Cooperation Strengthens Small Hospital Libraries in a Rural Area of New England: A Five-Year Experience* BY ROBERT J. SEKERAK, Directort Hospital Library Development Services

Charles A. Dana Medical Library University of Vermont Burlington, Vermont County, in the northwestern part of the state along the shores of Lake Champlain. The University of Before 1970, library facilities and services at the small Vermont, chartered in 1791, is located in Burlinghospitals in rural Vermont were essentially nonexistent. Similar findings were later encountered along the ton. Its Medical College was founded in 1820, and Connecticut River in New Hampshire and in a small area the college's clinical facility, the 549-bed Medical of upstate New York. The Hospital Library Development Center Hospital of Vermont, is the state's largest Services program was established at the University of hospital and is served directly by DML. There are Vermont's Dana Medical Library to improve these conditions. Financial assistance was received from the twenty additional hospitals at present, and thirteen National Library of Medicine, and by the end of 1974, of these have 100 beds or less. Approximately thirty-three hospitals had staffed libraries. Earlier that 22.7% of the state's population and 48.9% of its year it had been decided to begin emphasizing coopera- physicians reside in Chittenden County.t ABSTRACT

tion among the developing libraries, including the production of union lists and regular meetings of staff members from geographically proximate hospital libraries to plan and implement various activities. An additional one-year award from NLM was received in 1975. Results achieved during and after the period of grant support are reported. Cooperation among hospital libraries is seen as a feasible and beneficial undertaking provided that the participating libraries are internally supported and developing.

IN 1969 an analysis of hospital library facilities and services in the state of Vermont was conducted by the University of Vermont's Charles A. Dana Medical Library (DML). A questionnaire designed to determine existing resources and needs was sent to the hospital administrators in the state. Site visits followed, and conditions at all but two of the twenty-four hospitals were observed firsthand. Vermont is primarily a rural state, mountainous and still heavily wooded. Nationally it ranks fortythird in size and forty-eighth in population, with an estimated 483,300 people as of July 1977. The largest city, Burlington, is located in Chittenden *This program was supported in part by NIH Grant No. 2-GO8LM-01258-04 from the National Library of Medicine. tCurrently Reference Librarian at the Dana Medical Library, with continued outreach responsibilities on a part-time basis.

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BACKGROUND Results of the 1969 analysis confirmed the observation made by Stearns and Ratcliff at that time concerning the national plight of hospital library facilities: "The basic weaknesses of these libraries fall into four categories: inadequate collections, inadequate personnel, inadequate space, and the absence of any practical indexing system to facilitate use of collections that do exist" [I]. With only three exceptions, a Veterans Administration hospital and two psychiatric hospitals, conditions ranged from no libraries whatsoever to unsupervised, vintage collections that were generally housed in physicians' lounges and rarely used. Few health care practitioners were aware of the informational resources available through DML and other libraries of the NLMsponsored medical library network. Later that year a librarian with hospital library experience was hired by DML to plan a program, subsequently called Hospital Library Development Services (HLDS), to help establish and improve library capabilities at hospitals in Vermont. Weinsieder defined the kind of library (that is, information center) envisioned for these institutions: tPopulation figures and physician ratio provided by the Vermont Department of Health, Statistics Division, Burlington. Bull. Med. Libr. Assoc. 67(3) July 1979

COOPERATION STRENGTHENS SMALL HOSPITAL LIBRARIES ... A community hospital Information Center should be a comfortable, centrally located room that houses an up-to-date, broadly based book and journal collection, indexes to medical, nursing and allied journal literature, and basic audiovisual equipment.... The Center should be under the direct supervision of a service-oriented library technician who has attended the HLDS, the Countway, New England Regional Medical Library, or an equivalent training program. All of the collections and services should be freely available to all hospital staff members and health personnel of the community [2].

