Joan D Krizack.

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monwealth of Massachusetts). From fiscal years 1987 through 1992,
research funding continued to grow, despite the increasing scarcity of and
competition for research dollars, especially from the federal government.

Children's Hospital is the primary Harvard Medical School teaching
hospital for pediatrics, but its educational activities are not limited to
training physicians. In addition to internships, residencies, and postgradu-
ate programs for physicians, several departments also offer advanced
training programs for doctoral and postdoctoral students in the medical
sciences. The departments of Anesthesia, Cardiology and Cardiovascular
Surgery, and Medicine, for example, organize complete courses taught by
staff members. In other departments, including Orthopaedics and Neuro-
surgery, staff members present pediatric aspects within general courses on
their specialties. The hospital plays an important role in educating pediat-
ric nurse clinicians. The Department of Nursing is affiliated with twenty
academic institutions throughout the United States and provides educa-
tion at the baccalaureate, master's, and doctoral levels.

Children's Hospital also offers, among other programs, internships in
dietetics, social service, pastoral care, and clinical psychology; residencies
in pharmacy and hospital administration; formal on-the-job training pro-
grams for electrocardiograph technicians, housekeeping aides, respiratory
therapy technicians, and surgical technicians; affiliated programs in physi-
cal therapy with Boston University, Simmons College, and Northeastern
University, and in radiologic technology with Northeastern; informal
on-the-job training for laboratory technicians, unit secretaries, industrial
engineers, and autopsy attendants; and continuing education to meet the
recertification criteria of many health professions. Nearly every adminis-
trative and medical department at Children's Hospital is involved in
providing educational experiences for students who will be future health
care professionals.

Element 2: Institutional Control Children's Hospital is considered a
freestanding institution by the National Association of Children's Hospi-
tals and Related Institutions (NACHRI), although it is formally part of a
holding company. Children's Medical Center. Children's Medical Center
comprises Children's Hospital, the Children's National Research Institute
(which is currently inactive, but may be activated in the future to provide
organizational structure for research activities conducted by the Hospital),


Children's Extended Care Center (Groton, Massachusetts), Fenmore Re-
alty Corporation (a nonprofit corporation formed to acquire income-
producing real estate), Longwood Associates, Inc. (a for-profit subsidiary
that manages the Medical Center's real estate development), and the
Longwood Corporation (a nonprofit corporation owning real property for
the benefit of its nonprofit parent). The hospital runs two satellites: the
Martha Eliot Health Center (Jamaica Plain, a suburb of Boston), a neigh-
borhood clinic, and the Children's Hospital Specialty Care Center (Lexing-
ton, Massachusetts), an outpatient referral facility. The Children's Hospi-
tal League, a subsidiary of the hospital, is a nonprofit corporation operated
by volunteers; it plans and conducts various fund-raising events for the
hospital's benefit.

The Children's Medical Center is governed by a board of fifteen
trustees that is identical to the hospital's board. The standing committees
of the Children's Medical Center are the Audit Committee, Development
Committee, Executive Committee, Facility Planning Committee, Finance
Committee, Investment Committee, and Patient Care Assessment Com-
mittee. (It should be noted that the standing committees of all institutions
or organizations change with regularity.)

Element 3: Interactions with Other Institutions Children's Hospi-
tal is linked to many other institutions in carrying out activities related to
patient care. As examples, it has joint programs with Beth Israel Hospital,
Brigham and Women's Hospital, Dana-Farber Cancer Institute, Judge
Baker Children's Center, Massachusetts General Hospital, and the New
England Deaconess Hospital. In biomedical research it has joint programs
with Aga Khan University in Karachi, Pakistan; Harvard University's
Department of Biochemistry and Molecular Biology; the Massachusetts
Institute of Technology National Magnet Laboratory; the Whitehead Insti-
tute in Cambridge, Massachusetts; and Digital Equipment Corporation. In
research funding joint programs include those with the National Institutes
of Health, the Howard Hughes Medical Institute, the American Health
Association, and the Commonwealth of Massachusetts, among others. In
education it shares programs with Harvard Medical School (twenty-five
courses were listed in the 1991-1992 catalogue that third- and fourth-
year medical students could take at Children's Hospital), Boston English
High School, Bunker Hill Community College, Simmons College, and
most Boston teaching hospitals. Joint programs in administration include
those with the Massachusetts Hospital Association, NACHRI, and the
Medical Area Service Corporation, which provides transportation, pur-
chasing, and other services to institutions in the Longwood Medical Area,


and with accreditation and regulatory organizations such as the Joint
Commission on Accreditation of Healthcare Organizations and the Occu-
pational Safety and Health Administration.

