Document 3QYyEneozzrEJD7eEabnxXbp0

U3TH0P0LITAH IITS IHBURASCS COHPAHT NUHSOTJ 88BVICS XZXDZ18 SGPBKYI80BS A5HUA1 COX7SRXCl JAHUAHY - 1989 I I - * - HUBSIHO Slavics - 8UPSRV7S0BS' AHHUAS COHXBHBSCB January 28th - Tebruary 6th, 1929. Monday, January 28th, A. M. Place of Meeting: Sireotore' Soon. rreaent: Sr. Irankel, Sr. Araatrong, Sr. 8hepard, Mr. Burnette, General Suparrlaora, and Velfare Siviaion Bureau Heada and Staff. Chairman: Sr. TranJcel. Ganeral Beview of Velfare OiTiaion Aotiritiea for Tear 1928. Attaohsd are the Minutea of thla meeting. Monday, January 88th, P.M. Plaoe of Meeting: Sr. Prankel'e Office. Preaent: Sr. Prankel, Sr. Armatrong, Sr. Shepard, Mr. Burnatta, General Suparrlaora and Bureau Heada. Chairman: Sr. Armatrong. * Purpoae of Meeting: An Szohange of Oplnlona la ro Velfare Aotlvltlea. Plan of Approaoh: 1. Aetlrltlea of greateat lntereat and algnlfloanoa. S. Purpoae of Aotiwlty. a. Method of launehlng. h. Halation to Agenoy Staff, o. Beaotlon of Agenoy Staff, d. Heaption of Health Offioer. 8. Home Offloe Aaalatanoe to Superrlaor. 4. Progreaa of Aotlvlty. 5. Result. ^* -a Dr. Armstrong reported that a Hona Offioe Committee la Baking a study of tha ralatlonahlp between tha Waifart Division and ita outaida contacts. Ha auggaated that two or thraa General Supervisors ba appoint ed to oonfar with suoh ooaaltteej thaaa Supervisors to ba appointed by Mrs. la Malle. Exhibits, rirat Aid Booms, ato.* 1 2 Dr. Armstrong brought out this following points to ba kept in mind in reference to tha above! 1. Manager and Kurae should understand that tha service is restricted to first aid only. 2. Treatment is not to ba given axoapt in emergenoy care. S. Medication is not to ba used axoapt bicarbonate of soda, aroaatlo spirits of ammonia. 4. Treatments are not to ba repeated. (Individuals ask ing for suoh treatment should ba referred to their own physloians or olinlos.) 5. In ease of major aooidant or serious need for oars, nurse should ask Agent to oall a phyalolan, preferably the Metropolitan examiner. Dr. Tranks! pointed out! 1. The Supervisor should be lnstruoted to seleot a nurse who knows the polioles of our serrioe. 2. The nurse should be given a definite plan of prooedure in this eaergonoy add. 8. That answer to a Manager's letter Should oontain definite information in refersnoe to expense for serrioe. A seoond nurse will lnoreaee the eayense. lOTSt Dr, Trankel felt that the idea of an eaergonoy hospital should be maintained), that we should not give up having nurses at first Aid Sta tions, and that we must be oareful to do nothing that is unethical from a aedloal standpoint. I Decentralised Offiota. Sr. Jrankel requested the opinions of the Super-rigore in referenot to the following: 1. la it a feasible pro,} got for the Superrisor to under take the responsibility of oontaots in the field for the Welfare Division? 2. So we need ohanges in order to make this possible? S. If so, what ohanges would aaIce it possible? 4. What is the future of suoh activity? NOTE: Sr. Prankel spoke aost enthusiastically about Parent-Teaohers Associations and referred to thea as "the most deaooratio movement under the sun". Questionnaires: Sr. Frankel stated: It is an art to fora a questionnaire in suoh a way that answers give the desired inforaation. All questionnaires should .be referred to Eoae Office for teohnioal advloe and approval before . olroularisation. Tuesday, January 29th, A. K. Place of Heetlngt Class Soon. Present: General Supervisors and Soae Offioe Clerks. 1 Chairman: Kiss Kearney. Purpose of Keetingt To Study the Clerical as Outlined in the Job Analysis. Kiss Dougherty was in oharge of this seating end disoussed in detail the olerleal routine as outlined in the Job Analysis and emphasised the inportanoe of a thorough' knowledge of this sane. Substitute fumes. It was suggested that a for* be printed for use in reporting the employment of substitute nurses. Remuneration for Substitute Hurses. Supervisor* fait that the preaant system used la the raounoration of substitute nurses is not a satisfactory one. Decision: That Home Offioe prepare a salary soale for substitute nurses and submit it to General Supervisors for consideration; this to be planned on a monthly and daily remuneration basis. Automobile Upkeep for Substitute Suraas. Decision: A plan of remuneration to be outlined on a monthly and a daily basis. Monthly Reports: - General Report of Territory. Advisory Nurse Report. Debit Nurse Report. Supervisors are requested to send these reports in triplicate to Home Offioe so that a oopy may be retained in the Nursing Division, and ona eent to the Welfare Division and to the Superintendent of Agenoiea. Bxtra Clerloal Help for Deoentraliaed Offioe. Supervisors are to write Home Offioe for extra help whenever such help is neeessaxy, giving reasons for this request. Remuneration for Substitute Clerloal Help. Bills are to be submitted to Home Offioe. HOTS: ' In those oases where the Supervisor pays the substitute herself (we have no obj eotion to this) she must submit the receipt signed by the substitute before Home Offioe oaa honor her bill. -B- : . Statistloal Data and Beoords. Visa Bteeves reviewed the ^o'.lowinj: 1. Tha procedure used in tha analysis of tha year 1928 nuraing data. Sha pointad out that thoaa nursing oentars whioh averaged laaa than 200 oasas par year vara not tabulatad haoauaa tha expense of tabulating a avail nuabar of oaaas was not justified. 2. Bevlsed nursing forma. 5. Bating of nursing servioes. 4. Plan for reviewing nursing records in Daoantralized Offices. 8. Correspondence pertaining to oases in Decentralized Offloss. 6. Method of approving speoial nursing in Deoentralised Offioes. It was explained that in all plaoes vhara 12 hour duty is oustoaary that it is to be understood that an approval for 24 hours of speoial nursing aeana two periods of 12 hours eaoh. 7. Desirability of ohanging tha tens "satisfactory* and *unsatisfaotory" as used on lots H. 8. 7. XOTBi Dr. Prankel suggested tha tarns "Manual* and Mon-Manual* but decision was not raaohad. Dr. Prankel spoke, emphasising the naoeaslty for General Super visors oarafully reviewing the yearly statistics and using then in plans for the year. He stressed the value of the figures given than and what that partioular sheet should signify to then, that they should ask thenselves why ----- territory should have ------ rating while their territory had --r rating? Why is there a variation? Is it due to sonething in ay territory? What an X going to do as an administrator? Dr. Prankel farther stated that the Supervisors should find this sheet interesting and that it should present to eaoh a problem - that of finding out why her territory did not rank as high or even higher than some of the other territories. He asked the Supervisors to study ths sheet, give it serious consideration and see if they eould not, in some way, raise their rating, for lnstenoe, one territory had a rating of 75j{ satlsfaotory. Dr- Prankel wanted to know why it was not 76f or 78g satlsfaotory. This was a problem for the indi vidual Supervisor to solve for her territory. l ` * `<'? if , ' K 4 -r / , < A-1 $ v;"-, < ,,& Or. Prankel also stated that the disorepahoies in ratings night be dus to tho sizes of tho territories, population of territories, and the agencies with wbloh ve have oontraots. He felt eaoh Supervisor should raise the rating of her territory. He was Interested in knowing if the present peroentage of cases reported was the test possible. If so, why was it not higher? If not, why wasn't it? After disoussing this point, it was deoided that we have not reaohed the Unit of oases reported by families but that it is worth while to urge families in this oonneotion. Or. Prankel asked if it would be well this year to go a little beyond the actual recording of these figures to see the relationship between early .reporting and high oases or the reverse? The consensus of opinion was that the education of the Agent in the instruction of the family was the vital factor in the accomplishment of this. HOTS: It was emphasized that the oooperation of the Agent must be won and that it must be given definite organized information to use in the edu cation of his polloyholders if we are to get the best results. Tuesday, January 29th, P.M. luncheon Heating of General Supervisors, Vice-Presidents, and Superintendents of Agenoies. Plaosi Officers' Dining Room. During the lunohson, Hiss Johnson, Hiss Baglay, Hiss Ahern and several other Supervisors were oalled upon to give a brief resume of *Hy Territory as I See It*. Time did not permit all the Supervisors to speak. Hiss Hannah, Velfare Division, spoke briefly on oommunity activities of the Managers, literature distribution, eto. Bach Superintendent of Agenoies spoke briefly on matters pertaining to his territory. Mr. Bradley, Metropolitan Territory, in speaking of his territory said that it had always been dlffioult for him to understand why the agents did not use the nursing serrioe to its fullest extant. He said that his nota tion in refersnoe to it had always been along these lines: Xduoation - Agitation - Instruction. He said that he was very much interested in knowing how eaoh dis trict stands relatively with respeot to the nursing serrioe, polloies in foroe, -7- outs nursed, where nursing eervloe is ussd tbs least, and why. Es fslt tbsss probltms should bs disoussad with tbs manager who should follow than up until improvement is brought about. Ha said ha raliad upon tba Valfara Division in all its aspaots in rafaranoa to oarrying on tba work in tba Uetropolitan Territory. Ur. Tratbaway, Atlantic Coast Territory, suggested that wa gat out a booklet - something attraotive (to bang in the kitohen), tba title to be "The Uetropolitan Kursing Service". Ha said that wa should emphasise to polioyholders that they are paying for tba nursing servioe and that they are entitled to it. Es believed that this might make the polioyholders use tbs nursing servioe for people always want to gat tbs things for which they pay- Ur. Wilkes, Vioe-President, spoke of the mortality of each terr itory and each Stats in the Union. Ha believed a knowledge of this would appeal to the agent. He also agreed with Ur. Bradley in referenoe to the nursing servioe being oredlted to the district. '' Ur. 