It was perceived that the hospital administrators would require demonstrated evidence of need before authorizing significant expenditures for library materials and services. Thus, the initial HLDS approach was characterized by considerable support and assistance at little cost to the hospitals. Each hospital was required, however, to designate space for an information center and to employ a person to work at least half-time in the center. HLDS provided the necessary training and ongoing consultation. In 1970 the now defunct Northern New England Regional Medical Program (RMP) offered one-year subscriptions to Cumulated Index Medicus, International Nursing Index (INI), and Hospital Literature Index (HLI). These, plus the New England Regional Medical Library Service's (NERMLS) gift of Abridged Index Medicus (AIM) that same year, gave twelve new information centers a beginning reference base. RMP also made sets of audiovisual equipment available on a cost-shared basis to these twelve hospitals.* In return the administrators agreed in writing to continue the development already underway. During the following year three sets of the textbooks listed by Stearns and Ratcliff [1] were acquired with financial help from RMP, DML, and the University of Vermont's Office of Continuing Education for Health Sciences. These sets were loaned to the centers for four months in order to provide a prototype of a current, integrated hospital library. From the outset DML staff provided reference support, book loans, article photocopies, audiovisual software loans, and main entry information for cataloging the current texts that the centers were beginning to acquire. Expressions of interest in the HLDS program *Equipment included a 35-mm filmstrip projector and previewer, an audiotape cassette recorder, a super 8-mm cartridge film projector, earphones, and a desk-top portable screen. Each hospital had its own 16-mm film projector and 35-mm slide projector. Bull. Med. Libr. Assoc. 67(3) July 1979

were also received from hospitals and practitioners along the Connecticut River in New Hampshire and in upper New York State. Up to this time a portion of a U.S. Public Health Service Special Improvement Grant to the University of Vermont's College of Medicine and the DML budget were the main sources of financial support. Additional funding was sought to continue the effort in Vermont and to initiate contact with other hospitals. An application was submitted in December 1970 to the National Library of Medicine for a three-year Resource Project Grant. An award totaling $87,000 was received and became effective January 1972. The aims of the proposal were: (1) to establish information centers at the remaining Vermont community hospitals, at a minimum of nine such hospitals in New Hampshire, and at one hospital on the New York shore of Lake Champlain; (2) to test and refine HLDS methods, with the hope that they could be applied in other areas; and in time (3) to produce union lists of the centers' periodical and book collections. Grant funds were used to employ two additional staff members for the HLDS office. A librarian was hired to assist with the promotional, training, and consultative aspects of the program. The other employee was a library technical assistant with the responsibility of providing full sets of catalog cards in a simplified format for texts purchased by the centers. A portion of the money was earmarked for travel to the hospitals, in order to stimulate interest in library improvement and to conduct on-site training and consultation for those persons hired to direct the information centers. Other expenditures to aid the developing libraries included: initial subscriptions to AIM, INI, and HLI; the cost of collect phone calls to HLDS and DML for assistance; the purchase of temporary binding equipment for periodicals; the production of lists of the centers' periodical and book holdings; and the programming costs to produce by computer a list of DML's growing audiovisual software collection. By the end of 1974 thirty-three area hospitals had active libraries in varying stages of progress: all twenty hospitals in Vermont, twelve of thirteen approached in New Hampshire, and the one contacted in upstate New York. All of these libraries had trained personnel, and all but one had internal fiscal support. Their collections included reference materials, periodicals, texts, audiovisual equipment, and, in a growing number of instances, audiovisual software. These small libraries were now a part of the medical library network,

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utilizing with increasing frequency the resources and services available through the network. RATIONALE FOR COOPERATION The need to emphasize cooperation among the developing information centers, a long-range objective in 1970, became increasingly apparent several years later. In 1973 a draft of the NERMLS document delivery service plan [3] stipulated that there be a "refusal list" for hospital libraries, to be phased in over three years. On this list would be the 100 or so periodical titles in AIM. Once effective, a fee would be assessed for photocopies of articles drawn from the previous three years plus the current year of these titles. The Medical Library Network as a whole was feeling the strain of growing numbers of interlibrary loan requests from hospital libraries and practitioners [4]. DML planned to begin charging the information centers for audiovisual software loans and MEDLARS searches in 1974. Each hospital had been informed early in the program that cost-free support would not continue indefinitely. The NLM Resource Project Grant to HLDS would expire at the end of 1974, and if services such as cataloging and on-site consultation were to continue, some of the costs would have to be borne by the recipients. Additionally, book prices and periodical subscription costs, along with hospital costs in general, were rising steadily. During this time there had been a growing recognition of the importance of continuing education and in-service training to improved patient care. The Joint Commission on Accreditation of Hospitals cited continuing education as vital to quality patient care [5], and hospital-based education and in-service training programs had been an accreditation requirement for some time [6]. This realization, coupled with the dramatic increase in liability and malpractice litigation and the continuously increasing size and complexity of scientific knowledge, accentuated the need to continue meeting the informational requirements of health practitioners at all levels. As noted, however, the progress of the information centers varied one from another, and the levels of institutional support, both philosophical and financial, varied also. To the libraries at these small rural hospitals, coping with these conditions and needs on their own seemed a difficult prospect.

