public health services, such as communicable disease control and health education.

5. Effective incentives and controls must be developed within each state to insure meaningful implementation of planning. Health care institutions, in keeping with their role as main providers of health services, should be fully involved, along with consumer groups, both in the planning process and in the development of appropriate incentives and deterrents.

6. Institutional members of the American Hospital Association should recognize that areawide planning for health and hospital services is essential and it is strongly recommended that they actively stimulate and participate in the development of effective voluntary areawide planning agencies and support the establishment of control procedures that may be required on a local basis to assure compliance with a plan by all health institutions and agencies and to assure the availability of an appropriate range, variety, quality and amount of health services to the people of the area.

ATTACHMENT B

PROTOCOL FOR HEALTH CARE PLANNING WITHIN A STATE

(Approved by American Hospital Association, February 1967)

Three levels of planning are suggested within a state: (1) planning by the individual health service institution, organization, agency or group; (2) interrelated planning by the areawide planning agency, and (3) interrelated planning by a state planning agency, assisted at the state level by an advisory council that is fully representative of consumers and providers of health care. I. INDIVIDUAL HEALTH SERVICE INSTITUTION, ORGANIZATION, AGENCY, OR GROUP

1. A formal planning unit should be established within each health service institution, organization, agency, or group to concentrate upon developing services and programs.

2. Planning by such a unit is the foundation of comprehensive health planning in the community, area, and state. It should be done in relation to the demonstrated needs of the persons to be served.

3. Trustees, medical staff, and administration should be included in the membership of the planning unit.

4. Staff should be assigned to the planning function as an integral part of regular administration.

5. The planning unit within the hospital should maintain regular and close working relationships with the areawide health planning agency and with other health service institutions, to avoid duplication of effort, equipment, or facilities required to meet community health needs. Final decisions should be based upon agreement with the areawide planning agency and other health service organizations located in the planning area.

6. The planning unit should not be directly involved in programs of construction.

II. AREAWIDE HEALTH PLANNING AGENCY

1. An areawide health services, manpower, and facilities planning agency to deal primarily with personal health services should be used or established wherever there is an area, whether intrastate or interstate, of sufficient size and density to support a full-time professional staff.

2. The area wide planning agency should be permanent, and its activities continual.

3. The area wide planning agency should be concerned with the total spectrum of health activities.

4. The area wide planning agency may, but need not necessarily, serve as the coordinating agency for all health planning within the area.

5. It is desirable that the areawide planning agency be nongovernmental and be fully representative of consumers and of the providers of health care within the area who will be called upon to implement the programs that result from planning.

6. Existing health planning agencies that are recognized as effective should be utilized within the defined area of service..

7. Financing should be adequate; it may be entirely local and nongovernmental or may be a combination of nongovernmental and governmental funds but financing should not come from a single source.

8. The areawide planning agency has responsibility in two directions: (a) It should contribute to planning within each individual service institution, organization, agency, or group, through information, consultation, and interaction leading toward responsible decision-making based upon area need and related to other action within the area, and through the bringing together for action and final decision the planning efforts of all of the individual health service units in the area.

(b) It should contribute to the state planning effort the elements arising out of the necessities of its area, initiating recommendations for approval of projects that demonstrate adequate planning to meet the health needs of the people in the service area.

9. The area wide planning agency should have an adequate and qualified fulltime staff.

10. The membership of the areawide planning agency should not be too large; committees being used to carry out special tasks and thus involve more persons in the planning process.

1. It is desirable and necessary to designate a coordinating agency for health planning in the state. This may be either an effective existing state agency, or a new agency designed to bring together the planning efforts of the various health organizations, agencies, and groups within the state.

2. The state health planning agency should be responsible for developing a plan for the planning of the total spectrum of health services, manpower, and facilities in the state, covering both governmental and nongovernmental planning activities; for bringing together the results of the planning efforts of the areawide planning agencies and other agencies throughout the state; for the setting of priorities within the state and for action on program recommendations from the various planning agencies within the established priorities.

3. The state health planning agency should make effective and continual use of a statewide health planning advisory council (See I в).

4. The state health planning agency should set policies; establish administrative methods, including an appeals mechanism; and provide for review and approval or disapproval both of the processes of planning and of the projects recommended to it.