8mitbiest northwestern Territory, spoke in appreciation of Ulss Atobison's splendid work. He felt that the Debit Hurse should be con tinued and said that be believed it also was one of the most important oon*. trlbutlons that bad been made. He emphasised the importaaoe of the General Supervisor being given the proper assistance. Ur. Wright, Xeystone Territory, said he was at a loss to under stand why it was neoessary to urge the agents to , emphasise the value of the nursing servioe and spoke in highest terms of the Welfare Work In general. He was particularly interested in the yearly olassifioation of deaths and reduetion of death rate. Ur. Lawrence, Southern Territory, spoke of the value of the Debit Hurse and of the nursing servioe in general. He mentioned that there had been a turnover of 40< of agents in the Southern Territory in the past year, whioh brought to his mind the Importaaoe of oonstaat agitation in order to keep the new agents educated. Ur. Williams, Paoifio Coast Territory, emphasised the value of the Debit Hurse end spoke of hie appreoiation of the nursing serwl.be in general. Ur. Du Tlon, Uiddla West Territory, sgreed with Ur. lawrenoe that the turnover of agents mads agitation a most important faotor in keeping the new agents iutsrsstsd end giving them a knowledge of the nursing servioe. He was particularly daairous to keap in touoh with the number of oalls, saying he felt that we should have "more oalls and better ealla*. He felt this responsibility was the manager's in the earns way as the responsibility of produotlon Is the manager's. He stated that several managers had testified that Kiss Johnson's instruction to the new agents was invaluable. He also emphasised the great value of the Debit Burse. Ur. Hlnger, Southwestern Territory, spoke very highly of the nurs ing service and referred to the nurse who gave him his first instruction In this servioe, saying that he felt all hie euoeess in business was due to J - 8- that nurse. H* fait th# Dibit Sura* and har a*rrlo*a vara invaluable. Ur. Horth., Canada, emphasized that nursing service should not ha a naans of getting huslnass, that It should ha dlvoroad fron th* meroenery Idea. Ha fait that aaoh nan should ha willing to ssrra tha polioyholdars In soaa othar way than fron a huslnass point of rlav. Ur. Sorth, Cantral Territory, fait that education not only of tha polioyholdar hut of tha agent was most lnportant and ha said ha heartily agreed with Ur. Trethewey in his suggestion of getting out a booklet to supplement tha work of the Debit Hurso, for tha aduoation of the polioyholdars. Ha fait tha small folder "Your Iriand tha Hursa" is not adequate. Dr. Prankal, in closing the Basting, explained that tha work is being systematized so that the Superintendents of Agenoias will have definite information. He also spoka of tha problem of Group Hursing, stating that ho fait wa must oonsldor this from an entirely different angle. Ha expressed his appraoiatlon to tha Superintendent of Agenoias for thoir kindness in giving their tlmo and stated ha felt this was tha hast meeting we had avar had in rafarenos to tha nursing serrioe. Wednesday, January 30th, A. U. Plaoe of Heating: Direotors' Hoorn. Present: General Supervisors, Dr. Armstrong, Dr. Shepard, Dr. Dublin. Chairman: Hrs. La Kalla. Purpose of Heating: To dlsouss Kanual rulings and polloies governing th* Hursing Barrio*. HOTSt Dlsousslon of above topies was postponed until Tabruary 4th. *Tha Uses of Cc--""<ty Data.* - Dr. Dublin. Dr. Dublin brought to th* attention of tha Supervisors that it was possible for them to have the information they desire in referenoe to towns and oltias in their territories, and fait that they should not only waloom* such information but Should make th* best us* of it. H* asked for raooanendations as to th* improvement of Card 67 and ha requested that tha Supervisors carry on a oorrespon&ano* with th* Statistical Bureau in rafarano* to any help they needed pertaining -to the information oontalnod on thoao oards. Ha oallad their attention to th# Statlatloal Bulletin published -V's -9- monthly, whloh gives a picture of the oondltion of th* oountry whloh oan ha used as a background of oondltions in aaoh tarritory. Ha apoka of tha plan of tha Hatropolitan life Znsuranoa Company to cooparata with tha Anarloan Publio Health Aaaoolatton and tha Baited Statas Chamber of Commons in a plan whloh takas tha fora of a oompstitlon for tha purposo of helping oomaunitios to raisa thair haalth standards. Aooording to this plan, tha sarrloas of tha Amsrioan Puhlio Haalth Association in studying Haalth Departments will ha offered to haalth offioars of certain oitlas. At tha and of tha year, the oomaonitles whloh hare gone into this oompstitlon will ha giren an opportunity to show thair aooompliofc- ments and a prize will ha offered to that oity which indioatas that it has made tha bast effort to lmpnra haalth standards. It is expeoted that 40 to 50 oltias will respond to this offer and enter tha oompstitlon, thus bringing publio spirited oitizens, haalth offioars, nursing representatives, and Board members into this plan. -- Dr. Dublin emphasised tha opportunity our General Supervisors have to assist people and haalth offioars pooi-liy to sss tha value of this offer by passing this word along. HOTSs Tha Statistical Bureau will sand a list of tha oitlas and outline of plan to tha Supervisors as soon as it is in readiness. Monday, Tobruary 4th, A.M. and P.M. Flaoa of Moatingt Directors' loom. Presentt General Supervisors, Chairmans Mrs. La Malle. Purpose of Meetings So disouss Manual rulings and poliolee governing the Marslng Service. HOTls Continuation of meeting of Ian. 80th, A.M. Osteopaths. Questions Is the Manual ruling in re Osteopaths satisfactory, or should we oensider giving oars to policyholders under ears of Osteo paths (not M.D.) in those States where they are lloensed to praotioef She question was dtsoussed by General Supervisors, Dr. Armstrong, Dr. Shepard, and. Dr. Dublin. Deoislons HOTS: That the rule remain as is for the present. A letter with more detailed information was sent to eaoh General Supervisor under date of Maroh 22, 1929; Individual cun Living a problem that haa to do with Osteo paths to ha referred to tho Homo Offloo for dooislon. Visits to Mothers' Clubs. Question! Should visits to Mothers1 Clubs bo paid for? Deoisioni Dr. Trankel's dooislon at th* present time is not to pay for visits to Mothers' Clubs booauso ho fools that tho sorvioos rendered do not oorrespond to those that a nurse gives in tho home or the oare a Bother gets at a ollnle. However, a dooislon may bo based on the oonduet of the Mothers' Club. Dr. Jrankel said: *If you are going to do this, asoertain what is done at these olubs. Do they find out if the patient is in charge of a physician? Do they get in touoh with the physiolan7 All of this hinges around the doctor. If you are going to make studies, find out what the dootor says, what the local medical sooiety says, does the patient get medical oare? Without exam ination you sure not getting very far. This is the important thing If we are going to out down albuainariaa cases. HOTSt Supervisors are to make a study of organizations which hold pre-natal olassee to determine, 1. Adequaoy of oare given. 8. Polloy of Mothers' Clubs. Sewborn Son-Insured Baby gsrvioe. Question! In sueh post-natal oases where it is neoessaiy to give addi tional visits to the mother, is the nurse privileged to give additional oare to the baby? HOTSi Miss King to asks a study of the low post-natal visits in Metropolitan Territory. Why are we running a low nuaber of visits in one- tenth of our service and the other nine-tenths are relatively high? Dooislon deferred until after Kiss Xing's study. Iraoturs Cases. Question! Is Manuel, ruling in re fraoture oases satisfactory? Deoisionx Tes. Hunes should use good judgment in referenoe to this aatter and not be so tied down by ruling that oare is refused in those oases where it should be given. - 11 Poliomyelitis ind Oatsomyalitis Cases. Question: Is tbs Manual ruling in rs poliomyelitis and osteomyelitis oases satisfactory? Decision: Tbs Manual ruling is O.r. but tbe Supervisors should, know the facilities of each oommunity for suob care, and should, oonsider that it is our business to try and get these children well. That a committee be formed to get definite information in re care to poliomyelitis and osteomyelitis oases and that our riling in reference to the oars of these patients be based upon the findings of this oommittee of which 11 was suggested Dr. Armstrong be Chairman. Prsnatal-not-at-Home Visits. Question: What should be the policy in regard to paying for not-at-home prenatal visits? Deoisiont It was agreed, in so far as possible, to disoourage not-athome prenatal visits. The first and seoond visits will be honored but Supervisors should take up this matter with the organisations, explaining to them that wo do not feel we should be oharged for not-at-home visits. NOTE: Dr. Jrankel feels that tha nurse who falls to find a patient at home, should leave word at the home as to the time of her seoond visit. Assoolatlons will find a solution to this problem if we do not sanotion payment for extra visits to not-at-home polloyholders. Tee Basis Nurses. Question: Should a nurse engaged on a fee bafls be given the same fee paid to Assoolatlons within that looality? Deoisiont That eaoh ease be studied individually sad that Supervisor sub mit her rSoossiendation based on looality, area oovered, eto. NOTE! Dr. Trankel feels that suoh nurses should be eliminated wherever possible. 