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Resolution and Projected Outcomes Further consideration, which included a review of the literature on library cooperation and discussions with a number of information center librarians, led early in 1974 to the formulation of four

objectives: 1. To convince all information center personnel of the need to cooperate, so as to secure their commitment and support. 2. To bring about various kinds of cooperative

activity. 3. To demonstrate, particularly to the hospital administrators, some of the financial advantages of library cooperation. 4. To assess the impact of cooperation on the individual development of the libraries involved. The cooperation sought was to be essentially informal. There was no plan to implement written agreements or contracts. Working together seemed a natural and logical next step in the developmental process. Sharing print resources would receive primary attention. Work on a periodical union list had been started several months previously. A list of books would follow, and eventually a compilation of audiovisual software would be produced. It was hoped that these union lists would also provide the capability and incentive to develop methods for planned purchasing. Regular meetings of HLDS staff and the information center librarians would serve as the means to identify additional activities and projects and to monitor existing ones. The anticipated benefits to the parties involved were as follows. Information Centers. User needs would continue to be met in an efficient and timely manner. Duplicate collecting and holding of less-used materials would be minimized. Reliance on the medical library network would be reduced. Cooperation by the libraries might stimulate other interhospital cooperation (for example, in-service education programs). Medical Library Network. The network objective of providing equal access to the biomedical literature [7] would be maintained. At the same time some of the network overload [4] would be alleviated, because of the sharing of local resources. DML/ILDS. As a part of the medical library network, DML would continue to fulfill its responsibility to further develop and strengthen area hospital libraries and to provide for the inforBull. Med. Libr. Assoc. 67(3) July 1979

COOPERATION STRENGTHENS SMALL HOSPITAL LIBRARIES mation needs of the health care community [7]. At the same time, as the centers achieved greater self-sufficiency, requests for support would decrease. EFFECTING COOPERATIVE RELATIONSHIPS

Methodology In January 1974 a manually produced union list of periodicals was completed by HLDS. It included the holdings of most of the thirty-three information centers, as well as those of several other health sciences libraries in New Hampshire. Exploratory meetings with four geographically proximate groups of information center librarians were begun in March.* Although the meetings were relatively unstructured, there were several definite purposes in mind: (1) to introduce the concept of cooperation, (2) to allow the participants to explore the possibilities and ramifications inherent in cooperation, (3) to build solid relationships among the members of each group, and (4) to establish a unique identity for each group. By the end of the year, sixteen such meetings had been conducted at different hospital locations, each of the four groups having met three or more times. Because the NLM Resource Project Grant would expire at the end of 1974, an additional, one-year proposal was submitted in June, to afford the time and financial assistance needed to accomplish the cooperative objectives stated above. A four-month extension of the Resource Project Grant was allowed, and a new award of $8,800 was received, effective May 1975, to cover HLDS travel costs for the group meetings and some of the personnel and materials costs of the union lists. Once essential agreement with the principles of cooperation had been reached and group relationships and identities established, regular meetings were started in January 1975. The purposes of the meetings were (1) to plan and implement specified cooperative activities, (2) to consider new ideas and projects, (3) to discuss and resolve problems, (4) to share experiences on all library matters, and (5) to provide brief educational experiences, as *One of these groups, the Northern New Hampshire/Vermont Cooperative Group, composed of six libraries, was organized in 1972 with some funding from the Northern New England Academy, Inc. One of the member librarians served as coordinator-consultant for the group on a half-time basis through October 1973, and HLDS assumed that responsibility in 1974. Bull. Med. Libr. Assoc. 67(3) July 1979

