3. Permanente Hospitals 4. Permanente Medical Group 1. Permanente Foundation is a charitable trust which provides facilities and funds for teaching, training, research, and charity. 2. Permanente Health Plan is a nonprofit trust. Its function is to enroll members, collect funds, and keep records of eligibility. The funds collected by Permanente Health Plan are divided proportionately between the hospitals and medical groups, less the necessary administrative expense of Permanente Health Plan. 3. Permanente Hospitals is a nonprofit corporation which operates the hospitals and medical centers in the same fashion as any hospital is operated. It secures its income from two sources, a substantial portion from Permanente Health Plan's prepaid dues and a variable amount from private patents of Permanente doctors and other physicians in the area. 4. Permanente Medical Groups. These are independent groups of physicians organized as partnerships, each group covering a regional service area. These partnerships are as ideal as possible in their interphysician relationships, aims and incentives-eligibility for partnership being 3 years of service with the organization. The incomes of doctors compare favorably with those of privately practicing physicians in the same area. PROGRESS IN BUILDING FACILITIES The achievements of Permanente in this field are very striking. Beginning in October of 1942 with a modest little hospital of 80 beds in Oakland costing $300,000, there has been a rapid growth of unit after unit, till today Permanente has 6 hospitals (medical centers) in operation with a total bed capacity of 1,090 "general" beds. Three more are in construction, adding 520 beds to this number, and there are on the architects' board 4 more small ones that will add 200 more beds. In addition to these 1,810 beds in medical centers, the Permanente organization includes 2 rehabilitation institutions with 275 "rehabilitation" beds, as well as a hospital and clinic developed for several industrial plants in Utah. The growth of facilities made possible achievement in another field-that of hospital and medical center designs. The Kaiser Permanente Hospitals now under construction in Los Angeles and San Francisco present many new ideas in hospital construction. Each unit has approximataely 225 beds, and the 2 hospitals together will cost $6 million. By routing the public through outside corridors, an entirely new concept of hospital service is made possible. Rather than using the usual central corridor, which creates a traffic problem, the public enters the patients' rooms through sliding glass doors from the outer corridors running along 2 sides of each floor. Both walls of the outside corridors are glass from floor to ceiling, affording an "outdoor" environment. Drapes operated by electric motor from the patient's bedside afford complete privacy during visiting hours. Note: This is the ultimate organizational form of all permanente Medical groups. all of them have reached this form and there are some experimental variations. Not TABLE 1.—Permanente hospitals, clinics, and rehabilitation centers room. The usual public central corridor on each floor will be restricted to physicians, nurses, and employees. It will include decentralized nurses' stations and utility rooms. Drugs, medications, X-rays, treatment materials, instruments, linens, charts, etc., for each patient will be kept at stations just outside the patient's Each station will be devoted to eight beds, decreasing nurses' walking to one-seventh that required under conventional floor plans. Eliminating the public from this area and decentralizing nurses' stations provides more efficient service, allows closer observation of the patient, and permits the attending physician to determine at a glance the patient's condition and treatment. There will be a control station on each floor for a supervisor, who has direct vision of all personnel on the floor. These stations will control and route visitors down the outside corridors. The supervisor also will handle incoming and outgoing requisitions via conveyors and mail chutes, which are so planned as to serve each point for transportation of material-storeroom, pharmacy, laboratory, record room, business offices, and central supply. Requested materials are delivered automatically. The control station will be connected with each nursing unit by intercommunication systems. The obstetrical floor will have a built-in sound-proofed nursery behind each bed with a bassinet that is pulled through the wall separating the nursery and the mother's bed. When the bassinet is pushed back into the nursery, an automatic signal light notifies the nurse. A viewing window in the mother's room permits visitors to observe the baby in the nursery without danger to the infant. This plan caters to the principle of having the mother and baby together as much as possible for practical and psychological reasons. The two top floors of the hospital are planned for hotel type service for convalescent patients. As soon as patients become ambulatory, they will move to the hotel rooms where, in pleasant surroundings, they will finish out their stay. Such patients may eat in a buffet-style dining room, sleep late in the morning, participate in social recreation, watch television programs, and the like. 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. Funds provided to nonprofessional personnel, 10-year period____ Funds provided to non-Permanente physicians and other professional people, 10-year period--- $23, 500,000 10, 300,000 1,500,000 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. 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 medic 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 cell chemistry in cancer and means which may possibly remedy it. The Permanente Foundation Medical Bulletin, which is published periodi cally, 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 medical 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 excellent relations developed between the Alameda Contra Costa Medical Association and the Oakland Permanente physicians. This is in large part due to the enlightened 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. 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 The 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 |