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                                                                       1 G03 RM 00012-01
                                             SITE VISIT REPORT
                                                  OREGON
                                           REGIONAL MEDICAL PROGRAM
                                                February 19, 1968

                SITE VISITORS:

                Alfred M. Popma, M.D.,.I-',egional Director, Regional Medical Program, Boise, Idaho

                Dr. Stephen Abrahamson, Director of Research in Medical Educa-tion, University
                     of Southern California School of Medicine, Los Angeles, California
                Carl Lyle, Jr., Yi.D., @ssistant Director, Division of Education and Research
                     in Community Medical Care, University of North Carolina, Chapel Hill,
                     North Carolina


                DP,LviP STAFF:


                Alexander M. Schmidt, M-.D., Chief, Continuing Education and Training Branch
                Vincent J. Carollo, M.D., Operations Officer
                Frank Karel, Public Information Officer, Division of Regional Medical Programs
                Mrs. Patricia McDonald,'Public, Health Advisor@, Grants Reviela Branch

                OREGON Rt-v.P STAFF:


                M. Roberts Grover, Jr., M.D., Program Coordinator
                Edward Vance Yung, M.D.-, Director, Survey and Planning
                Mrs. Barbara Gaines, R.N., Assistant Director, Continuing Education
                Mr. Jerry 0. Elder, Assistant Director, Survey and Planning
                Miss Susan Rich, R.N., Assistant Director, Survey and Planning
                Mrs. Da-'Le Caldwell, Director of Information
                Mrs. Judy Halterinan, Executive Secretary

                REGIONAL ADVISORY GROUP:


                HerL7,an A. Dickel, M.D., Chairman

                PROTECT PERSONNEL:


                Mr. Dick Herron, Director, Instructional Aids, University of Oregon Medical
                     School






                 D R A F T                                                  1 G03 RM 00072-01
                                             SITE VISIL" iZEPORT
                                                   OREGON
                                          REGIONAL MEDICAL PROGRAM
                                              February 19, 1968



                 GENERAL


                 The meeting was directed by Dr. Myron R.  Grover,  Program  Coordinator,
                 and was attended by his staff and the Regional  Advisory  Group  Chairman.
                 It was obvious to the site visitors that this is a competent, enthusiastic,
                 and active grouD.  Considerable progress has been made by the staff
                 since the submission of the cra-Lit request, and the documentation of  the
                 preparedness of the Region to become operational.  Planning seems much more
                 comprehensive and sophisticated. This is probablv due  at  least  in  part
                 to the participation by the staff and Regional Advisory Group in a
                 recent management workshop, put on by well  known  management  consultants.
                 Equally obvious was the fact that the Regional Program  has  elicited  wide
                 spread interest and support.  A few days prior to the site visit, a
                 workshop conference was held which involved  individuals  from  throughout
                 the Region (Note the appended discussion of this meeting  by  Dr.  Sloan).

                 The @'irsl- part of the visit was spent re-examining the evidence that  the
                 Region was ready to become operational. Dr.  Grover  indicated  that  they
                 had done considerable're-thinking of their program in the past few months,
                 especially in light of the recent revision of the  guidelines,  and  the
                 concepts of regionalization expressed therein.  The Oregon Regional
                 Medical Program recently devoted considerable time  to  consideration  of:
                 a) needed staff; b) assuring involvement of  the  proper  elements  in  the
                 region in the planning and decision-making processes; c)  adequate assess-
                 Lae-,it of the medical needs of the R'egion; d)  the setting of proper
                 priorities for action-in the Region,'and e)  adequate  evaluation  of  the
                 program.

                 ]Zccrul.tiii(-,nt of staff has continued, and two young  physicians,  who  are
                 interested and apparently skilled in education and evaluation,  are  to  be
                 adclcd to the staff within the next few months.  Regional  involvement  is
                 L)ein@ r(-,-assessed, with studies.being made of the composition of the
                 Reaional Advisory Groi4'p, task forces, etc. All health  resources,  socio-
                 economic groups, and geographic areas ate to be included  in  the  program.
                 The staff travels a great deal to build interest in the Program, and a
                 newsletter has a circulation of approximately  12,000.  The  Program  seems
                 to have good support throughout the-region.