deemed appropriate by the members. The original intent was for each of the four groups to meet every other month, although weather and other exigencies sometimes interfered with this. Different hospital locations were chosen each time, primarily to expose the members to various kinds of library facilities and operations and to focus attention favorably on the libraries within the hosting institutions. The four groups met together each year to define area needs and directions, discuss mutual problems and experiences, and become better acquainted. Coordination of the individual and combined group meetings-scheduling, notification, agenda, and postmeeting reports-was done by the HLDS office. In order to further facilitate resource sharing, it was decided to produce by computer subsequent revisions of the periodical union list, as well as the intended list of the centers' book holdings. The master files of the HLDS cataloging service for the centers were used as the data base in this latter instance. The time and expense involved in the programming for the two lists have been offset by the relative ease in updating and production. Various retrieval capabilities were also specified in anticipation of cooperative purchasing. Annual revisions of each list were planned, with the monthly HLDS newsletter serving as an interim measure to assure maximum currency of the periodical list. A planned similar listing of audiovisual software has not yet been realized because of various factors detailed in the following section. From the outset health sciences libraries in New Hampshire not affiliated with one of the cooperative groups were also encouraged to participate in the project, at least in terms of their periodical holdings. The number of print loan transactions resulting from this cooperation has increased substantially each year, and there has been a corresponding decrease in the number of requests made to DML. Precise figures are provided below and in Table 1. Beginning in January 1974, information center requests to DML for articles from the list of AIM "refusal" titles were also tabulated. The intent of this record keeping was to gather concrete dollars-and-cents evidence of the benefits of resource sharing. In addition, the librarians were encouraged to seize every opportunity to make their administrators and library committees aware of the total cooperative effort. Throughout this period HLDS provided training, consultation, full sets of catalog cards, and its monthly newsletter. DML staff members contin-

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TABLE I COMPARISON OF PRINT INTERLIBRARY LOAN REQUESTS FILLED BY HOSPITAL LIBRARIES AND

THOSE FILLED BY DML, 1974-1978

Year

Hospital Libraries

DML

1974 1975 1976 1977 1978

1,221 2,727 3,069 3,932 4,170

3,889 3,176 2,356 1,919 1,288

ued their work with the centers for reference services and print and nonprint loans. Results From January 1975 through April 1976 (when NLM support ended), twenty-one meetings were held, each group having met at least four times. An area-wide conference took place in November. A broad range of cooperative projects were considered; the main ones undertaken by one or more of the groups included: -The exchange of typed listings of hospitalowned audiovisual software -Prepurchase consultation regarding books, periodicals, and audiovisual software The exchange of duplicate materials at the meetings and through the HLDS office for the area -Consolidated listings (including exact holdings information) of the major reference tools owned by the individual members; for example, indexes, directories, statistical

compilations -The exchange of periodical tables of contents for current awareness and loan purposes -Consolidated listings of significant reference bibliographies produced by the individual members -Miniworkshops stressing basic skills; for example, publicity and promotion, book selection, record keeping and reporting -Reports by individual members on other library conferences and workshops attended -A questionnaire survey of area hospital librarians to determine salaries, fringe benefits, and working conditions. The consolidated listings of reference tools and bibliographies are no longer maintained. Compila-

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tion had been done by various group members, who found the process very time-consuming and difficult from the standpoint of procuring up-to-date reports. Tables of contents of periodicals are rarely exchanged at this time, due to the revision of the copyright law (Public Law 94-553), which took effect on January 1, 1978. These listings and exchanges did result in considerable numbers of interlibrary loan requests for article photocopies. The meetings also served as current awareness forums. Library matters and trends at the regional and national levels, as well as other items of relevance (such as the pending copyright legislation), were introduced, usually by the HLDS Director, and incorporated into the discussion and planning. Information of this kind had rarely been made directly available to the hospital librarians in this area previously. Written reactions to these issues often followed. On one occasion a letter summarizing opinions regarding a document delivery sharing program was composed by one cooperative group during its meeting and mailed the same day to the regional medical library. On another occasion a letter was written and mailed to the state congressional delegation on the copyright law. One of the best aspects of the meetings was the spontaneous sharing of job-related experiences, expertise, problems, and solutions. Many a reinvention of the wheel was spared. Moral support was another key outcome. The need for such support and interaction is intensified when oneperson libraries are involved [8]. One of the members described the group meetings as "therapeutic necessities." Concurrently cooperation emerged behind the scenes: several librarians devised a delivery system using personnel who traveled regularly among their hospitals; one librarian visited another to see the library operation firsthand and to learn a simplified method of cataloging; two librarians at psychiatric hospitals decided to coordinate their periodical acquisitions more closely. Phone calls for materials needed in a hurry or for help with difficult reference inquiries became commonplace. The first computerized edition of the periodical union list, consisting of 470 unique titles held by thirty-six participating libraries, was completed in August 1974. An update produced a year later showed an increase of 100 titles and included three new participants. The first book list produced by computer, containing approximately four thousand entries, was also issued at that time. Roughly 25% Bull. Med. Libr. Assoc. 67(3) July 1979

