmity, abnormality, or pregnancy.

The above broad definition was subdivided into hospitals, nursing and convalescent homes, and domiciliary institutions. These were defined as follows:

Hospitals. A hospital is any establishment offering services, facilities, and beds for use beyond 24 hours by 2 or more nonrelated individuals requiring diagnosis, treatment or care for illness, injury, deformity, infirmity, abnormality, or pregnancy, and regularly making available at least (1) clinical laboratory services, (2) diagnostic X-ray services, and (3) treatment facilities for (a) surgery or (b) obstetrical care or (c) other definitive medical treatment of similar extent.

Nursing and convalescent homes.-A nursing or convalescent home is any establishment offering services, facilities, and beds for use beyond 24 hours by 2 or more non-related individuals requiring treatment or care for illness, injury, deformity, infirmity, or abnormality, including at least room and board, personal services and nursing care. Domiciliary institution.-A domiciliary institution is any establishment offering services, facilities, and beds for use beyond 24 hours by 2 or more nonrelated individuals requiring room and board and personal services which they cannot render for themselves because of a deformity, infirmity, or abnormality.

Careful examination of these definitions will indicate that without any question, an institution providing care for chronically ill patients may often be classified as a hospital. On the other hand, there will be many institutions, some of which are now called hospitals, which, because of lack of laboratory, X-ray and intensive day-to-day medical care would be better classified as a nursing and convalescent home.

We do not believe that the definition of "hospital for chronically ill" and "nursing home" in Senate bill 2758 clearly indicates the

type of classification of facility that the bill is intended to benefit. In fact, we question that it will accomplish its purpose on the basis of such a differentiation.

The basic problem is to provide more beds for the patients in need of long-term care, a group presently inadequately cared for and one which, because of the aging of the population, is increasing greatly in number.

The chronically ill need care in facilities of different types and the grouping of these types of facilities is affected by the size of the community and various other factors.

Some chronically ill patients are in need of surgery and other intensive care which requires all of the diagnostic and treatment facilities of the general hospital.

A second group of chronically ill patients may need only some of the facilities available in a general hospital, but for an extended period. For example, they may need physical therapy, occupational therapy, as well as periodic medical and diagnostic services.

Where a sufficient number of this second group of patients can be gathered together, they may be cared for in a special unit of a general hospital or in a chronic hospital which will be somewhat less expensive to construct. Such patients may need less nursing care and operating costs will be less than for care of the typical acutely ill patient receiving short-term care in a general hospital.

A certain number of the chronically ill may not require extensive medical care and concomitant facilities. For example, patients with inoperative cancer or with disabling forms of heart trouble, and those badly crippled with arthritis. Such patients primarily need kindly attention, adequate nursing care, and some recreational facilities. Depending on the degree of acuteness of their illness, such patients may be cared for in a nursing home.

It is sometimes possible, where there are large numbers of chronically ill, as in a metropolitan community, to have facilities specially constructed and staffed for patients who are classified by degree of medical and nursing care required. Where this is possible, if the average patient needs less treatment and nursing care than is available in the average general hospital, the cost of the facility and the cost of maintenance of the facility decreases.

An example of the complexity of caring for patients, separated by classification, was illustrated in the discussions in the classification conference to which we have referred. That group generally agreed that most homes for the aged were nursing homes, as the aged who need only domiciliary care at time of admission to the home during their period of residence inevitably become ill and require nursing

care.

It is undoubtedly true that some homes for the aged would not have such nursing care available even when needed, and, indeed, it is one of the dangers of establishing institutions with limited care that patients who require more nursing care or more intensive medical supervision may suffer because the specialized facility is not equipped to meet their need.

The conferees concluded that homes for the aged inevitably became nursing homes.

A particular danger of multiple grades of facilities for the care of long-term patients is the tendency for patients to remain in a facility