8atisfaotor7 nurses should be plaoed on some other basis than' feet the resignations of unsatisfactory nurses should be considered. ''-v .";' :V ' - -- ;:^T-"*f'->''- s " ' * *^:v'. _ -V ' '-*'- - 18 - U.Kfi `V - r, W u, ' < J < fr< Payment for Tm per Visit utmi. Question: Shall we change our plan and reimburse nurses for Tlsits at the termination of tv ^ oase? Deolslon: Saoh SuperTlsor is to make a study of this question among the fee per visit basis nurses in her territory and submit her resomaendatloa to the Some Offioe. Automobile Adranoe and Upkeep. Question: Is the present automobile advance sufflelent? Supervisors agresd that the amount of automobile advanoe be reatrlcted to $250. NOTE: Before ooming to a decision, a study will be made to determine the average number of visits made per day by nurses, eto. Eduoatlon of Agents re Nursing Service. Question: Should the Premium Receipt Book be used for the distribution of information pertaining to the Nursing Servloe? Would it be more advisable to adopt a stloker for use on . P.B.Bs. ooataining the information: CALL THB DOOTOE AND IBB SUBS1 - Telephone # Should we supply saoh Deoentralised Offioe with a rubber stamp oontalnlng this 'information? Deolslon: The Supervisors were requested to make a study of this question and.to submit a definite reoonmendatlon in referenoe to it to the Borne Offioe. - NOTB: It is important that Supervisors do not deoide on the use of stlokers or rubber stamp without consulting with Borne Offioe. Looal Supervision. Question: Bov many staff nurses oan a Looal Supervisor supervise efficiently? Should Looal Supervisor supervise nurses within a oertaln radius of her own staff? Deolslon: A Looal Supervisor should be able to supervise the nurses within a oertaln radius.of her looal center. This is partlouldrly true where the staff is limited to 8, 4, or 6 nurses. NOTE: A Looal Supervisor should be able to systematise her work so that .r.i..1-/?,>" ", 18 - he Is able to go out within SO ailea of her territory to supervise other nurses, the Senior Nurse to be left in ohmrge of the staff, which position will enoourage her and arouse her Interest in seeking prcnotlon. Monthly Report Tons for Dooentralised Offloe. A fora to be arranged by Home Offloe and tried for a period of one year after whloh tine its efflolenoy oan be determined. Demonstration Visits to Maternity Cases Delivered in Hospitals. Questiont Should these visits be continued? Deoiaiont Demonstration visits have a value and should be eontinued. Praotioe Centers. Dr. Tranks! felt that in prinoiple we should aim to get well trained nurses and not have the problem of training nurses. Me definite decision was reaohed as to the establishment of Praotioe Centers. NOTBt Dr. Traakel felt that a nurse going into the district for a definite period of time in oharge of a looal Supervisor would profit by this and should be able to go Into a dlstriot and oarry on in the same manner as the nurse who has been under the looal supervision. He felt also that we should not think in terms of development of large Praotioe Centers, Staff Conferences for Hurses in Outlying Dlstriots, Question! Should a nurse who has had experience in a Praotioe Center be assigned to hold staff meetings with looal nurses? Deolsiom Tee, this is an exoellent plan and should be oarrled out. Publlo gsalth Course loholarshlp Tom. She following ohange was made in this font Berrios Bating was omitted. SOTS: Muoh controversy arose over the professional rating of 80jf but the final vote was to leave the professional rating of BOf to stand. : ?^:;i.^:.v;^i:^^ .- -ir^ y::>14 *- -r^rp^^<f^i(i&p0^. Pliability daring Absonoo at Sohcol or Praotloa Center, It iraa the consensus of opinion that doduotlon of the premium for disability lniurano* should be mad* from ths nurss's last salary check btfors leaving for oourss. This *111 bs taksn up with saoh nurss at time of applying for soholarshlp. Hew 8alary 8ohsduls. Supervisors ir oonfsrsnoa outlinsd a ns* salary sohedule whioh has basn aoosptsd by Pr. Trankel. NOTE: Saoh Supervisor has boon supplied vlth a oopy of the sohedule. Baoh Supervisor is requested to past* the no* sohedule in Job Analysis. Plan for Circularizing District Offloe Aoooqnt Policyholders. Supervisors should study the Pistriot Offloe Aooount and males plans to rsaoh and oduoate all polloyholders to a knowledge and oorreot us* of the Pursing Serrlo*. Disability for Debit Burses and Advisory Purses, question: Should Debit Burses and Advisory Burses be given Disability Insuranoe? Deolslont If employed for a year, they should have Disability Insuranoe. Duties of the Advisory furs*. 1. Xduoat* the Agent. t. Oontaot with Visiting Burs* Association. 9. Tind out what Polloyholders want. - 16 - ^Establishment of Honing Strrioa. Question! Sow are w* to moot the demands of Managers for nursing ssrrloe in debit* and* up of less than 4000 polloies? Seolsiont Or. Prankel said that aa a rula ssrrioe ahould not ba aatabliahad but oartain azoaptiona may make it adTiaabla to do so, auoh aa Group. Tha plaoa in question being tha oapitol of tha Stata. A pronounced high morbidity or high mortality among our polioyholdara. HOTS! It nay ba wiaa to aatabliah auoh a aarrloa aran for exper imental purposes. A oommunity with a high maternity aarrloa. A oommunity where wa are trying to out down a high Infant mortality. HOTSt Or. yranJeal said that ha was particularly interested in knowing tha result of aarrloa in small communities both from tha point of rlaw of oost and tha amount of bedside nursing, and that auoh Information oould ba obtained only aa a result of special study. Ea stated that tha small oommunity is one of tha moat difficult problems of eontrol wa here. Question! How ahall wa prorida nursing serrioe to polioyholders living Just outside tha oity limits in those plaoss where the organ isation refuses to giro suoh ssrrios?, . Ssoisiom Sr. Pranksl said that the first thing to do is to sss if wa oan make aa adjustment with the V. H. A., unless there are soma spsoifio reasons why they oaanot go beyond. A slight increase in fee night be neoesaary. ... Pro-Tided tha number of polioyholdara living outside tha boundary runs ap to 10 or lBjf of our polioyholders, ws ought rery definite ly to ooasldor the establishment of our own nurses. A oaraful analysis of the situation should bo made in order to determine what our attitude in reference to establishing nursing sarvloe should bo. SOTl! If Supervisor oanaot make suoh an analysis, It Should bs dona in the Soma Offiss. The following polioies out up for diaouselon and it was dsoided that they remain aa outlinad In our Manual t Pre-natal Cara. Post-partum oara. Post-partum oara to Midwife Caaaa. Cara to Inaurad Bahiaa. Cara to Inaurad Slok Bahiaa. Inaurad Bahiaa - Talfara Viaita. HOTS: Heeding oaaaa ahould ha liatad on Torn V.3. 92 and H.8. 6-V, and not on Torn 5.3. 6 aa a aiok oaaa. Hourly Sarrioa. Attendance at Oparationa. Inaulin. Patianta raporting at auh-atationa. Infant Valfara and Tuharouloala Caaaa. Clinio Sarrioa, Delivery Samoa, Walfara Viaita. Hathod of auhnitting rocorda whan patianta ara inaurad in both tha Metropolitan and John Hanoook.' Cara to Chronioa. Crediting Calla By Piatriot. Deoiaioni Baoh diatriot to ha oraditad with ita own oalla in all plaoaa haring nora than on# Managar. Baoh Managar to ha furnlahad with a report of his particular diatriot, and aaoh Superintendent oif Aganolaa to ha furnlahad with reports of all distrlots in his territory. Hone Office will prepare tha 1928 report for this work hut eaoh Supervisor is requested to take oare of aiailar work for the year 1929. Supervisors are requested to instruot the Visiting Burse Associa tions in raferenoe to this natter to gat their oooperatlon in keeping the records aooording to this plan. HOTS i Kiss Ahern and Miss Baglay ware requested to suhalt aa outline of tha method followed in their offloes in reviewing reoords. Prlnoipal Aapaota of Industrial Hurling. - Pr. luu. Dr. Lanza in hit talk on Group Pursing eaphasizod the isportanoe of all who had to do with our Hurting Sonrloo (organizations, salarlod nuraae, oto.) realizing the magnlfioent opportunities presented by Group Huralng. Ha fait that at tha prasant tima tha Group wara not availing thaaaalvaa of tha zarrloa and wara they to avail thesselves of our nursing sarvlos) that wa ars not praparad to glva than tha sarvioa wa hava pronlsad. Raglonal Confaranoas. It was suggastad that raglonal conferenoes, bringing raprasantatlvas of organizations together to diseuss tha question of Group nursing, bo held In a few large oitlas. Ho definite daoislon was given In ra this natter. Satisfaotory and TJnaatlafaotory Visits, Tha question cane up as to what constitutes a Satisfaotory* and what oonstltutas an Unsatisfaotory* visit. Tha oonsensus of opinion was that tha only visit that Is truly unsatisfactory is tha one where tha patient has not bean found due to a wrong address. It was deoidod to appoint a oomittee to oonsldar tha drafting of rules for guldanoe In Group Hursing, and for re-drafting oertain other rulings in tha ltenual pertaining to Group turning. Tha Comitteei Sr. Lanza, Chairman Mrs. Sa Halle Hiss Baglay Sr. Shepard . Hiss Ion ' 7..: Hiss faterhuxy Kiss Kosrs Kiss Hidden Hiss teanay Hiss Stssvss Hr. Kopf Sr. Lanza bsllavsd that one seating ef this Coanittee Should bo hold in Chicago, 111. Hursts, Patients, and Pookotbooks. - Sr. Burgoss1 Study. Supervisors wished to go on rooord as endorsing tho reooaeendatlons fonulatod by Sr. Burgsss, naaolyt 1. To rsdueo and lsprove tha supply. S. To replaoo studonts with graduates. S. To holp hospitals neat eosts of graduate sarvioa. 