COOPERATION STRENGTHENS SMALL HOSPITAL LIBRARIES

of these entries were held by more than one library. From January 1974, the date of the first periodical list, through April 1976, the date of termination of NLM grant support, the participants reported in excess of 5,000 interlibrary requests filled. Since the expiration of external funding, HLDS and DML have gradually reduced their involvement. Fees are now charged for most support services, and a New England region-wide quota system, further curtailing cost-free interlibrary loans, was initiated in October 1977. HLDS continues to coordinate one meeting annually of each cooperative group (there are now only three, as a result of realignment and merger early in 1976) and to plan and conduct the yearly combined meeting of the three groups. Each group also meets periodically without HLDS support. Additional updates of both union lists have been produced, and a growing number of health sciences libraries from New Hampshire have submitted their periodical holdings for inclusion. This list now stands at nearly 800 titles, with forty-seven libraries participating. Because production of the book list requires far more time and effort, it has been necessary to limit participation, and although another revision is in process, its cost effectiveness is under scrutiny. The union list participants reported over 2,600 requests filled for each other in 1976, nearly 4,000 in 1977, and over 4,000 in 1978. During 1978 an arrangement was made with the twenty-eight-member Consortium of Central Massachusetts Health-Related Libraries to exchange periodical union lists on a six-month trial basis. Requests are made interconsortially only when they cannot be filled locally. A similar arrangement is now in effect with the fifty-eightmember Health Sciences Library and Information Cooperative of Maine. Efforts to compile a union list of audiovisual software have been frustrated for several reasons. The software collections of the area libraries are small, consisting primarily of repeatedly used materials for staff education and training. Although most hospitals are also beginning to acquire patient education software, this material is even more difficult to loan because of frequent use and the inability to predict when items will be needed. In a number of instances the audiovisual component is not a part of the library. Certain hospitals are unwilling to loan audiovisual materials because they fear damage or loss. However, this has not been a problem for those members of the Bull. Med. Libr. Assoc. 67(3) July 1979

cooperative groups who share software informally. Finally, HLDS no longer has sufficient personnel for such an undertaking. Since mid-1975 the staff has been gradually reduced from four full-time to two employees, one working 50% time and the other 33% time. Assessment

Getchell, in reviewing the perceived effects of cooperative effort on the individual libraries of the Consortium for Information Resources of the West Suburban Hospital Association near Boston, states: "Breaking out of an historically autonomous and isolated mode of operation and entering into a dynamic group effort unique to them, presented to each librarian a challenge and a potential for dramatically changing library practice within each hospital" [9]. The individual progress of the information centers has been monitored through written reports consisting of an eight-point evaluation. In 1974 a ninth category, "cooperation," was added. A recent analysis of these records revealed that the greatest gains were made by those librarians who were most active in the cooperative activities. For one thing, administrators and library committees were impressed by the efforts to band together in order to minimize costs while maintaining high levels of service. Even more importantly, however, persons from those libraries which had not achieved full development were exposed through the group meetings to those who had. This provided concrete illustrations, which proved to be more persuasive than philosophical arguments, concerning the benefits of a fully developed and supported library. Requests for support services to DML have decreased steadily since 1974. Table 1 depicts the yearly increase in print loans filled by the hospital libraries themselves and the sizable decrease in the number of such requests filled by DML. The quota system for interlibrary loans begun in the New England region late in 1977 was the first financial restriction involving this important service. The fact that over 10,000 requests were filled among the hospital libraries prior to the quota system is a significant indication of the excellent cooperation that has developed in this area. Requests for nonprint loans and reference support have also declined, due in part to the imposition of fees but also as a result of increased self-sufficiency, both individual and collective. 327