Because it is located in the Longwood Medical Area, which is home to
six health care delivery facilities, ^^ Harvard Medical School, Harvard
School of Public Health, Harvard School of Dental Medicine, Harvard's
Francis A. Countway Library of Medicine, the Forsyth Dental Center
School for Dental Hygienists, and the Massachusetts College of Pharmacy
and Allied Health Sciences, every conceivable kind of affiliation, formal or
informal, has developed between Children's Hospital and the surrounding
medical community over the years. Much of this interaction had been
intended to improve care for patients, but with increased frequency joint
programs are coming into existence for education at all levels, and for
biomedical research. Because Children's interinstitutional connections
are extensive and complex and represent all four of the institution's
functions, they will be investigated in more detail at the organizational
unit level.

Element 4: History and Culture Children's Hospital was chartered by
the legislature of the Commonwealth of Massachusetts in 1869. Its his-
tory, from the hospital's founding through the early 1980s, has been
recorded in two books and a pamphlet. From my reading of these histori-
cal works and serial publications of the Development and Public Affairs
Department, certain facts that helped to shape the documentation plan
began to emerge. For example:

The nation's first pediatric radiology department was established at

Children's Hospital in 1900.

In 1903 the informal ties to Harvard Medical School were formalized;

hospital chiefs of service from this time on hold positions at Harvard.

In 1914 Children's Hospital was one of the first U.S. hospitals of any

type to create an independent physical therapy department.

In 1938 Dr. Robert Gross performed the world's first successful

surgical procedure to correct a cardiovascular defect, laying the

foundation for modern cardiac surgery.

In 1947 Children's Hospital made the transition to Children's Medical

Center, becoming the first pediatric medical center in the country.

From the perspective of documentation planning, one of the most
important points that becomes clear is that the health care delivery,
biomedical research, and education functions arc closely integrated. Pa-
tient care has always been the primary function of Children's; biomedical
research, mentioned prominently in the original mission statement of the


hospital, was the second function, with education following closely. It is
important to note that when research at Children's Hospital came into its
own in the early 1920s it did so within the existing departmental struc-
ture, rather than as a separate department or organization devoted to
biomedical research. The implications for documentation planning are
clear: because the health care delivery, biomedical research, and educa-
tion functions are integrated, it is expedient to plan to document these
functions within selected hospital departments or divisions instead of as
isolated functions. At the same time, it is important to have an overview of
the functions and to think functionally when devising the documentation
plan. The exception is the institutional administration function which
operates separately from the other functions and is therefore documented

From the vantage point of an employee. Children's Hospital's institu-
tional culture is readily apparent. The institution has a strong sense of
tradition and is proud of its history. For example, an annual lecture on the
history of the institution has been given for many years and is well-
attended. Employees at all levels are conscious of Children's leadership
role in pediatric medicine and are proud of being part of what they
consider a special enterprise. The hospital is compassionate both to its
employees, who are valued, and to its patients, who receive a remarkably
high level of care. On occasion, for example. Children's Hospital has found
funding to pay transportation costs to Boston for a dying child's grandpar-
ents. The culture of Children's Hospital is also permeated with ambition;
individuals are personally ambitious, and the institution is ambitious for
children, believing that with hard work all barriers to pediatric health can
be overcome.

The culture of Children's Hospital may be summed up in the words of
George H. Kidder, chairman of the Children's Hospital Board of Trustees:
"Children's is about people, and being mindful of the human side of this
place is the key to guiding it into the future. Building solid, supportive,
and trusting relationships is the way to ensure that this hospital fulfills its
mission of providing the finest care to children." ^^ Supporting this tradi-
tion of compassion and trust is Children's logo — a nurse closely holding a

Element 5: Institutional Constraints The hospital's operating budget
for fiscal year 1992 was $255.3 million, and it ended the year with a
favorable balance of $24.5 million. The hospital gained $7.7 million from
patient care operations and $28 million from favorable prior year adjust-
ments. However, $11. 2 million was used to refinance debt.

Viewed over a seven-year period (FY 1986-1992), the institution's


financial situation is strong. Audited surpluses were recorded for the
entire period, ranging from a low of $0.2 million in 1989 to a high of $24.5
million in 1992. Also, after experiencing four years (1986-1989) of
negative cash flow, the hospital reported significant positive cash flow in
FY 1990-1992. The period of negative cash flow is accounted for by the
construction costs for two buildings that were added to improve facilities
for in-patient care and research.