4. To got publio support for nursing education. - 18 '*? Meeting of Pursing Supervisors* January 26, 1929. Improvement la Mortality Sr. Prankel Z do not think it ia naoaaaary to tall you that we have had rathar an intereating yaar. Z ahall not attempt to do nora thia morning than to try to bring out tha highllghta of what haa happaned during tha paat yaar in oonparlaon with tha paat yaara of tha Valfare Division. Probably tha moat lntaraating event of tha yaar, and probably tha one that plaaaad me Boat of all, la tha faot that wa hava a new Vice-Preaident in tha Valfara Division. Thoaa of you who know tha oonduot of thia lnatitution do not hava to bo told that thia promotion waa not due to influanoe or ao-oallod "pull*. Z hava navar oeen any body advanced in tha aarvloa in thia Company axoopt on aorit. It la delightful for aa today to ba abla to tall you of how plaaaad tha Praaldaat waa to ooaaidar Sootor Armstrong's promotion whan Z suggoatad it. Z ahould ilka to expound on thia vary auoh at length. Z oould do ao If Sootor Armstrong vara not praaant. Ea la an ex tremely aodeat individual, frequently hiding hla light under a buahel, and for that raaaon, all Z oan aay la that Z hava bad no experlenoe quite aa delightful aa tha yaara I hava had with Sootor Araatrong hare - with ay faithful, loyal, good.friend. Z look forward with pleaaure to tha poaalblllty that in tha future tha plana whloh ha and Z hava dlsousitd might mean only ana thing, and that la tha batter- aant of the aarvloa whloh tha Valfara Slvlalon ought to ba in a poaltlon to give. Z aa going to atart thia morning at tha w/ong and poaalbly, and tall you tha reaulta of tha work of tha Valfara Slvlalon, aa stressed la tarma of mortality. Zn tha laat analyala, what wa are doing must ba measured la tha reduotloa of tha death rata and la tha prolongation of life. Z aa doing thia not only beoauae tha Suparvlaora are hare, but baoauae It la tha flrat opportunity that tha Valfara Slvlalon itaalf haa had of hearing what haa baea eoooEpliahed. I do not hava to aay to you, aa Z have aald heretofore, that tha data whloh are given to you thia morning are glvaa to, you In oonfldanoa and are tha data whloh tha President eventually uaaa at tha rmum.i oonvantlon. Tou are In tha fortunate position of loosing it savaral days in advanoe. V# hava had a auoeaasful yaar from tha standpoint of mortallty. Z as going to road you aoao of tho flgurea. Zt haa baaa auooaeaful In every respeot but one, naaaly, that our daath ratefor 1988 la Just a trifle .above that of 1987. da daath rata among In dustrial polloyholdtrs In 1987 was 6.4, par 1,000 and it want up to 8.6 in 1988. That la not a narked difference. Tha oauaae of it ara vary plain indeed. Zt is due primarily to tha influansa.apldanlo in tha early part of 1928 and tha latter part of 1928, whioh only bo-1 gan to refleet Itaalf, I may aay, at tha and of tho yaar aa far as our mortality waa oonoerned, owing to tho faot that frequently our death I < - 19 - olalma 4re not pall until a week or tan day* or even two weeks after death oooura. Many of tha deaths in 1926 probably vara raoordad in 1929. Tor that reason, 1 an aomawhat doubtful aa to whether our 1929 mortality at tha and of tha yaar will ba any battar than our 1928 mortality. Aaida from that ona factor of tha alight inoraaaa in tha ganeral daath rata, Z think we ara aufa to aay that our raoord for tha year la rather good. Viewing our mortality over a period of yeara, aa we hare been doing right along, and Tiering our atatiatioe from 1911 to 1928, 1911 being tha first year for whioh we hare any aecurate etatiatioal raoord, tha reaulta, of oouraa, are oontinuingly gratifying. Tha decline in our mortality einoe 1911 haa been S1.2jtf. If we look at it from the atandpoint of dollars and oenta, wa paid out Juat ahort of $50,000,000 in 1928 for Industrial daath olalma, and if tha mortal ity of 1911 had prevailed, wa would hare paid out $22,000,000 mors, $22,000,000 you will note, ia about half of what wa actually paid out. Of oouraa, we are always interested to know what that means with raapaot to the population mortality. Katurally, we oan make no olala for anything for whioh we are not responsible. There haa been a marked improvement ia the population mortality aa well aa la the Company mortality. Taking the whole period of years, from 1911 down through 1927, our mortality deollna was SSjtf and in tha general popula tion it was only 16jf. The Government atatistiea for 1928 are not available. Va do not, aa a rule, gat these figures until wall into 1929. I think it is rather aa interesting oommentary on the situation that praotloally within fifteen days after tha olose of tha year, the Statistical Department is able to fdraieh us with a oomplete raoord of our mortality statistics, whereas it will taka the United States Gov ernment almost nine months to aooomplleh what wc are able to do, aa I say, within the first fifteen days of the year. Ve have no government statistics, of oourse, for 1988, therefore tha last oomparabla data ara for 1927. --- Vow what wa may take oredit for is the difference . between S5rf and 16<. I have said this repeatedly for years. Ve have no way of explaining this narked improvement in our mortality over the population mortality other than by the assumption, whioh Z think is quite a j notifiable assumption, that it la due to the aooompllshments . of the Velfare Division, whioh ara having seme effeot on the general population and, of oourse, ara effecting an improvement in our mortal ity. That this means is that there has been a soring ia 1927 - just for the year, remember - of ever 88,000 lives. X am pausing for a moment beoaase X want that to sink inj " X want you to realise just what this mesas. Those of you who are mathematicians oan figure out how many lives we are saving evezy day, by dividing this number by 860. Zt means that about 100 lives a day were saved in 1927 alone. If you want to look at It from the standpoint of saving, it means that ia one year we saved over $11,000,000 in daath olalma. Tha oumulatlve saving for Metropolitan Industrial polioyholdara over the whole period, 1911 to 1987, is roughly 815,000 lives. Tha saving in mortality over and above tha population mortality is $75,000,000. That la a wary ueeful and handy number. Tou can a imply say that what this really means is a saving of #75,000,000, and at the rat at which wo are going I think it is only a question of time whan you ladios will be able to go into ths fisld and say *a sort hagatalls of 100,000,000*. There is anothsr very interesting way of putting it. You oust remember that our mortality in 1911 was worse than ths population's mortality. What has happsnsd is that our daoraass has oome down so that today ths dsathratss for ths Company and for ths oountryat-large ars almost ths sans. Ts praotloally have passed ths dsath rats of ths population at various ysars. How has our sxpsotation of Ilfs oh&ngod with rsspsot to ths populatlon-at-larga? Both of thorn havs improvod - ours mors than ths population's. Ths sxpsotation of lifs of Metropolitan polioyholdsrs has lnorsasod 9.79 ysars. Just a ~little hit mors and ws would havs bssn ahls to say ths sxpsotation had bssn lnorsassd by tsn ysars. It would havs boon so much nioer. In ths population thsrs was a gala of only 6.06 ysars. Bo not misunderstand that. It doss not msan that our dsath rats is bettor, but bsoauss our dsath rats was so muoh worse in 1911, it means that our sxpsotation of Ilfs has lnorsassd by almost tsn years, whorsas in ths general population it has only lnorsassd a little over six ysars. In 1911 ths dsath rats among our insured was 2if higher than among ths gsneral population. In 1909, of oourse, it was even worse. At ths present moment our death rate is aotually lower than in the general population. It is rather interesting, to study this from the standpoint of disease beoause, after all, our work has been ooneentrated along certain definite lines. We made no effort whatever orer a period of twenty ysars to do anything oonstruotive along ths line of canoer. Ws havs not bsoauss there is nothing to do except to havs general oampalgns of eduoation for early diagnosis.^Jurther than that, there in vez7 little whioh oan be aooomplishsd. J We bars not gone into the field of heart disease to any extent. Ws havs not at tempted to go Ipto the field of venereal disease, bsoauss vs thought that was a subjeot for others to undertake. What is of real laportanoe is to determine to what extent our work has been refleoted in our mortality. How far have our campaigns of personal hygiene among polibyhblders and the work that we have done in oonneotlon with publio health been refleoted in the improvement in our mortality? That is shown most olearly. It is frequently amusing as I read these figures for the year. When you oome to the speoifio diseases, you will find that in typhoid fever there is a reduotlon in mortality in this period of just short of 80j. Typhoid fever is disappearing in the Waited States. There ought to be none, and while our rate is extremely low, I still feel that from time to time we ought to be hammering away at this thing. I was thinking of the epldemio we had in Hew York State. Typhoid fever is due absolutely to Impure water or milk and we oan eradioate it completely, by our eduoational oampalgns. r f-r--s ;.'t ' -VOl* '', ,ci .- -V1 rSi*.y * *,,' 'vr^'V. 21 - Talc* th* campaign we ar* oariying on againat ooamunioable dlaa**a of ohildren. I do not want to talc* too auoh oredlt for that. I do not think w* haw* known a trmndou* lot about measles, although w* bar* oarrled on a oaapaign. 21* *am* iu true about whooping oough. But w* do know about diphtheria and from thi* atatomont that I hop* you will all r*adt you will * that w* bar* really aooompllshed something. In oano*r, our lnoreas* has b**n llg, whil* th* population lnoreas* is 28g. It is at least tan years sinoe we first started oiroularisation reoommending early examination. This may possibly have influenoed th* faot that our lnoreas* is so muoh loss than that of th* general population. You will b* particularly interested in the diseases in connec tion with ohild-bearing. If th* nursing servlo* has meant anything, it ought to haw* been evidenoed in connection with these diseases. Considering the whole period, from 1911 to 1927, we show a deorease of 20.7g in all diseases, as oompared with 10.9g in the population. In puerperal septloemla, however, our deorease was only 27 si, oompared with th* population deofreas* of 31.2g. I think it is safe to say that septloemla is something orer whloh w* hare very little oontrol. On th* other hand, in albuminuria, our reduotlon has been 31.9g, as oompared with th* reduotlon in the general population of 0.4g. Do you appreolat* what that means? Shis, nor* than anything else, shows the effeot of th* prenatal oar* our polloyholders : . oeive through th* nursing serrlo*. - Our reduotlon in mortality from aooldents has been 17.4g, as oompared with 8g in th* general population. "first Aid" was on* of our first booklets and has always been on* of th* most popular. V* can see its *ffoots in this greater reduotlon in our mortality from aooldents as oompared with that of th* general population. In auto mobile aooldents alone, there is an lnoreas* of 713g. Th* lnoreas* in the population has been eren nor* - 790g. You will see that auto mobiles ar* beoomlng on* of th* most important oauses of death. Quit* a number of oltles ar* now going to show marked improvement in the death rates from automobiles as a result of new trafflo laws and safety oampaigns. I wish eaoh on* of you would get a oopy of this memorandum whloh Sootor Dublin has prepared and study it oarefully. It is an extremely valuable dooument for you ladles to have In the field. I have asked Dootor Dublin to prepare son* supplementary data for me, to show how our mortality for th* year 1927 oompared with the year 1920 and how it oompared with the population improve ment for th* same years. When I reoelved this, I found that w* had not been sitting as pretty as I thought w* were. As a matter of faot, what really happened was that our improvement for those two years was 4.9g, whereas the population improvement was 8.1g| in other words, the improvement in the general population was better than ours. That worried me. I then analysed the figures even more oarefully, and learned that there is nothing to worry about in a .2g difference. y , s.