5. The state health planning agency should provide for cooperative working arrangements among governmental or nongovernmental agencies, organizations, and groups concerned with health services, manpower, and facilities; and for cooperative efforts between such agencies, organizations, and groups and similar agencies, organizations, and groups in the fields of education, welfare, and rehabilitation.

6. The state health planning agency should develop, in cooperation with statelevel agencies from other states, the necessary interstate arrangements to provide for planning as needed for health districts and planning areas located within two or more states.

III-B. STATEWIDE HEALTH PLANNING ADVISORY COUNCIL

1. A statewide health planning advisory council should be established on a permanent basis to assist the state health planning agency.

2. The advisory council should be made up of lay and professional members, selected for their leadership qualities, who represent the total state. These should include representatives of providers of service, of consumer organizations and the public, and of areawide health services, manpower, and facilities planning agencies.

3. Members of the advisory council should be selected for their ability to evaluate planning presented for their advice by the areawide health planning agencies and to recommend its effective implementation.

4. The advisory council should not be too large but, as is recommended for the state planning agency, should use committees to carry out special tasks and involve more persons in the planning process.

5. Consideration should be given to establishment of the advisory council as a statutory entity to assure the most effective, balanced use of highly qualified leaders to provide guidance to the state health planning agency.

6. The advisory council may be staffed by the statewide health planning agency.

7. Financing of the advisory council should be independent of the institutions, organizations, agencies, or groups whose programs it will review.

Mr. VAN DEERLIN. Mr. Springer?

Mr. SPRINGER. I have no questions. Dr. Caseley's statement speaks for itself. It is an excellent statement. You have brought up two or three points here that have not been touched on in any other statement or discussed before this committee from any other witness.

Dr. Caseley, thank you very much for coming here and spending this time with us. You may be assured that your views will receive every consideration when this matter comes to be debated.

Mr. VAN DEERLIN. Mr. Ottinger?

Mr. OTTINGER. Thank you, Mr. Chairman. Thank you for a very excellent and interesting statement, Dr. Caseley. I have been very much concerned about the existing shortage of hospital facilities which in many areas of the country is in a critical state. I have introduced legislation to meet this problem and I intend to offer it as an amendment to this bill we are considering.

The Public Health Service last year made a survey of hospital facilities throughout the country and found that by its standardsprimarily based on an annual rate of occupancy of 90 percent or greater-some 143 hospitals throughout the country were in critical condition.

In our own area we have a hospital with an emergency situation where the patients who are accepted actually have to stay in corridors. The delay in giving people medical attention is very serious. There have also been newspaper articles reporting dangerous health hazards to people resulting from the length of time they have to wait to gain admittance for examination in hospitals.

I would like to know how your association would view a one-shot endeavor to directly finance some of the critical needs for facilities? Personally I would support a longer term and larger effort to overcome the problem of hospital shortages throughout the country. I think however, that with the financial situation we find ourselves in in this country today, I think we would be unlikely to get a massive program started at this time. Nonetheless, I think we ought to make a start-particularly with respect to the most critical situations.

I don't know whether you had a chance to see the legislation itself. It is a comibnation of direct, emergency Federal grants and loans. We would be very anxious to have your views on it.

Dr. CASELEY. I have indeed had a chance, Mr. Ottinger, to review the legislation and there is no doubt that there are geographical areas in the country where there are instances of acute overcrowding. This is only one facet of the hospital establishments broad problem areas. Modernization of particularly the urban, the older major hospitals is critical, but possibly if there is one thing that supersedes all other problem areas it lies in the acute shortage of manpower.

Actually the thing which gives the administrators of hospitals. worries bordering on acute anxiety neurosis is the day by day wonder whether we are going to be able to keep the institutions we have

totally operating. When a new hospital is opened in a metropolitan area I am sure that subconsciously each hospital director and each board of trustees secretly wonder how they are going to cope with the problem of obtaining key employees; so I would say that while your concerns are real and valid, to provide the staffing for improved, increased, and advanced hospital facilities, is an increasingly difficult problem.

We have the concerns for modernization which are equally pressing and more critically how we are going to man and staff the institutions that we presently have.

Mr. OTTINGER. Do you have any suggestions for us in terms of your manning, the staffing problems? Do you think the Federal Government has a role in trying to assist in fulfilling those needs and shortages?

