upset of the whole housekeeping service whenever a new head is installed. It seems to me, but I am open to conviction, that there are two ways in which we may secure better housekeepers. The first is through schools which can give the foundation work in science and practical work which the hospitals cannot for lack of teachers and equipment. The second, in continuation of the first, is the old apprentice system. In the old days, when a boy wanted to become a goldsmith he served his apprenticeship for so many years under a master workman, and in due time became himself a craftsman. Nothing better could be devised for the study of hospital conditions. We must have an apprentice field where the half-fledged housekeeper will serve her time under a master housekeeper who can train her in the best ways of meeting hospital conditions. This master housekeeper may be established in both large and small hospitals. There are many women suited to a larger place who would be lost in a small one, and more who would fit into a small place, but would be utterly incapable of dealing with a large one. I leave these two points with you: the question of preliminary training, where it shall be had; and the question of apprenticeship, how it shall be arranged. I know that both can be worked out when you set your minds upon the ideal housekeeper.

REPORT OF THE SUB-COMMITTEE ON

UNIFORM ACCOUNTING.

C. IRVING FISHER, M. D.,

Presbyterian Hospital, New York.

In speaking to you of hospital accounting, I am presenting the results of work done chiefly by others, not by myself. Most of the members of this Association have received a copy of the recent book, "Hospital Financial Reports and Statistics," upon this subject. The treasurer of our hospital, Mr. W. V. S. Thorne, has given liberally of his time to the development of this system, and has also had the book printed at his own expense for distribution. I have several copies of this book with me and will be pleased to hand a copy to any one attending this Association who is interested in becoming better acquainted with this subject. We are looking forward to the time when hospitals, and other similar institutions, will present in their annual reports statistics worked out by a uniform method, in order that we may intelligently compare our own report with that of others, and so learn lessons in order and economy from the experience of one another.

The first whom I heard suggest the desirability of uniformity in hospital accounts was Dr. Hurd of Johns Hopkins Hospital. That was several years ago, and he told me that the most encouragement he received at that time was from the president of the board of trustees of one of the oldest hospitals in the country, who wrote to him saying "that the system of accounts in his hospital, which was begun in 1735, when the hospital was established, was highly satisfactory, and they had no desire to change. If others wished to adopt their system and make it uniform everywhere, they would not object."

This recalls the story told of a prominent Baptist, who was asked to give his influence toward church unity. His reply, in effect, was that he was much interested in the subject, he would be very glad to have all the denominations unite. He said: "Let us all get together and all be Baptists."

But we shall hardly get together in uniform accounting if we look at the subject in that way. Several years have passed since it was first proposed to this Association that we should strive to bring about uniformity in the matter of hospital accounting. Three years ago an agitation started in New York on the question of raising funds for hospitals. Various societies which became interested in the movement discovered on looking over reports that they could make no intelligent comparison as to the money expended and the work accomplished by the various hospitals. There were a succession of meetings of the Hospital Saturday and Sunday and other associations, and the question of expert and uniform accounting for hospitals began to take shape. Then the representatives of four large New York hospitals held a series of business meetings, and the result was a pamphlet which was distributed two years ago, and which was very favorably received, and which has now been followed by this larger book on this subject. Several hospitals have adopted the system therein set forth, with perhaps some inconvenience in the beginning, and several more in New York are to make this year's report according to this method. The Massachusetts General Hospital has adopted the system.

Mr. Thorne, our treasurer, who is an active officer in one of the largest railway corporations of this country, has, as I have said, been very enthusiastic. Railway officials handle their business to make money, and they want in a report nothing but the plain facts, whether these facts are pleasant or unpleasant. This mode of approaching hospital accounts you will find in this book.

I propose this afternoon to show you some pages of books kept in our hospital which I have had photographed and transferred to lantern slides, and which will be thrown. upon the screen before you.