It should also be noted that the Commonwealth of Massachusetts
adopted new hospital finance legislation (Chapter 495) on December 31,
1991. This law deregulates hospital revenues, allowing hospitals to nego-
tiate discounts with managed care organizations and insurers. At the same
time, the legislation significantly reduced Children's reimbursement from
the Commonwealth for bad debts and free care. The long-term implica-
tions for Children's Hospital, while not altogether clear, are optimistically
viewed by its administration. In addition it is not clear how the Clinton
administration's health care reforms, which emphasize competition and
managed care, will affect Children's. The hospital is already planning how
to change to remain competitive in the new environment.


There are 149 freestanding children's hospitals in the United States
and 42 that are part of a larger organization.^"^ Of the freestanding
institutions, 45 are children's general hospitals comparable to Children's
Hospital. In New England there are only 2 other freestanding children's
general hospitals: Newington (Connecticut) Children's Hospital and
Hasbro Children's Hospital in Providence, Rhode Island. There is one
listing for a New England children's hospital that is not freestanding:
the Floating Hospital for Infants and Children at New England Medical

These statistics, together with the fact that Children's Hospital is the
largest pediatric research facility in the country, clearly indicate that the
hospital is close to being a unique institution within New England. (It is
also the only freestanding children's hospital in the country to have a
full-time professional archivist.)


This analysis involves reading through Chapter 1, "An Overview of the
United States Health Care System," and Chapter 2, "Health Care Delivery



FIGURE 8-2 Dental operating room in Children's Hospital, Boston, 1992.
Source: Development and Public Affairs Office, Children's Hospital

Facilities," to gain a perspective on the U.S. health care system and the role
of hospitals within it. These chapters also help point out the types of
relationship a hospital might have with other institutions and organizations
that are part of the U.S. health care system and indicate some of the changes
in the system that can be expected with the advent of health care reform.



The Archives Committee decided that archival materials would be col-
lected primarily for institutional operations and historical research pur-
poses. Secondarily, they will be collected for biomedical research pur-
poses.^' The implication is that research data may not always be main-
tained in the hospital's archives; however, the archivist will attempt to
find an appropriate repository for research data that is not housed in the

The Archives Committee also decided that documenting the medical
components of Children's Medical Center (the Hospital and Children's


Specialty Care Center) would take precedence over documenting the real
estate components of the Medical Center.


This is the most general level — the level where the selection process
begins. Of the five functions of Children's Hospital (patient care, health
promotion, biomedical research, education, and institutional administra-
tion) the Archives Committee agreed to emphasize the administration and
biomedical research functions. Administration will be emphasized be-
cause of the institution's virtually unique position in New England, be-
cause by documenting administrative activities thoroughly, all of the
other functions will be documented generally, and because documenting
the administrative function will be helpful in carrying out current hospital
administrative activities. Biomedical research will be another focus of the
documentation plan because of Children's position as the largest pediatric
research facility in the world and because the institution has significant
accomplishments in this area. The documentation plan will also focus on
health promotion because it is an area of activity that is gaining in
importance owing to the federal government's emphasis on cost contain-
ment and managed care.

Patient care will be documented by virtue of the fact that Children's
Hospital has retained all of its patient records and logs since it opened in
1869. This decision was made before the documentation planning effort
began. ^^ Patient care is also documented in the multitude of articles
written about patients and published in the various official publications
originating in the Development and Public Affairs Office and constituting
the recommended core documentation. Education is more difficult to
document because much of it is done in conjunction with other (usually
educational) institutions that have archival programs where the bulk of
the documentation resides. The Francis A. Countway Library of Medicine,
for example, hold materials documenting aspects of the classroom educa-
tion of Harvard medical students who received clinical training at Chil-
dren's. For this reason, the documentation plan will place slightly less
emphasis on education.


The first step is to identify the medical and other nonadministrative
departments, indicating their divisions, subdivisions, and programs as
appropriate. Table 8-2 outlines the territory to be documented. Originally
I thought that with the Archives Committee's help I would be able to


