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There will be no multiple-bed wards in the hospital. Each room will have a maximum of two beds, with many single-occupancy rooms also provided. Beds will be of the electric-motor type with adjustments controlled by the patient. Alongside each bed within reach of the patient will be a lavatory with hot, cold, and ice-water taps, radio and phonograph outlet, piped oxygen, and individual clothes closet.

ECONOMICS The Permanente record of performance in this field is probably one of its greatest contributions. Throughout the 10-year period, it has remained constantly and impressively sound.

The greatest tribute to this economic achievement is the present loan secured from the banks for our new construction. One million dollars of the new $9,500,000 project was donated by the Henry J. Kaiser Co., and the Kaiser Steel Corp. The remainder will be financed by commercial banks. This marks a milestone in hospital construction and opens new horizons. The traditional mistrust and reluctance of the banking world in respect to hospital financing has been breached by the performance of the Permanente plan over the past 10 years. This is even more striking when one considers that this record was established while giving the members of the plan more and better medical and hospital care for their dollars than any other plan in the country and, at the same time, providing financially for facilities, equipment, teaching, training, and research-all a necessary part of the complete program.

The following are a few random statistical figures : Funds provided to Permanente physicians and other professional personnel, 10-year period.--

$23,500,000 Funds provided to nonprofessional personnel, 10-year period.. 10, 300,000 Funds provided to non-Permanente physicians and other professional people, 10-year period.-

1,500,000

INCOME FROM HEALTH PLAN MEMBERS

65.3%

PRIVATE AND INDUSTRIAL HOSPITALIZATION
AND OTHER SERVICES

26.1%

OTHER INCOME

PRIVATE PROFESSIONAL FEES

4.0%

CHART 1.--Distribution of total income, March 1952.

EDUCATIONAL AND RESEARCH PROGRAM Permanente believed that a medical plan worthy of perpetuation, in addition to being economically sound, must provide teaching and training to stimulate high quality of care and research to contribute to medicine of the future. These objectives have been continuously stressed. Permanente has its own nursing school and its intern and approved residency training programs. A separate research laboratory building was recently acquired at Belmont, Calif., and a quarter of a million dollars per year has been budgeted for this program. An educational-leave program has been developed for all physicians and educational activities are encouraged. During the past year, considerable effort has been devoted to working out an affiliation with a medical school so as to develop further these educational activities.

The Permanente Foundation hospitals offer a variety of opportunities for interns and residents to learn the art and practice of medicine. Residencies are offered in all the major specialties. The interns rotate through all the major departments. While on these services the interns take part in seminars, staff rounds, and other educational conferences.

The Permanente School of Nursing was established in 1947 for the purpose of preparing young women in the art and science of nursing. Special emphasis is placed on the teaching of the methods of protecting and maintaining community health and on the skills and techniques of bedside nursing. The course of study and practice continues over a 3-year period. During the first 6 months the student spends the greater part of her time in study. Upon completion of the preclinical period the student enters into a regimen of constant study and clinical experience in the various departments of the Permanente Hospital in Oakland, where her work is carried on under the guidance and supervision of the Oakland Hospital staff. No effort and no thought has been spared in constructing a course of studies which gives the student nurse an opportunity to acquire an excellent and basic foundation in the profession of nursing.

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The research activities sponsored by Permanente fall into 2 spheres. Clinical investigation concerned with the study of new diagnostic techniques and therapeutic agents and the development of new knowledge of disease is supported and encouraged on the part of any interested member of the medical staff, A number of research fellowships are maintained to further this work. Studies of cardiac drugs, agents for controlling the symptoms of peptic ulcer and other gastrointestinal diseases, insulin stress for the symptoms of arthritis, and medir. inal agents giving promise in hypertension are examples of the projects which are now underway. Apart from the clinical field, Permanente pursues a program of fundamental research which at present includes a study of the physiology of the regulation of the appetite and a project concerned with the disturbed ce!! chemistry in cancer and means which may possibly remedy it.

The Permanente Foundation Medical Bulletin, which is published periodically, is now in its 10th year. This periodical is “Dedicated to the advancement of medical care” and is composed of new contributions to the field of Ledical knowledge largely from the staffs of Permanente hospitals and the Permanente Foundation. The Educational Proceedings for the Permanente Hospitals is pub lished 10 times a year and is essentially a record of staff lectures, educational seminars and of proceedings at weekly grand rounds. It is intended to provide reviews and new developments in the field of medicine which may prove useful in the care of patients.