- - 22 - Ixpendltures Of eourae there art sob* things that w# ar* sot raspossl'bl* for and for whioh t* oaaaot b* hold aooouatabl*. Take th* things for whloh w* ars aooountabl*. In th* dis*as*s of childhood, our Improvement was 23.9jtf as ooaparad with 23.2 is th* g*n*ral popu lation. Last year was a diphtheria y*ar all over tha United States, so both our mortality and that of th* Oovernaent war* sffeotad by it. Our rata inoraasad 7.4i, and th* Oovernmsnt rats inoraaaad 6.6rf. in influenza and pnauaonla, w* show almost ldantioal gains with th* Government. Setting down to th* diseasas of ohild-bearing, and this is extremely significant, w* had an inoraase of 6.7j{ in puerperal sssptloemia. Thera was no ohaag* in th* Government statistics. In albuminuria, notwithstanding th* whol* yaar was worse for us than ~ for the general population, our deoress* was ll.ljf as compared with the population deoraas* of 7.9^. When I saw those figures, X no longer worried about the rest. In other words, where we are doing something, we are showing good results, even in bad years. from all the statistics whloh w* have baan able to gather from every part of tha United States, tha influenza apidemlo seams to b* altogether on th* wan*. It has passed Its paak completely on the Paolflo Coast. In 1918 we had a mild apidemlo in September, and there was a reourreno* in Seoeaber whloh ran into January of 1919. We ars now at the end of January and ther* has baen no reourrenoe, I am hopeful, therefore, that w* ar* going through this year without a devastating apidemlo. What has all this meant to us during th* year with reepeot to expenditures? Z am taking up now tha finanolal aspeots of this whol* situation. W* oom* now to this one sheet that amases me and pussies a* beoaus* Z do not understand anything about figures. Tou sa* what has happened. I do not know whether you all have these sheets in front of you,'but I am not goitre to. spend muoh tin* on this partioular eubjeot. Th* interesting thing is that we spent *14,000 in 1909 and w* spent 18,476,963.92 in 1928. Vow that is an amaslng lot of money, hooter Armstrong oalled ay attention th* other day to the fact that this was 2$ or 8 times as large as th* budgets of all th* national health orgaaizationa, inoluding th* national Health Counoil, Vational Tuberoulosls Assooiation, Amerioaa Public Health Assooiation, and th* American Heart Asaooiation. How if that is the oase, w* ought to be accomplishing something. Th* disbursements of th* Welfare Division for th* entire period were over *37,000,000. As X have frequently said at conven tions, don't let's bother about this beoaus*, after all, what la *37,000,000 among friend*? It doea not mean anything. I am more interested in the distribution of it and I want to say now, that on* of th* things Z am going to stress at this oonvention is th* problem of finaao* and the problem of a eyatem of aooounting that will give us information. Ws hava not oonoernsd ourselves partloularly about this oni of it, other than to epend money. We have been fortunate enough to be able to get it without any partioular oomment or oritioism from our superior*; but when w* begin to spend *3,400,000, - 83 - then Z think we have to ait up and taka notloe and aaa whether we are (pending it wisely, whether we are spending it eoonomloally. One of the things I should liks to do this year is to make sure that we are spending it wisely and that we know how we are spending it, and while Z appraolate, of course, that none of you desire to talk flnanoes or the details of it, nevertheless Z am going to spend just enough time during the oonvention to try to bring home to you the necessity of uniformity in your aooounts, particularly now that we are getting decentralized offioes, and by reason of the faot that what we are going to have in the near future is not one offioe, but fourteen. We have absolutely separated the Paolfio Coast and Canada. There are certain things, of course, which oannot be done in decentralized offioes, but just as far as it is possible, Z want to transfer the finanoial end of our work into the deoentralized offioes. That means we shall have to be able to cheok up the expenditures made by you ladles and the gentlemen here, who are administrators of separate municipalities, or oall them.what you please. They are administered under your direction, but we here in the Home Offioe have to know eventually whether the .work that you are doing compares with the work that is being done in another terri tory. Therefore, without attempting to oomment, Z am simply asking a question here when Z want to oall your attention to certain things that strike me immediately as I read this sheet. Z am referring to one that is called 7inanolai Statement 1088 for General Welfare, oompared with 1987. This is for the y ","" entire Welfare Division and has no speolflo reference to nursing. Remember what you are going to do in the distrlot offioes and deoen tralized offioes. Bventually I hope to be able to transfer to you not merely the aotlvitles, but likewise the finanoial control. . . --XS , I want Mr. Burnette and Dootor Shepard particularly to note these. I have an item here bn salaries.Xsee lnl928 the Pacific Coast is being oharged with over $13,000 for salaries and the same i item la the Canadian Head Offioe is only |5,100, Praatty, Z think there is something wrong with our system of aooounting. lor that reason, I shall not go into it more oarefully. We have to7 set up some fora of aooounting that will be uniform for everybody, Home Offioe, Head Offioes, and deoentralized offioes. I am hoping that we can distribute our expenditures for every bureau and for every deoentralized and head offioe so that at the end of eaoh month and not at the end of eaoh year, we oaa say "these are the faots", so that we ean make monthly comparisons as to the work that is being done and the expenditure that is being Involved. Ur. Burnette probably is allotting items differently from the way we in the Homs Offioe are doing. Z do not went to go into this too muoh in detail. He ean dlsouss this later with Dootor Armstrong. But Z want the ladies to understand. - I went to know, for example why on the Paolflo Coast Head Office $1,800 was spent last year.for campaigns and in Canada nothing at all. I find an express item - one of the things for whioh Z have - 24 - 'bean jumping on our Homo Offloe for the last alx months. Our ex press aooount went up this year, I think, $25,000. In the Paolflo Coast Bead Offloe, express Items were $4,400j In Canada, $2,400, Juet half that of the Paolflo Coast. The postage aooount was $600 on the Paolflo Coast and $211 in Canada, What Is the postage aooount In the deoentrallzed offices? Te ought to he In a position at the end of eaoh month to know exactly what is being spent for these various items. Our postage aooount was $4200 in the Home Offloe. Our travel aooount was $7500. I am not quite sure whether that inoludes travel ing expenses of the decentralized offloes or not. .This is as com pared with $2,055 on the Paolflo Coast and $2,700 in Canada. Bow you see how odd this seems, when it appears that the Canadian head Offloe, according to these figures, has a travel aooount only one third as - large as the Home Offloe. Bow I am sure this Is lnoorreot; in other words, we are not charging theee items up uniformly, later on when you come to analyze these figures as X have done, you will find that some of these oharges have been put under the nursing traveling expenses in the one territory and not in another. One of the things I am hoping you will do when you are in oonferenoe here, is that you will take up this problem of a re porting form. It is one of the things we should start the first of January or, in faot, the first of December as far as nursing is oonoemed. This applies to the head offices as well as to the deoen trallzed offloss. The sheet showing the summary of our expenditures is ex tremely interesting. As Z have said to you heretofore, we have never worked under any definite budget, but I have always Imown what the President had in mind* and I have tried to keep ourselves within a fixed limit. Last year, 1927, our disbursements were 1.82g of the premium inoome, and it is interesting to note that for the year 1928 the ratio is exaotly the same as in 1927 - 1.82g. In that 1.8g are lnoluded oertain items whloh, in the polioy of the Company, are oharged against the so-oalled 'general welfare*. Tor instanoe, the expenses in oonneotlon with radio broadoastlng, while we are not responsible for them, are oharged against us. There are a number of other items of this kind whloh are lnoluded. Then we deduot these, we get the net disbursements of the Welfare Division. These were 1.61g of the presd.ua inoome in 1927 and 1.62g in 1928. Running over a period of years, our disbursements are a little more than 1.5g of the premium inoome. Text year I want these figures for every decentralized offloe. I am hoping that our aooounts oan be so kept that we oan di vide them up and show comparisons of disbursements in preolsely the same way as we are now showing it for the nursing. Bvexy item of ex penditure ought to be oharged against eaoh territory. I think our aooounts are now reaohing the stage where we oan oharge even litera ture distribution by territory. In the Home Offloe aooount, exoluding those items for whloh we are not responsible, the disbursements amounted to 1.56g of the premium income. In the Paolflo