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fied support and provided better direction for the DISCUSSION AND CONCLUSIONS endeavors in particular and for the cooperative An active information service is essential to the Instead, the responsibility of in general. libraries patient care, education, and research efforts of informed was left to the the administrators keeping hospitals, and its worth can be demonstrated even members. group individual at the smallest institutions. Initial financial outlay We believe that effective cooperation presupneed not be substantial, but a commitment to established and reasonably well-supported poses personnel trained in fundamental library skills is libraries. It is to be hoped that the current hospital required. Twenty-four of the thirty-three hospitals of the cooperative concept does not prominence with which HLDS has been involved have 100 beds in the result neglect of the essential developmental or less, and yet the great majority of these now libraries. of these needs have libraries which are staffed and financially supported. Continued inflationary pressures have mandated greater coordination and cooperation among libraries in general. The increased emphasis on local responsibility in the medical library network has further accentuated this trend for health sciences libraries [4, 7]. NLM's Consortium Improvement Grant Program has provided additional philosophical and financial impetus. These factors have resulted in an increase in the number of consortia formed, particularly among hospital libraries [10-14]. The picture is not entirely satisfactory, however, because many of the nation's health institutions still do not have adequately supported and developed libraries. Matheson and West, in discussing the NLM Resource Improvement Grant Program, conclude that "the need for such a program remains; there are still large numbers of basic unit institutions without adequate library resources" [15]. West and Howard cite similar inadequacies regarding library materials and services among area health education center programs [ 16]. Our experience has been that cooperation among hospital libraries is worthwhile. However, the impact of the revised copyright law on the mainstays of cooperation-resource sharing and planned acquisition-cannot as yet be fully assessed. In addition, several shortcomings in the HLDS approach can be noted in retrospect. First of all, the HLDS Director was somewhat reluctant to delegate tasks and responsibilities to group members, primarily for fear of overburdening them. Consequently, two of the cooperative groups were hesitant to continue meeting and working on their own with minimal support. Fortunately, internal leadership has surfaced in each case, but only after a considerable delay and interruption of activities. In addition, no strong effort was made by HLDS to involve top hospital administrative personnel. Such involvement, particularly during the early deliberations, might have further solidi-

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REFERENCES 1. STEARNS, N. S., AND RATCLIFF, W. W. An integrated health-science core library for physicians, nurses and allied health practitioners in community hospitals. N. Engl. J. Med. 283: 1489-1498, Dec. 31, 1970. 2. WEINSIEDER, B. G. Cooperative venture proves

successful. Hospitals 46: 52-55, Jan. 16, 1972. 3. The document delivery service plan. In: New England Regional Medical Library Service (NERMLS). Regional Medical Library Program, Region I, New England Regional Medical Library Service (NERMLS): Plan for the Future. Boston,

[1973].

4. FINK, W. R.; BLOOMQUIST, H.; AND ALLEN, R. G. The place of the hospital library consortium in the

5.

6. 7.

8. 9.

10. 11.

12.

13.

national biomedical communications network. Bull. Med. Libr. Assoc. 62: 258-265, July 1974. PORTERFIELD, J. D., III. Accreditation problems. Hospitals 49: 12, Apr. 16, 1975. JOINT COMMISSION ON ACCREDITATION OF HosPITALS. Accreditation Manual for Hospitals, 1970. Chicago, 1971. National Library of Medicine regional medical library program policy statement. Bull. Med. Libr. Assoc. 60: 271-273, Apr. 1972. ST. CLAIR, G. The one-person library: an essay on essentials. Spec. Libr. 67: 233-238, May/June 1976. GETCHELL, M. E. The impact of consortium dynamics on hospital library practice. In: Fink, Wendy R., et al., eds. Dynamics of Hospital Library Consortia. Waltham, Mass., West Suburban Hospital Research and Education Association, 1975. p. 244-255. MOULTON, B., AND FINK, W. R. Components for consideration by emerging consortia. Bull. Med. Libr. Assoc. 63: 23-28, Jan. 1975. HOLTUM, E. A.; McKLOSKEY, J.; AND MAHAN, R. Coordinators for health science libraries in the Midwest Health Science Library Network. Bull. Med. Libr. Assoc. 65: 224-230, Apr. 1977. KOPLAN, S. M.; CHEWNING, C. J.; AND BUMGARNER, J. Cooperative library services for Atlanta's hospitals. J. Med. Assoc. Ga. 65: 55-57, Feb. 1976. MILLARD, S. K., AND ANDRIATE, G. S. MEDCORE: commitment to cooperation. Bull. Med. Libr. Assoc. 66: 57-58, Jan. 1978. Bull. Med. Libr. Assoc. 67(3) July 1979

COOPERATION STRENGTHENS SMALL HOSPITAL LIBRARIES 14. BOLEF, D., AND FISHER, J. S. A health sciences libraries consortium in a rural setting. Bull. Med. Libr. Assoc. 66: 185-189, Apr. 1978. 15. MATHESON, N. W., AND WEST, R. T. NLM Medical Library Resource Improvement Grant Program: an evaluation. Bull. Med. Libr. Assoc. 64: 309319, July 1976.

Bull. Med. Libr. Assoc. 67(3) July 1979

16. WEST, R. T., AND HOWARD, F. H. Area health education centers and health science library services. Bull. Med. Libr. Assoc. 65: 368-376, July 1977.

Received November 13, 1978; revision accepted March 6, 1979.

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