MEDICAL SOCIETY RELATIONS

Progress in this field has been slow. The bright spot has been the excellen! relations developed between the Alameda Contra Costa Medical Association and the Oakland Permanente physicians. This is in large part due to the enlight: ened viewpoint of the local leaders of the medical society and to the help of their exceptional executive secretary, Rollen Waterson. The Los Angeles Medical Society has been very cooperative, as has been the San Bernardino County Medical Society.

Extensive efforts are being made to resolve our difficulties with San Francisco, Solano and Multnomah medical societies. It is interesting that the major element of concern is what the Permanente plan will do to individual practice It has always been our contention that individual practice is here to stay and Permanente will not hurt it, but help it. A recent medical economic survey shows that Oakland, which can be considered the stronghold of Permanente (1 in 8 of the population belongs to the health plan), has the second highest private physician income in the country. This means that Permanente takes care of people who ordinarily do not get or are unable to pay for medical care, and, secondly, that Permanente's presence in a community may stimulate the population to be more medically conscious and to seek more care from their physicians. The county hospitals and welfare agencies are the only groups really losing patients in any appreciable numbers to Permanente.

A LOOK INTO THE FUTURE-OPPORTUNITY UNLIMITED

It is commonly stated that it takes 30 years to get a new idea across Permanente's tenth anniversary marks the end of the second decade of the existence of the fundamental Permanente concept. At the start of the third decade, new horizons are opening up. The lifting of barriers to the financing of facilities as demonstrated by the projected new construction, cannot help but make an impressive demonstration to the physicians and hospitals of the country. The excellence of these new facilities, their innovations, the quality of work being performed, the educational and research programs developed, will add in no small measure to their pyramiding evidence of worth and soundness.

We are striving to prove (1) that high quality medical and hospital services can be rendered the people at a cost they can afford; (2) that this can be done to the benefit of all parties concerned-the people, the physicians and the hospitals; (3) last and not least, to prove that all this can be done by private enterprise without necessity for government intervention. Any doctor can so organize his work and his companions in practice to do the same job that a Permanente medical group is doing. There is nothing sacred or secret in the idea. This cannot help but become more evident in the coming years.

There appears to be a definite acceleration evident in our progress toward these goals. The great interest displayed by doctors, labor, government and the people in the Permanente idea encourages us to believe that the accolade of "mission accomplished" cannot be too far off. It is appropriate at this time to express our appreciation to all those who have worked with us, our trustees, our physicians and fellow workers, our health plan members, the medical societies, civic and union leaders, and the fair opposition. Opposition to change is natural and healthy; the effect of this opposition was to stimulate us to do a better job,

[From the New England Journal of Medicine, October 30, 1952)

THE PERMANENTE PLAN's First 10 YEARS With the cost of medical care rising progressively, with insurance plans such as Blue Cross and Blue Shield forced to increase their premiums while their benefits provide for decreasing proportions of the faster rising costs, and with less and less of the worker's income from wages or salaries available for savings, it is a question whether the supplying to considerable segments of the people of some form of prepayment plan for total medical care can be indefinitely postponed.

Details of the plan are worthy of study, for, although Dr. Garfield's presentation might be interpreted as being tinged with enthusiasm and self-interest, the facts of its accomplishment are impressive. It has also been a financial success. In the 10 years since the plan was established and while it was developing, participating physicians and professional personnel have been paid $23.5 million, and over $10 million has been paid to nonprofessional personnel and $1.5 million to outside physicians and professional people.

The organization consists of the following parts: a foundation that is a charitable trust providing facilities and funds for teaching, training, research and charity; a health plan that enrolls members, collects funds and apportions them among the hospitals, medical groups and administration; hospitals that are nonprofit corporations operating medical centers; and medical groups of independent physicians organized in partnerships, each covering a regional service area. The incomes of the doctors in these groups compare favorably with those of physicians in private practice in the same area.

In closing his report Dr. Garfield makes the following statement of the future and of the aspirations of the Permanente plan:

We are striving to prove (1) that high quality medical care and hospital service can be rendered to the people at a cost which they can afford; (2) that this can be done to the benefit of all parties concerned—the people, the physicians, the hospitals; (3) last and not least, to prove that all this can be done by private enterprise without necessity for government intervention. * * *

* The great interest displayed hy doctors, labor, government and the people in the Permanente idea encourages us to believe that the accolade of "mission accomplished" cannot be too far off. The workers at Permanente feel that new horizons are opening up for the coming decade. * * *

* * * The lifting of barriers to the financing of facilities, as demonstrated by the projected new construction, cannot help but make an impressive demonstration to the physicians and hospitals of the country. The excellence of these new facilities, their innovations, the quality of work being performed, the educational and research programs developed will add in no small measure to pyramiding evidence of worth and soundness.