Coast Bead Offloe account, they amounted to 2.09g, and In the Canadian Bead Offloe aooount, to 2.11g. - 25 Sub-dividing these amounts, we find that the disbursements under nursing In tha Home Offioe account aaounted to l.SPjfj in tha Paolfio Coaat Head Office, l.fijtff and in tha Canadian Head Offioe, l.S3<, I hare triad to determine Thy tha coat of nuralng in Canada should be higher than on the Paolfio Coast or hare. Tha average ooat par visit in Canada la still lover than in the United States. Tor that reason, these are the things that wa must study very oalmly in order to find out Thy these averages differ so markedly. There is a difference betveen 1.2<f in tha Homa Offioe and 1.83 in Canada. Thera arc a number of things of that kind shown in this statemant. Under General Welfare, for instanoe, $85,000 was spent on the Paolfio Coast, and only $54,000 in Canada. These are tha kinds of variations that we have not in the past considered baoause I felt the thing we ought to do first of all was to get our work standardised. Hew that we have our Tork standardized to a certain extant, it is necessary to get down to these refinements of our work. Z hope you will gat ooplas of these sheets and study them. 1 am thinking of you in terms of administrators. I think last year Z called you "presidents". As administrators, you must know not merely what you are doing, but what the other administrators are doing,, and make comparisons. I wish we eould get these statements out monthly Instead of annually. Zt would help tremendously in de termining There we stand. Other items I should like to eall your attention to are the various surveys whioh the Company has undertaken: the burial survey, oomrnon oold investigation, diphtheria oampaign, influenza investigation, study of munioipal health department praotioe, eto. We have made a study of latent tuberculosis among sohool children in Philadelphia, in oooperation with the Henry Phipps In stitute under Dootor Opie. This is not mentioned in our Annual Report, baoause there has not been enough progress made. Dootor Opie is having examinations made of sohool ohlldren who presumably are perfeotly well, and through a epeoial method whioh they are developing they are enabled to asoertain naoent tuberoulosia long before it oould be dlsoovered by any other method now in existenoe. He hopee that as a result of finding tuberculosis ohlldren in this very naoent stage, by proper oare and by proper diet and treatment, he is going to prevent a large number of these ohlldren from getting motive tuberoulosia. We are making a study la Hlssourl of tha problem of silloosls among miners, in oonneotion with the United States Bureau of Hines. There is considerable research work being oonduoted at. Hount HoOregor in oonneotion with the Calmette aerum. I received the other day from Dootor Baudouln a statement of what they are doing in Hontreal. We are subsidising a study here in Hew Tork being made by Dootor Park in oonneotion with the Calmette serum, whioh is being oarrled on under the most oareful control. At the present moment, we are not prepared to express an opinion one way or another. It Adventuring for Health Tield literature Bureau Is a matter for reaearoh and at the present time la a very contro versial subjeot. There are a number of physioians who olalm that the Calmette serum should not be used. However, we are interested In It and are having this experimental work on infanta done here to a limit ed extent, and on animals at Mount MoOregor. I wish to oall your attention to the Annual Report of the Welfare Division. It has been made a little more elaborate this year beoause we are oelebrating the twentieth anniversary of the Welfare Division - 1909 to 1929. This has emanated primarily from the brain of one of the smallest in our office. The smallest, however, does not mean the weakest. Little Hiss 7ox, sitting demurely baok there in the corner, has done a perfectly corking pieoe of work on this report. This Is being printed in a fairly large edition. It is called "Adventuring for Health - A Series of Expeditions in Behalf of the Metropolitan Life Insurance Company's Industrial Polloyholders Then It goes on to describe what these expeditions are and what they have accomplished. I should say here that the.Publloity Division has done a splendid job with the illustrations, whioh graphically describe in an allegorical form the various aotlvitles of the Division over a period of twenty years. I am hoping that this will be a sort of a Bibls. It will be beautifully gotten up. Our managers should use it and our agents should use it and they should show it to the type of people who are interested in our work. It is not for dis tribution to our polloyholders, but,I am qixite prepared to say that you ought to bring it to the notloe of people in the United States who make publlo opinion. I would like eaoh of you to get before you leave a oopy of the report that wo make annually to the Welfare Committee of the Company. It is a different report from this. It goes into details and is a summary of a report that is mads to the Welfare Committee monthly. It summarizes everything that we have done during the year. The report begins with nursing, and there the figures are very olear. We have had more oases and made more visits. I do not want to go too muoh into detail here beoause you oan find all this in the report. We had 649,000 oases in the Industrial Division alone, as oonpared with 564,000 last year. ,, There was an increase la our expenditures in the Wurslng Division from $3,178,000 to just short of $3,600,000. As I told you before we spent last year $5,400,000, all told. Out of that $5,400,000, almost $3,500,000 went for nursing serrloe. A large peroentage of our budget is spent for nursing. The oost of nursing in both the Oroup and Intermediate Divisions has lnoreased. I should like to give you a bird's-eye-view of all the other aotlvitles of the Welfare Division. The distribution of literature lnoreased this year. We distributed over 48,000,000 oopies as oompared with 46,000,000 oopies in 1927. This distribution was made under the most careful supervision, at least as far as the Home Offloe is oonoemed. ' The accomplishments of the Jield Literature Bureau Sooial and. Health Agencies Bureau - 27 - hare a significance for all of us, that is, their method of record keeping. This is the division that is under Hiss Hannah. It is assuming responsibility for the oorrespondence with all of our agents. I think you ladies in tho field will oome to realize what that means, as you undoubtedly hare the same experience that I do of meeting men who oome up and tell me how pleased they were with the last letter I sent them. Xren the Superintendents of Agenoiea admit it creates a splendid esprit de corps. Hiss Hannah will be glad to show you the various forms that are used in her bureau. In this connection, it is interesting to note that the Printing Division uses one large requisition form for all the material a Manager may need, with the exception of that of the Welfare Division, for whioh there is a special form for re quisitions. The result is that there is an absolute record not only for each territory, but for eaoh distrlot. We know from one day to the next just what the status of the manager is with respeot to literature distribution. These records will be placed at your dis posal, and. they will be plaoed in the hands of the managers. We are trying to plaoe everything that we possibly can at the disposal of the superintendents of agenoies, and I wish you would get in touoh with Hiss Hannah and see how thoroughly this is done. At the baok of the annual report to the Welfare Committee, you will find a oomplete statement of the literature distribution by pamphlet, not only for last year, but for the entire period sinoe the pamphlet was issued. This is very useful beoause it shows whioh pamphlets are desired most by the field and whioh they are using in the largest quantity. On further going through this report, we find the Sooial and Health Agenoies Bureau, as It is now oalled, has likewise done an important pleoe of work this year. I am hoping that you will hear more on the subject of exhibits, elean-up Campaigns, and diphtheria oaapalgns. In Hew York State, where we carried on an intensive diphtheria oampaign, in oooperation with the 8tate Charities Aid Association, the diphtheria death rate outside of Hew York City has been going down continuously. Hew York City is now starting a oam paign to whioh we have given flmanoial help. Our slogan originally was aHo diphtheria by 1930*. Bootor Wynne, the Health Commissioner, has added one year and hopes to wipe diphtheria out of Hew York City by 1981. Z wish to say one word about another interesting pleoe of work that Hiss Crosby, in particular, has been oarxylng on. We are making a study of lnsuranoe in dependent families. You may remember I spoke of this last year. We have known, from studies whioh I have made, that many of the families reoelvlag oharitable support were paying large lnsuranoe premiums. Dootor Berrldge was, therefore, authorised to make a study of this whole question, and Hiss Crosby has been in oontaot with sooial agenoies throughout the oountry gathering data. We now have 111 cooperating sooial service agenoies in the United States making studies of Insurance in families under 8ohool Health Bureau their oart. Z aa hopeful, considering the splendid way In which this is being taken up by the sooial agencies, that when we hare all the data together, some definite plan can be established with respect to insurance in these homes. This problem will be one of the most impor tant presented at the Eati...al Conferenos of Social fork in San Pranoisoo next June. It is a step along a new line to make sure that we are doing the right thing and the proper thing among families who are dependent either on publio or private relief. - There are other items of interest in oonneotion with the Bureau of Sooial and Health Agenoies. You will note that they received nearly 2^,000 letters last year and sent out over 21,000. That will' give you some idea of the volume of work being oarried on. A new motion picture film is to be shown at the business meeting. The four films that we havs are in constant use. A definite record is kept showing how many people have seen these films. "Too lfany Pounds", whloh was issued only about a year ago, has been seen by nearly 800,000 people. "Hew Ways for Old", the diphtheria film, has been seen by nearly 4,000,000 people. "One Scar or Many?" which you might think would have passed into oblivion by now, has been seen by 1,500,000 people} and "forking for Bear life" has had ths largest attendance of all - 5,200,000. frankly, I believe these reoords are inacourate. 