                 '.he Oregon Regional Medical Program will continue planning while operational
                 activities are in progress.  The staff is currently preparing a county-by-
                 county analysis of man ower, facilities, transportation, educational pro-
                                       .P
                 @rams, minority groups, and private and professional organizations.  A
                 cooperative study with the Washington & Alaska Regional Medical Program is
                 bein- made of patient origin. These studies  will  provide  information  on
                 the actual system of health care in the Region.  The subcommittees of the
                 Regional Advisory Group are determining goals for the  delivery  of  health
                 care.  The function of the Oregon Regional Medical Program  is  seen  as





                                                                           1 G03 @M 00012-01
                 D R A P T                          -2-



                                                                      X4
                 developing  projects  to bridge the gap between the e  sting health care
                 system and  the  desired system,.

                 Doubts raised by the Review Committee about the  Oregon  Regional  Medical
                 Proaram's readiness to move into the operational stage  were  removed  during
                 the site visit. Major advances have  been  made  in  the  decision-making
                 mechanism since the application was submitted.  The Region now has a
                 workinry list of objectives for operational projects and a scheme for
                 setting priorities a-inona projects.  Conscientious review is given by the
                 Regional Advisory Group to the submitted projects, as shown  by  the  fact
                 that it refused to approve several projects in the form submitted.  Several
                 other projects have been approved by the Regional Advisory  Group  and  will-
                 be submitted as an operational supplement by March 1, 1968.


                 BEART, CANCER, STROKE',CIRCUIT POSTGRADUATE PROGRAM

                 There was evidence of  substantial support in the Region for this project.
                 The Chairman of the Regional Advisory Group  was  especially  enthusiastic
                 about its potential.   The site visitors felt that the major  weakness  in
                 this Drooosal is the technique for evaluation, but that the  Uni  ersity  has
                 talent available which the ORMP'should utilize.  The site visitors addressed
                 themselves to the following issues raised by the Review Committee:

                      1.  Personnel:  The site visitors were reassured that the   personnel
                          budget is appropriate. Persons  have  been  designated  to  fill
                          most of the positions, but were not asked  to  make  commitments
                          until funds are  available.  The  department  chairmen  involved
                          have indicated willingness to employ  the  halftime  people  for
                          the rest of their time. The  budget  does  not  include  persons
                          expert in television production, but the talent  at  the  Univer-
                          sity will be available to the ORMP.

                      2.  Transportation:  The site visitors felt that there is an obvious
                          noed for a station wagon to transport videotape and slide
                          projection equipment and that the amount requested for its pur-
                          chase is reasonable.

                      3.  Conti-@-.-.t.  '-r-,.c;,:ruction and consultation:  The Region is aware of
                          the need i@or contact beyond that provided during  this  circuit
                          course.  Other circuit courses are being prepared; one on coronary
                          care, and another concerning carcinoma of  the  cocoa.  The  circuit
                          courses will provide the opportunity to gain  the  interest  and
                          involvement of practitioners in the  Regional  Medical  Program,
                          and to determine the types of continuing education programs
                          needed by the physicians and others in the Region.  For example,
                          previous experience with the circuit course has  suggested   the
                          need for short courses on inserting intervenous  pacemakers   and
                          interpreting-electrocardiograms.





                   D l@ A  P  T                         -3-                       1 G03 R.LM  00012-01



                         4.   Emphasis on  t-.eaching methods:     The Region  recognizes  the  need  to
                              identify the',educational interesfs'.and needs of the physicians,
                              as  noted  above.  They  seem  to  havea realistic sense of the
                              difficulty o@  this, and will seek    'way@@ to accomplish this objective.


                   RECO@@IENDATION


                   The site visit   team concluded that the Oro               al  Medical  Program  is
                                                                  .gon Region'
                                                                    d that  the  circuit  course  pro-
                   ready to move into the    operational stage    a)a
                   ject should be   supported.  The Region should b@     encouraged   to  arrange  for
                   assistance from the C'lle-e of Education 'f,th'e      University   ol Oregon for
                   better evaluation of    the pro'ect.









                M E M 0 R A N D U @i                            February  25, 1968

                to:        For the  Record,

                from:      Associate  Director   for Organizational Liaison, DRMP

                subject:   Attendance at Workshop-C-onference    'of Or egon Regional Medical
                           Program, Febru@ry 15-16, 1968



                           On February  15. @..i968 Irepresente@.the',Division in a Workshop-
                Conference of the Oregou,Re-ional Medical Prlp
                                                                 grami.  The  audience   consisted
                of  about 150 people,-rostly physicians and hospital     directors  or   administra-
                tors, and a few nurses, From  all  partsof  Or@go'n,.five  members  of  the  Regional
                Advisory  Group, and the headquarters ORIT stai@f..'@@I  was'responsible  for   pre-
                sentin@  a  ".4ational  Viewof  Regional  Medical'Progrims.'@  Dr.  Herman  A.  Dickel,
                Chairman  of the Regional.'.'Advisory Group of trip OaT " described  the   history
                of organization of the Oa!P and-said  that,  o:,f..alT'the  agencies  and  institutes
                involved, the University'.,qf Oregon. Medical S,tlxooi- had given up-the  most  in
                malting Dr. vi. Roberts Grbvpr available  as  a..@ll'-,time  Program  Coordinator.