Certainly, this plan is worthy of careful study by physicians throughout the country as one type of program that may not only erect further defenses against the encroachment of socialized medicine but actually provide more and better medical service, at lower cost, and at the same time maintain the dignity of both doctor and patient.

In the 10th anniversary issue of the Permanente Foundation Medical Bulletin, issued in August 1952, Dr. Sidney R. Garfield traces the development and growth of the Permanente plan in the Pacific coast States. It was originally designed to meet the serious dearth of facilities and medical services in the San Francisco Bay area created by the mass dislocation of people into wartime shipbuilding. Actually, it evolved as the result of a decade of earlier attempts by a group of interested and far-seeing persons to provide the best hospital and medical

1 Garfield. S. R. 6:1-12, 1952).

Report on Permanente's first 10 years (Permanente Found. M. Bull.

care to average workers at a cost that they could afford. According to its director, the plan, as it actually worked out, was the outstanding wartime niedical service outside the Armed Forces; the list of its achievements seems to bear out that estimate.

At the end of the war in 1945, when shipbuilding was discontinued and the workers were dispersed throughout the country, the relatively few who remained served as a nucleus for the continuation of the plan on a community basis. Now, in 1952, the Permanente plan serves 250,000 members iņ California, Oregon, and Washington, as well as large numbers of patients who are not members. The acceptability of the plan and its popularity are fully attested by the fact that new facilities are now under construction that will provide for an increase in membership to 400,000.

The scheme was designed to eliminate the waste resulting from poorly planned facilities and from the ineffectual coordination both among the physicians themselves and between them and the institutions in which they worked. It was accomplished by a well-coordinated group practice operating in well-planned medical centers. It is a prepayment plan based on the insurance principle for the provision of a comprehensive medical service. The fee for service was abolished, but all the prepaid funds have been going to physicians and hospitals. It has apparently been a successful experiment, designed to provide complete medical care of the highest quality to large groups of people at a cost that they can afford and that they can budget. One experiment deserving such scrutiny is the Permanente plan.

(From San Francisco Chronicle, August 20, 1953)

KAISER'S DREAM HOSPITAL TO OPEN IN WALNUT CREEK

(By Milton Silverman, Science Writer, the Chronicle) The hospital that couldn't be built-a medical dream house for doctors, nurses, and especially patients—will be opened for public inspection Sunday at Walnut Creek.

It's the $2 million, 94-bed Kaiser Foundation Hospital to serve eastern Contra Costa County.

Built like a rambling ranchhouse in a 7-acre garden, it is an air-conditioned, electronically operated structure in which practically everything works with pushbuttons, including the bedpans.

Almost every phase of the new hospital represents a revolution in hospital design, a revolution long urged by patients and staff members.

8 O'CLOCK WAKING

When the hospital opens officially next month patients will not be awakened at 5 a. m., or some other ghastly but standard hour, but at 8 o'clock.

Instead of being greeted with a cold washrag in the face and a thermometer in the mouth, they can start with coffee and toast. Each room is equipped with its own electric coffeemaker and toaster, within arm's reach of the patient.

Each room is also equipped with a wash basin, running icewater, a radio with a choice of four stations or a phonograph, a telephone, a pushbutton to raise or lower the head or foot of the bed, and a closet, all within arm's reach. A patient will not have to clamber out of bed to get a drink, a bathrobe, or a lipstick.

LANAI OUTSIDE

Each room opens out to a lanai, or veranda, through sliding glass doors. The doors can be covered by sliding drapes which the patient opens or closes by a pushbutton.

In the obstetrical wing an ingenious arrangement is used to move the baby in and out of its mother's room, giving all the advantages of the living-in system but none of the disadvantages.

When the mother wants the infant near her she pulls a contraption like a stainless-steel fle drawer, and out slides the baby's crib next to her bed. When the baby is scheduled to return the file drawer is pushed back and the baby rolls into its own private, air-conditioned nursery.

A separate nursery is available for premature infants.

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