designate certain departments that would be documented only by the core
documentation (i.e., departmental annual reports; minutes of departmen-
tal committee meetings; photographs of departmental staff, events, and
interiors; departmental policy and procedure manuals; and department
publications, such as newsletters and brochures). After talking with the
Archives Committee, it became clear to me that this approach would not
work at Children's Hospital because everyone thinks that his or her
department is important and worthy of being fully documented in the
Hospital Archives. Although all medical departments will be documented,
not all of the departmental divisions and subdivisions will be documented
beyond the level of documentation residing in the department chief's files.
The Anesthesia Department was the first to be studied for documenta-
tion possibilities. One reason for this was purely practical — the associate
chief of the department was a member of the Archives Committee and
sympathetic to the documentation planning process. Other reasons were
that the Anesthesia Department was not well documented in existing
archival records and that the department is relatively small and not
complex, thus providing a good starting point. As a first step, I did
background research by rereading the sections of the hospital histories
devoted to the anesthesia department and reading through the last five
years of departmental annual reports. Then I met with the chief, the
associate chief, the clinical director of the Pain Treatment Service (which is
one of three department subdivisions that the associate chief recom-
mended be documented more fully), and the department administrator. I
used the questions and topics listed in Table 8-3 as the basis of the
meeting. (The questions in Table 8-4 may be used as a basis for developing
documentation plans for administrative departments.) The documenta-
tion plan for the Department of Anesthesia was reviewed by the three
physicians and the department administrator who were interviewed. The
final report was signed and dated by the department chief and the
archivist and distributed to appropriate people within the department.



The department is organized into four divisions and one subdivision, all of
which are among the largest such programs in the country:

• cardiac anesthesia

• multidisciplinary intensive care unit (MICU)

• division of respiratory therapy


TABLE 8-3 Checklist of questions and topics for medical departnnentai

1. Is the department organized into divisions/sections?

2. Describe the patient care (inpatient and outpatient) activities of the

3. Describe the health promotion activities of the department.

4. Describe the teaching (predoctoral, resident, fellow, technologist, continuing
education, etc.) activities of the department.

5. Describe the research (clinical and basic) activities of the department.

6. What are the departmentwide committees?

7. What is unusual about the department?

8. What is most important to document about the department?

9. What record series are needed in documenting this?

10. Describe the electronic records systems in place.

1 1 . Does the department generate:

a. Annual reports?

b. Departmental newsletters, patient brochures, information sheets, or other

c. Photographs or other audiovisual materials?

d. Committee minutes?

e. Policy and procedure manuals?

f. Departmental organization charts?

g. Records of teaching activities?
h. Records of research aaivities?

i. Patient records other than ofhcial medical records?

12. Has a departmental history been written?

13. Are there caches of departmental records that are not being used for current
operations? If yes, where are they located?

• operating room

• pain treatment service

The department has several committees: Clinical Competence, Educa-
tion, Fellowship Selection, Quality Assurance, and Research.


The department is one of the largest pediatric anesthesia departments in
the world, and its services are used for every possible type of pediatric


TABLE 8-4 Checklist of questions and topics for administrative department

1. Is the department organized into divisions/sections?

2. What are the departmental functions?

3. Does the department operate special programs?

4. What are the departmentwide committees?

5. What is unusual about the department?

6. What is most important to document about the department?

7. What record series are needed to document this?

8. Describe the electronic records systems in place.

9. Does the department generate:

a. Annual reports?

b. Departmental newsletters, patient brochures, information sheets, or other

c. Photographs or other audiovisual materials?

d. Committee minutes?

e. Policy and procedure manuals?

f. Departmental organization charts?

g. Records of teaching activities?
h. Records of research activities?

i. Patient records other than official medical records

10. Has a departmental history been written?

1 1 . Are there caches of departmental records that are not being used for current
operations? If yes, where are they located?

operation and for many procedures done outside the operating rooms,
such as diagnostic radiology and radiation therapy.


The department has what is probably the largest anesthesiology training
program in the United States, educating residents and fellows and provid-
ing continuing education programs for physicians. Residents from Beth
Israel Hospital, Brigham and Women's Hospital, University Hospital, St.
Elizabeth's Hospital, Massachusetts General Hospital (MGH), and occa-
sionally others rotate through Children's for two to three months. At any
given time, the department has about fifteen residents. Fellows come for
between six months and three years to become specialized in pediatric
anesthesiology and/or pediatric critical care medicine. The department is


involved with two continuing education programs — an anesthesia review
course with MGH, and the Harvard Medical School Department of Anes-
thesia's review course.


The department engages in a significant amount of research, publishing
over 100 papers per year. It participates in the Harvard Anesthesia Center
Research Grant (HACRG), which is run out of MGH. The program, which
has been funded by NIH for more than 20 years, trains anesthesiologists in
research. Participation in the HACRG program may lead to a Ph.D. from
Harvard or MIT.

Other research is organized by division, and all faculty are encouraged
to engage in research activities. Cardiac Anesthesia engages in clinical
studies and conducts basic research in conjunction with the Department of
Cardiology and Cardiovascular Surgery; the Multidisciplinary Intensive
Care Unit engages in clinical and basic research involving critically ill
patients; operating room staff do clinical research; the Pain Treatment
Service has its own laboratory and engages in clinical and basic research


Established in 1986, the Pain Treatment Service is the first multidisciplin-

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