1 aa quite sure the number of people who have seen these films is double these figures. Z am rather pleased with our new film. This was likewise prepared by the Bureau of Sooial and Health Agenoies. It has a startling title, "Han against Xiorobe". I should like you ladies to help in haring this film shown la your territories. Zt is splendid from an edueatioaal point of view. Zt shows the development of the miorobe theory from its inception in the seventeenth oentury to the present time, when we have entirely wiped out so many of the plague diseases. ...... And now a word about the 8ohool. Health Bureau. Z oannot go into that with any great detail, but Z feel that last year was an ex tremely suooessful one. fe had our usual meeting with the Educa tional Advisory Group. Hiss filllamson will tell you more in detail what we have accomplished and the various studies that have been made, fe have developed one thing this year whioh Z think we oan use in the field. Tinder the ausploes of our Xduoational Advisory Oroup, we made a study of the health work done in the sohools of Xewton, Massaohusetts. Zt was a very comprehensive-study. Z have in my posses sion the first oopy of the monograph published by the Sohool Health Bureau relative to this study. This is one of a series of monographs fhioh have been Issued from time to time. This monograph goes into great detail regarding the system of medioal sohool examination aa oarried on in Xewton, ilassaohusotts. As most of you probably know, our system of medioal sohool examination leaves very muoh to be desired. The average oommunity is years behind in this phase of health work. This is true to some extent even in my native olty of Philadelphia. Montreal Health Surrey Parent Teaohera Bureau Thia monograph la to be aent to every aohool auperintendent In the United Statea; and X presume it oan be uaed Juet aa well in Canada. I shall advise the auperintendent that if he la interested in trying to get a system similar to thia, and if it requires larger funds than he has at hia disposal, or the cooperation of the women's olub, the parent-teaohers' aaaooiatlon, or the chamber of oommerce, we will send a oopy of our letter to our manager in his locality, and have him get in touch with the school superintendent to determine ways and means of developing batter aohool examinations in his city. This la really the first big oontaot we have been able to work out between our managers and the Sohool Health Bureau. I have no hesitancy in aaying that if this la done properly, in one year we ah&ll have adequate sohool health examinations in at least fifty - communities in the United States. This is something you ought to be talking about, thinking about, and eventually you ought to be co operating with managers and school superintendents in the development of this campaign. I should have mentioned one thing in passing - the Survey of the Publio Health Activities of Montreal. 1 feel that each one. of our supervisors ought to have a oopy because, while It deals spe cifically, it shows a rather exhaustive study along modern lines, the types of survey and appraisal that would be made in any commun ity, and this, I think, will give you a pioture that is rather good and rather olear. There are two other things that we want to try to do this year. In Hiss Burgess' burtau we must try to effeot a better and greater oooperatlon with the women's olubs of the United States, similar agenoies la Canada, and with the parent-teaohers' associa tions. X have for years felt that we have a tremendous opportunity if we oan get oloeer to these associations. They are still in a rather disorganised form, sad yet, there Is a national Congress of Parents and Teaohers. X was Interested to asoertsin whether our people know anything about parent-teaohers associations. Proa What X myself had seen of parent-teaohers' associations, they wers rather kid glove affairs. X belonged to ono myself at the Horaoe Harm Sohool. To used to be invited to hear some worthy man talk about the problems of ohlldrsn; then we bed punch and oaka, and went home. Of oourse, It wae very nice to"meet the other nioe fathers and mothers there, but it did not aoooapllsh auoh. Therefore we mad6 a study this summer to find out whether any of our polioyhollers or agents knew anything about tho parentteaohers' associations. This study was made with Hr. Bradley's cooperation in two distriots in tho Metropolitan Territory, and to my amassment X found out that in one of theee dletriots 15jf of the polioyholdere who were parents were oonneoted with the parent-teaohera' associations. The average for the two distriots was 8j(, The same wae true of the agents. How that was an amazing thing. Ve have now reaohed the stage where it might be worth while to try this more - 20 Federation of Women's Clubs nationally. I am not oonvinoed Just how we can do It. If you have any suggestions, let ua haws than. I can think of nothing better that wa oould do than to gat our Xnduatrlal policyholders and our agents Interested in these associations. With respeot to the Federation of Women's Clubs, I am gratified to think that, if anything, the chanoes there are better then they hare been. I suggested some time ago that, rather than go on with a rather lndlsorlminate program of health, it lnolude the studies that we hare since made with them and whloh we printed. We suggest ed that it might be well, to coordinate their efforts and hare their work done under an adrisory group. As a result, they hare an advis ory group consisting of a dozen associations, inoluding the American Publio Health Association, the American Child Health Association, the United States Government (through the United States Publio Health Service), the American Sooial Hygiene Association, the national Tuber culosis Assoolation, and the Metropolitan life Insuranoe Co. Repre sentatives of these associations met here a few weeks ago. It was a very delightful meeting. The Committee is now beginning to formulate the health program for the federation of Women's Clubs and work con sistently with them, and I hope in the next six months something very definite will be developed. With respeot to the Immigrant Serrioe Bureau, the one novel thing that we are trying this year is to see whether ws can educate the immigrant polloyholder and his family, partioularly the polioyholder who does not know Zngllsh. We are trying out, first of all, an experiment in 10,000 homes. We wish to see whether it is really worth while. This is a booklet to enable the foreigner, to. teach himself, with the aid of -embers of his family who may understand a little Snglish. It is an extremely simplified method of learning Sngllsh. Hr. XIey submitted a report to me this morning, but un fortunately the book has not been out long enough for us to have any definite knowledge of its value. A special Investigator is now visiting homes in oertaln olties to find but what the result is. As far as we have gone, we are quite .enoouraged and apparently the book let oan be used in the average home of forsign-born people where the ohild or someone else knows Zngllsh and will be able to help the other members of the family. The seme method oould be applied in Canada, although the booklet might have to be ohanged somewhat. I wish you would ask your nurses to assist in trying to bring home to our polloyholders the faot that we have this Immigrant Barrios Bureau, at the disposal of the foreign-born. How muoh this means only comes home to us now and then. The ether day we had a letter from one of our large Group polioyholders and that nan was .so delighted with what had been done for one of his employees that he printed his own speolal oiroular telling about this ease and oalling attention to the Immigrant Servioe Bureau. These he distributed among his employees, and he not only wrote to me, but he wrote to the Group Division. Cost of Medloal Cars - 31 - Anothar interesting study whioh ve hers been engaged in is the study on tbs oost of msdioal care. last year ve offered to make a study of this bind for tbe National Committee on the Cost of Medical Care and we printed 100,000 calendars which we are distri buting among our policyholders. I am afraid that the result of this study Is not going to be entirely satisfactory; yet we are obliged to complete It. I cannot help feeling that the method whioh we haws used is wrong. The matter was laid before eaoh Superintendent of Agencies and he selected one agent in each district to distribute the calen dars. Due to changes in the agency staff and various other causes, we are not receiving a full return on the calendars. It is for this reason I wrote to the managers and asked their oooperatlon in contin uing this study for another six months, Ve received the most marvelous response that we have ever had to any clroular letter. 73< of the agency staff has volunteered to distribute these calendars and see that they are filled in properly. This year each man will be responsible for only ten oalsndars and in this way I think we can be certain of better results. The nurses have also volunteered to oooperate in this study, and I would ask eaoh one of you to do all in your power to see that ve get a 100^ response from the nurses. The nurse is in a par ticularly fins position to help in this study. I am very desirous that this seoond survey shall show good results and that we shall have an aoourate picture of what medical oare costs. Ny own belief is that we are on the verge of a very revolutionary obange in the praotloe of medioine and that this study la going to be most helpful in the eventual solution of the problem. The Committee on the Cost of Kedioal Cars Is a fact-finding body. They are extending their studles^to hospitals and dispensaries and are giving speolal consideration to Tthe physioian, to determine what a man must earn after his ysars of training and study and tha oost of his sstabllshment. The study being made by Dootor Burgees on the oost of nursing is bsing tlsd up with ths study on the oost of medleal oars. I hops Z have glvsn you a fairly oomprehtnslv# ploturs of ths Velfars Division. Zn regard to the Nursing Division, Z am going to touob only ths highlights and glvs you soma of ths figures. Ths totals ars vary intsrasting. Vs have had over 6,000,000 oases and havs spsnt $25,000,000. Ths average oost per visit has jumped from $.48 in 1909 until now it le $.97. 