There is a good deal of it, of course, which is expert bookkeeping. Some who have written to me have said: "I have read the book with a great deal of interest, but it

seems to me very elaborate, too elaborate for a small hospital." But the system is quite adaptable to small hospitals, as I hope to show. Some have said: "The great hospitals in New York have expert accountants; we are superintendents, who have to be superintendent, bookkeeper and head nurse, all in one." Well, I was once superintendent, head nurse and bookkeeper, and there was no expert accountant in the small hospital under my charge, so I know whereof I speak. The conditions are practically the same, and a finished system is, in the long run, a labor saver. I do not think there is a hospital in the land that has not got an expert bookkeeper somewhere available, at least for the working out and installing a system of accounts. There is no board of hospital trustees but has within it practical business men who are interested in getting out an annual report for the public on business lines. The treasurer is often a banker or railroad man or merchant, and has an expert bookkeeper in his office. He will, perhaps, be glad to say to his bookkeeper: "Mr. Jones, I am treasurer of this hospital, and I will pay you $100 or $200 a year to look after their bookkeeping for me. Go out to the hospital once in a while and give the superintendent a steer on the books, and bring such accounts as you can to this office, and keep things in shape for a proper report." Find your expert bookkeeper, give him a copy of "Hospital Financial Reportsan d Statistics," and ask him to set you going in the right way. It is simple and easy.

Lights are turned out and photos of pages from hospital books and cards are thrown on the screen, accompanied by explanations as to how the forms and tables can be modified to suit the needs of hospitals of all sizes.

DR. HORNSBY: We have your system of accounting at our hospital, and we have met with some few difficulties, which, of course, may be due to our own stupidity rather than to any defect or fault of the system. For instance, the question of the distribution of accounts. Take rubber gloves: we want to know first what we pay for rubber gloves, and if there has been any increase in the price. Then I want to know also what my operating room expenditure totals, so that rubber gloves must be charged there also, and I can carry on that same comparison ad infinitum. This particular difficulty we have met I am quite sure you have solved.

DR. FISHER: In the Presbyterian Hospital rubber gloves are purchased and distributed by the pharmacist. In his department, as in every other department of our hospital, "Books of Detail" are kept. We know how many pairs of gloves have been purchased each month and the price paid, and to which department distributed. Rubber gloves are a "Medical and Surgical Supply." The same method is observed in regard to drugs, which are also classified under the heading, "Medical and Surgical Supplies," explained on page 16 of the book.

LADY MEMBER: We have some difficulty in grading the service, the nursing, and the service of the wards and kitchen and laundry departments. Can you explain that to us?

DR. FISHER Kitchen and laundry are treated under "Department Expenses," see pages 3 and 18 of the book. Our method of getting the proportion of the laundry cost which was chargeable to the various departments and for private patients was to count every piece that went through the laundry for one week and work out a percentage basis from that count. This, if not absolutely accurate, is practically so.

LADY MEMBER: Are the diet kitchens included under the culinary department?

DR. FISHER: So far as an annual report is concerned, all kitchens would be classified under one "Kitchen" and "Stewards Department." When it comes to what we need to know in the hospital, the "Books of Detail," already spoken of, will show what each kitchen has cost.

DR. J. H. S. PARKE, Montreal: The point Dr. Hornsby raised is an important one; that is, how are these accounts to be distributed to the different departments. We want to get a system that will show at the end of a year if our expenses have gone up, or in what department the expenses have increased. In the matter of wages, I think most of us distribute this in some way or another; we want to be able to tell whether this increase of wages was an increase in the number of help that is coming to us or not. Rubber gloves are distributed in perhaps one, two or three different departments, and other things in the same way. We want to find out whether our wards are the extravagant part or whether the increase in our drug account is chargeable to the ward, to the operating room, or to the emergency department. I think we all appreciate the work that has been done by this system of bookkeeping.

DR. HORNSBY: We distribute rubber gloves and charge against our operating room expense account; but we keep a stockledger, and that stock ledger or stock inventory carries through it rubber