                           Dr. Grover the:r.:told @hat  had  actually:been  accomplished  so  far,
                the  cooperative  arrangements  established,   the'@r recruitment  program,   organi-
                zatioral pattern, the de--i@ion-inaking procei-s-bei-ng used, the first operational
                proposal to support circuit courses     3.n community'@ospit'als by teams  sent  out
                from the medical schools,i,and  the  reasons  f6,r:expectations  of  this  workshop.

                           The Workshop @ag.designed   as a two@way excharige; 1),  orienting
                hospitals  and  hospital   directors from all p@res'o'f Ore'on regarding the
                                                                           9
                                          'ials   of the Oregon.-ilegi6nal Medical Program, and
                nature, c,,oalsl and potent
                                        staff and'members of thd  RAG  as  to  the  specific  needs
                2) orienting the OM
                as perceived by doctors   and  hospital  administrators  in  the  eight  sub-regional
                districts into which Ore-@o:n has:been divide& for,organizational purposes.

                           Dr. Hilmon Castle   addressed the luncheon  meeting  on  "The  Pains  of  k,
                Bec @4
                    .Greg Operational"--@ery   entertaining anct-.info'rmative, and excellently
                presented. He isafine speaker ;and  has,  I  know,  been  very  helpful  to  Regional
                Medical Programs whereveir-@e has consulted o'r'made a presentation.

                           For the first one   and-a half  hours.:of the  afternoon,  the  partici-
                panLs met in their sub-@egional.groups     with"'an assigned moderator  who  was  a
                member of the  Re-ional  Advisory  Group  or  thd.@taff,  and  discussed  the  problems
                they 'Laced in making avdilable'to their pat@@n'ts'.the highest quality of medical
                care in  the  field  of  he"t  disease.  They  t@eA broke  and  reconvened  in  plenary
                sessions to review the rfe@ds  expressed  by  ea'ch re'ion.  The  similar   pattern
                was to be followed the next day.. for  cancer  and' s@roke,:and  I  can  recommend






                                                                                                     2





                 this as  a  good  format  fo'r such workshops    in bther'regions.
                                                                                       I  was  able  to
                                                                    a-Li
                 stay  only  for  the   session on   heart   disease, d   the  most  urgent  needs  ex-
                                                                          ,as follows:
                 pressed  in  this  area   wer6 for all  parts  of  Oregon:

                            1)     Continuing'.'education
                                                          .Lor doctors and nurses.

                            2)   Training    df physicians  a-Lid nur.es in the map,-.fement of
                 patients   with    myocard,'-al:infarction and   the Operation of coronary care
                 units.


                            3)      Development of methods for lon.'&-,di.4.tance-.consultation and
                 analysis  of  electrocardiograms   for   any   unusual p'r@oblbms  which  may  arise.

                            .4)  The  provision  of  loan  nurses  w;io could be sent to various
                 hospitals  freein  up  a  nurse  to  go  to  a  center f6,r training in coronary
                                   9
                 care nursing.
                            5)   Development.of  means  for  transporting   the   severely   ill   myo-
                 cardial in-@carction patient wit@,the possibility 6f cardiopulmonary -
                 resus C4 tat4on   and   continuance    electrocardio am monitoring enroute.  Great
                                                                   gr     -
                 interest i-7as  expressed  i:zl.the  use  of  helicopter @mbulances to cope with the
                 large  distances  of  easte;rn   Oregon.

                            Dr. Grover has,'Promised    to  send  to.-the.Division  the   summary   of
                 needs identified and exp@essed by      sub-regio-@;'E;  for:.heart  disease,  career,
                 and s@-roke.  These  should  be  of  general  inte-rest.%.to  the  Division  and  its
                 Advisory Groups.