Dr. CASELEY. The Federal Government I think has stepped in at a critical time and is fulfilling a very key role in the development of manpower. If I had a criticism it would be that maybe it is a half a decade late, but the support for medical education, for nurse education, for the allied medical sciences, all representing specific bills aimed at rectifying in partnership with the States and local facilities and the private section of educational establishment, I think this kind of partnership is going to be the best hope on which we can look toward resolution of this problem.

There is probably nothing more frustrating than trying to attract into a critical field such as the health establishment, people of competence. The brains of the country is in competition with a booming economy. The present manpower shortage, which is of olympian dimensions, affects the hospital field more than others because it has traditionally and historically been invested with a sense of philanthropy in which even the employees of hospitals have philanthropically helped to subsidize the institutions themselves.

I share your concern with the rapidly increasing hospital costs, but I would point out that maybe the American public should retrospectively be thankful that this thing didn't occur earlier and that they did have the benefit of this subsidization of the institutions by the employees themselves.

They are now demanding obviously their fair rewards in competition with all other elements of the economy.

Mr. OTTINGER. Do you think our efforts in this regard then are adequate at the present time?

Dr. CASELEY. To the extent that there is always a problem of interdigitating the Federal effort with the local effort, and this is progressing well, I think that we probably have right now sufficient funds to do the job.

This must, however, be an expanding effort because as we become geared up the allied medical sciences, for example, find new educational outlets. As more universities are willing to take on a baccalaureate program, and colleges, and associate arts degree programs, then the place for additional shared funding will undoubtedly be more dramatic and I think the need will be increased.

Mr. OTTINGER. So far as the Federal Government is concerned, do you feel the same way on facilities, that the Hill-Burton program is adequate to take care of the present needs and that we can afford to

wait for the President's Commission to study the overall problems for renewal and changes in Hill-Burton in 1969?

Dr. CASELEY. I think, sir, that the Hill-Burton program has never been adequate to fulfill the full spectrum of the needs which are represented by the entire hospital field. As you well know, the major emphasis in the early stages of it and rather all through the program has been toward rectifying the large gaps in institutional needs in the more rural areas.

The needs that we see generating in the suburbs and in the urban areas for modernization, as I have mentioned previously, really emphasize the basic inadequacy of the funding of Hill-Burton.

There is a much bigger job to do than there are resources available to do it.

Mr. OTTINGER. Thank you, Mr. Chairman.

Mr. VAN DEERLIN. Dr. Carter.

Mr. CARTER. I appreciate your excellent statement very much, Doctor. How long have you noticed this shortage of manpower in your hospitals? How long have you had this complaint? You say you have a shortage of manpower in hospitals throughout the country. How long have you had this shortage of manpower which we have been speaking of?

Dr. CASELEY. My experience in the hospital field dates back to 1947 and we were beginning to generate shortages in certain critical and newly developed areas of the highly technical fields then.

The nurse shortage really began to become one of national concern in the 1950's. It has been aggravated on a compounded annual basis I think since. This, doctor, would be my response to the evolution of the critical shortage.

Mr. CARTER. In what field particularly do you have these acute shortages now?

Dr. CASELEY. Nursing I think stands out as the No. 1 area of concern. Now, let me preface my remarks. I am excluding from this the physician shortage because I am talking about the hospital as an organic institution.

Nursing is obviously the single most highly critical item. Technicians, both primarily in the more sophisticated areas, the newer developments in diagnostic, biochemistry and hematology, this sort of thing, therapists, and actually clerical workers become a very, very critical item of shortage as we reframe and restructure the work of the nursing personnel and divest the nurse of everything conceivable that we can in the way of clerical and other duties to let them be truly the patient's nurse, and so I can say, I am sure without any fear of contradiction from my colleagues, that the shortage is general and that there is no area in the entire hospital field that I can think of where there is a plethora of workers.

Mr. CARTER. Have the Government training programs along these lines helped you very much in training clerks? I notice in some hospitals we do have training programs throughout our country for clerical aids and different types of technical help within the hospital. Have they been of assistance to the hospitals?

Dr. CASELEY. These have been of major assistance and I think there is another area of support from the Federal Government that should be alluded to. The Manpower Training and Development Act has