7ou wll notloe that Group nursing, as well as Zntsrmsdlats nursing, has inoreased. X do not think ws are getting ths oorrsot number of oases nursed per 1,000 polioles in any territory. Tou will see that from certain other data that Z am going to give you. Zn other words, I think injustloe is being done in osrtaln territories. Tor that reason, an aotual oomparleon among territories cannot be made. Aocording to the figures we are now using, the lowest number of .4 ,,t V a?.': >' 5` > " i r ^ t -rj: i / . \ iV*','* , * h ;,,l * ' >V^fcz? ' '* v-tVrfh;;y$ - 32 - cases nuraed par 1,000 policies la in the Middle test - 16.1. Than oooaa the Xeystone Territory with only 16.7 par 1,000. The highest la the Pacifio Coast with 40 per 1,000. The Southern oomes next with 38.7 per 1,000. As I say, I us questioning these figures. If they are true, they bring out certain vary interesting data and tha query neoessarlly arises, why are we running so much higher in one territory than in another? Taking Canada, knowing that a good deal of the work there is among the French Canadian population, their rate might ha explained in part, hut not in full. Another outstanding point is the number of maternity visits. Canada shows 59<, while the Metropolitan Territory shows only 3C<. Of course, we know why that is the oasa. I have always felt that we were giving too such time in Canada to maternity cases and not 'enough to acuto conditions. On the other hand, the average number of visits in maternity cases varies from 6.5 in the Metropolitan Territory to 9.3 in Canada. That is due, of oourse, to custom. I do not know whether we are making too few visits in the Metropolitan Territory, and yet this work is being done here under a competent organization. Te may be making an exoess number of visits in Canada. That I aa trying to get is a system of recording and reporting so that we can make comparisons between territories and between dis tricts. This should be your particular job during the oomlng year. Take, for example, the average number of visits par ease, exoludlng maternity cases. This varies from 3.5 on the Faolfio Coast to 5.9 in Hew England. I cannot imagine there is suffloient differenoe in the treatment of aouta conditions to Justify these differences. The low average on the Pacific Coast may be due to a younger population with fewer severe illnesses. On the other hand, why should the number of visits average nearly 6 per patient in Vow England? last year, Hew England alone spent $5,000 on nursing, which is more than all of Canada and all of the Paoifio Coast. Canada spent $87,000; the Paolflo Coast spent $2,000. These are things to which we should give serious oonsldsratlon. What uniformity is there about our work? Does it mean that where we pay on a visit basis an entirely different situation arises than where we have our own nurses and where apparently the time of the nurse is not adequately employed in nursing of aoute conditions so that, in addition, she can run up thousands of welfare Tisits a year. Vhat is there in the individual territories that brings about suoh a narked change in conditions as is lndioated by the wel fare visits alone? Z have had these figures prepared in the hope that by analys ing them in a comparative way, we oould determine whioh phases of the work require our most oareful attention. X am trying to show you the value of these sheets. Xt is not going to be worth while getting them up unless they are used - unless you use them, first, for your own information, secondly, for the information that you may oommunloate to your looal manager, and thirdly, I am hoping that you will able to discuss it with your Suparlntandant of Agenoies. Do you believe it la going to be worth while for ua to go Into thia matter oven aora exhaustively than wa hare gone Into It in the past? Za It worth while getting additional information along thia line, and la it poaalble to do.so, not merely on the annual basis, but on the monthly basis. I should like to have an exprasaion of opinion to thia before your aeetinge finally adjourn. The preparation of theee data la an expenalve item. Wa had to abandon it eoae year* ago. We are new trying to arrange the nurelng data by die triot. We are -trying it In Hew York, first of all, but thia would apply to any oity where there la more than one manager. We are trying to give the Superintendent of Agenoles the information whloh ha ought to have. At present we are taking every reoord for the year 1928 in the Metropolitan Territory and having the oases analysed so that Mr. Bradley will have within a week a careful analysis of all the work per distriot and not simply per oity. The question was raised hare, X think by Mias Steevea, as to whether thia information oould be gathered mors readily in the deoantralls offices than hare in the Home Offioa. It does not make muoh diffarenoa where it is dona. The thing I should Ilka aaoh one of you to do thia year ia to taka those figures and study them carefully, comparing the data for your territory with those of the other territories. Another new development of the nursing senrloe has been the appointment of the debit nurse. My own belief is that If we oould put a debit nurse in every distriot in the United States, it would be the best thing we ever did. The oontaots whloh she makes with agents and managers and the information she gets from personal Interviews with polloyholders are more valuable to the nursing servioe than anything else. We oan safely assume that a debit nurse costs somewhere around $2,OCX) per annum. To put one into 780 distrlots would make the cost, roughly speaking, #1,800,000. The question arises, how far oan we extend this work? I have been making some studies as to whether we oan oombine the work of a debit nurse with some other enterprise. We made two experiments this year. One was what I term a liaison nurse. This is not an exaot description of her work, and we shall have to find some better term. This liaison nurse is not necessarily attached to one distriot. She travels from one dis triot to another in large olties, her important work being, first of all, to meet the new agent, not immediately when he enters the servioe, but four or five weeks after. The only time she has for this work is when the agent is in the offloe. Her liaison work is to take oomplaints to the nursing asaoolation with whloh we are affil iated. She has to explain to the agent what the nurse is doing, and explain to the nursing association what the agent is doing. The oost of employing a debit nurse will materially In crease the oost per visit. I hops to .make a further experiment this instructing the agent .. - 34 - year and employ a debit nurss In all cities where the increase in the ooet per visit would be |.05 or less. This would include Boston, Hew York, Cleveland, Detroit, St. Louis, eto. I am hoping to have the opportunity of discussing this with you individually. The point I want to bring out is that if we could oombine the work of the liaison nurse with that of the debit nurse, she would meet the agent and teaoh the agent, and the remainder of her time she would spend in visiting polioyholders and doing the work the debit nurse is now doing. We would get a bird's-eye-view of each district in whioh she merles. She would average 25 visits a day. She can do a great deal, and within a year I am hoping we can get a picture of the entire community. We must concentrate this year on the agent. We have no means at the present moment of educating him. The literature does not do it; the ciroular letter does not do it; the manager does not do it. The manager has not the time. Z feel we have to make an effort to try personally to sducats ths agent. Ws have tried it out ae an experiment this year, and In Chicago we appointed Uiss Johnson as Znstruotor-at-Largs to sduoats all the agents in ths oity. I may say the reaeon Kiss Johnson was invited hers to day as ths only one outside the supervisors, la beoauae I want her to tell you what she has done in Chicago in this experiment, to show what it means to go into a distriot office, sit down with an agent, and show what he can learn through personal oontaot. I want you to think of this. What els# oan ws do? I have ay idsaa of what ws might do, but Z am afraid to mention them because of ths oost. Ws oannot do this in smsll oitiss. Ws have to limit it. Ears is where your opinion is muoh mors valuable than mins. Can ws think of an advisory nurse on a territorial basis, for communities outside of large oitiss? Could she visit them often enough? Eow great is the ohange in agenoy staffs? Our difficulty lies in ths turn-over of the agency foroe. A new man oomes in and gets no instruction. Esrs in Esw York City he does, beoause hers ws have ths sohool for nsw agents. Kiss Kearney gives two leoturss on ths nursing ssrvios every week to the olass for new agents. Those men have some acquaintance with the nursing ssrvios In ths beginning of their servioe. What oan wo do in the smaller oomaranltlee in the way of giving, if poeeible, personal 1nstruotion? Zs this something that you, as supervisors, oan do? Zf it is not your funotion, and 1 question whether it is, what method is there that we oould use? Z know of nothing more important to thle group. Z am not going Into the question of professional standards. Zt Is not neoesssry. Z think ws oan definitely say that the standards nursing today in the Metropolitan are ths equal of ths standards of any ooaaunity in ths United 8tates. Our real problem today, our one great weakness, is that we are not reaching all the people we should reach. We must begin to use the agent, after Instructing him, so that the nursing ssrvios may beoome better known.