My former CEO used to say at townhalls that he would answer questions on anything but parking. I never understood until I became a COO and now I am inundated with parking complaints. Several small things can be done, such as finding ways to encourage employees to take buses, shuttles (we provide convenient free shuttles to our main campus form other sites freeing up main campus parking spots). I have seen hospitals and others subsidize public transportation costs for employees to make it easier and have heard of one place that convinced the city to put in a direct bus line to their location. We are currently getting ready to build a new garage and I am trying to make sure that when we build it, it will have room for growth for several years after it opens, but this is not easy.
We have a similar problem in Cincinnati. We currently have 142 inpatient pediatric mental health beds, which is the largest of any children’s hospitals in the country, but it is still often not enough. We board children in medical surgical beds, taking up space that other children at times need and delaying the start of true treatment. We are attempting a few things to modify the demand including putting psychologists in many of our primary care practices and in the local schools. We hope to help the parents and children with resiliency and head off problems before they are at the crisis stage. We have also opened partial day hospital at one location with another one planned. Finally, we have opened what we call a bridge clinic. If a child presents to the ED during the evening or night hours and is borderline on need for admission, we can discharge them home and have them seen in the bridge clinic the next morning. Also under consideration is putting pyschiatrists in our ED so that they can determine best course of action. Hard to stem the tide on our own, but the local community health budget is already stretched to the max with other priorities.
Interesting topic and certainly a challenge. Similar to the question of whether patients should be in specialty ICUs or general ICUs, there is clearly a volume phenomenon that improves outcomes for a wide variety of reasons that extend beyond just the physician. I think that centralizing the care to a few centers is appropriate, especially in a geographic region that would not place huge travel burdens on patients. The volume challenge is getting worse as surgeons and other procedure based specialists are coming out of training with much less experience than the earlier generations. Whenever I have been asked to perform a spinal tap on a child where others have failed, I have to remind myself that the younger generation trained in an era where vaccination rates are high. As a resident in a really busy pediatric ED in the 1980s I could do as many as 10 spinal taps in one shift. Now some trainees finish a three year residency not having done ten in their whole time. The martini clinic is a great example of organizing the care around the patient with everything truly designed to improve the quality of care, not the ease of the providers and the improvements in outcomes. The variation in surgical programs can be quite huge and really shouldn’t be. A lot can learned from the Martini clinic approach even if you don’t limit to two or three centers in terms of how they structure care, how they review performance (most american hospitals are no where near as rigorous at evaluating performance and taking steps to ensure people improve to the benchmark or get help).
This is a challenge, but once an organization goes to subspecialty ICU care it is next to impossible to revert back. Closed units develop their own cultures and standards that the providers are comfortable with, so even if the actual outcomes would be the same, it is challenging to house patients in a different unit with different cultures. Once a certain volume is reached there are very clear benefits to a cardiac or other specialty ICU and you have certain reached that volume. Is it possible to have some patients in the other ICU, but that receive care from the cardiac surgery team or in conjunction with your team? Having them in the other unit not being cared for by the cardiac team is extremely challenging and unlikely to lead to good care and good relationships with the other unit. If you get better by doing a lot of something, it would be hard for a unit that only takes overflow volume to become good at caring for complex patients that they only see infrequently.
Not sure how the new EHR is more demanding and requires more documentation than any other. The requirements are usually more to do with regulation and billing and coding compliance challenges. Keys to EHR success include having engaged providers who become superusers and can help streamline documentation, reduce mouse clicks, eliminate duplicate documentation, automate data field population, reduce note-bloat, judicious use of the copy/paste function (some have eliminated this function as it invariably increases note length, introduces errors and sustains poor communication), adapts for your environment with requiring intense specialization. Physicians blame a great deal on the EHR system, some of which would be there if they were documenting in paper and would be more challenging in paper format than EHR.
Medical tourism is not for the faint of heart. It is a challenging business with a great deal of risk and unintended consequences. Some challenges include making sure your organization is truly culturally competent, particularly at the care provider level, significant increase in expenses related to costs for this population (translators, travel arrangements, scheduling complexity, very, very delayed payment practices, business cultures that differ significantly from your own, unreasonable outcome expectations, etc etc. A huge challenge for most US systems occurred in the past two years when the price of oil dropped significantly, so did medical tourism. We are still waiting for payment for some of our patients from FY 2015. If you have a truly elite hospital that can be expected to maintain significant outcome differences and a really strong brand, then it is an area where the margins can be very high and worth the risk, otherwise there are easier dollars to chase.