                            My  overall  im@@ession  of   this   workshop': was that the O.T2 has
                 succeeded  remarkably  well  in  making  its  pote@tial  known   to   the   practicin-
                 pi,,,-sicians, hospital directors,  a-,.id     administrate.ts  of  Oregon.  The   grass-
                 roots have  been  frank  a-i'd  eloquent  in  the  ex'pres'd-ion of  their  needs,  and
                 cooperative   arrargements.'-are   being fostered:to  "t   things   done.   One   type
                 of  cooperative  arran-em@t  demonstrated  in  this.'ideeting  was  that   each   mar,
                 there usually represented three or four othe"rs back- home who were covering
                 his  practice  while  he  was  ax,7ay,.and  counting gn  him to report back to them
                 the proceedings of this @meeting.


                                                                  Mart
                                                                  g ret.@. Sloan, M.D.-





                                                                   I G03 M 00012-01

                                     OREGON REGIONAL MEDICAL PROGRAM


                                      OPERATIONAL GRANT OBJECTIVES

                         The following objectives for operational grant requests were
                   developed by members of the Oregon Regional Advisory Board and its
                   subcommittees.  These objectives are currently being studied and re-
                   fined.  As the program develops.? it is anticipated that further changes,
                   modifications and additions to this list will be made.
                         Many of the objectives were abstracted from  u@idelines for Regional
                   @e i@@Zr@r@s. published by the Division of Regional Medical Programs,
                   National Institutes of Health, U.S. Department of Health, Education and
                   Welfare, Public' Health Service, and are contained in Public Law 89-239.

                   in the Oreo           oppratinnal arant applications must meet the
                   followim c

                   1.   Meet a need identified by the community, Oregon Regional Medical
                        Program date., or subcommittee information.
                   2.   Demonstrate availability of facilities to implement project.
                   3.   Demonstrate availability of personnel required for implementation
                        of the project.
                   4.   Demonstrate a high probability of improving patient care.
                   5.   Provide a method of objective evaluation.
                   6.   Demonstrate compatibility with existing patterns of health care*
                   7.   Demonstrate relationship of any research activities to goal of
                        improved patient care through regional cooperative arrangements*
                   8.   Identify revelance to heart,, cancer, stroke and related disease
                        categories.

                   9.   Identify that funds requested are for project based within the
                        Oregon region.
                   10.  Demonstrate that applicant is.not a proprietary of federal agency.
                   11.  Demonstrate comparability with concept of regionalization.
                   12.  Assure participation in project by both purveyors and consumers.
                   13.  Demonstrate inherent technical merit.
                   14.  Provide for cooperative arrangements,
                   15,  Avoid duplication of existing effective efforts.






                                                                           I G03 R14 00012-01


                     .Qperational grant applications iqrg strengthened when the following
                     t,bjectives are met by  iLh I
                                               -@ grant,,

                     1.   Provide maximum results with least costs*

                     2.   Create no new manpower hardships.

                     3.   Avoid misuse of manpower*

                     4.   Provide for voluntary eff'ort.and contributions'.

                     5.   Demonstrate a type   of program that will ultimately attract
                          support from other   than Regional Medical Program.

                     6.   Consider all health resources of region in planning.

                     7,   Utilize existing resources*



                     2/13/68
                     sef








                                                                          I G03 RK 00012-01

                                               PRIORITY CRITERIA

                     A,  THEETAPEUTIC EFFECTIVENESS

                          Rating:
                           12  1.  Early diagnosis to prevent complications and/or'cure
                                   the disease.

                          @2.      Return  to  productive  life,
                          @3.      Adapting to conditions imposed by the disease or its
                                   treatment,

                          @4.      Death

                     B,   INCIDENCE

                          @l.      Very cm=nly occurring disease.
                          @2.      Comonly  occurring disease.
                          @3,,     Uncommonly occurring disease*
                          @4.      Rarely  occurring   disease.

                     C,   AGE

                          @l,      Occurs  in  patients  mostly under 40 years.
                          @2.      Occurs  in  patients  mostly 40-65 years.

                                                                 -90 years.
                          @3.      Occurs  in  patients  mostly 65
                          @4.,     Occurs in  patients  over  90 years,

                     I)*  DISTKNCE FR(*l AN ACRIKVABLE GOAL IN OREGON

                          @l.  Very far

                          @2,  Moderately far
                          @3.  Near

                          @4.  Very Near









                                                                  I G03 R14 00012-01



                   E.  DIFFICULTY IN ACHIEVING GOAL

                      @l.  Easily obtained

                      @2. Moderately easy

                      @3.  Difficult

                       1 4.  Very unlikely

                       0   5.  Impossible









                   A+B+C+D+E  Priority

                   A grant with the highest priority in each categoryvill receive the
                   numerical rating of 28.









                   2-13-68