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Despite reports of higher profitability in recent years, hospitals are failing at a faster rate than ever before. Although many hospitals leave decisions regarding revenues and costs to chief financial officers and their staff, this is a recipe for disaster. From research conducted over the last 4 years on hospital bankruptcies and turnarounds, the author found that a common series of actions will help organizations evade collapse. The author explored these turnaround strategies through research and analysis of a variety of hospitals and health systems that had a high probability of immediate financial crisis or collapse. His continued observation and analysis of these hospitals in subsequent years showed that most hospitals never emerge from their bleak financial conditions. However, a few hospital administrations have successfully turned around their organizations. Copyright © 2008 Heldref Publications [ABSTRACT FROM AUTHOR]

Background: SARS CoV-2 virus (COVID-19) impacted the practice of healthcare in the United States, with technology being used to facilitate access to care and reduce iatrogenic spread. Since then, patient message volume to primary care providers has increased. However, the volume and trend of electronic communications after lockdown remain poorly described in the literature., Methods: All incoming inbox items (telephone calls, refill requests, and electronic messages) sent to providers from patients amongst four primary care clinics were collected. Inbox item rates were calculated as a ratio of items per patient encountered each week. Trends in inbox rates were assessed during 12 months before and after lockdown (March 1st, 2020). Logistic regression was utilized to examine the effects of the lockdown on inbox item rate post-COVID-19 lockdown as compared to the pre-lockdown period., Results: Before COVID-19 lockdown, 2.07 new inbox items per encounter were received, which increased to 2.83 items after lockdown. However, only patient-initiated electronic messages increased after lockdown and stabilized at a rate higher than the pre-COVID-19 period (aRR 1.27, p -value < 0.001). In contrast, prescription refill requests and telephone calls quickly spiked, then returned to pre-lockdown levels., Conclusion: Based on our observations, providers experienced a quick increase in all inbox items. However, only electronic messages had a sustained increase, exacerbating the workload of administrators, staff, and clinical providers. This study directly correlates healthcare technology adoption to a significant disruptive event but also shows additional challenges to the healthcare system that must be considered with these changes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Electronic messages are growing as an important form of patient-provider communication, particularly in the primary care setting. However, adoption of healthcare technology has been under-utilized by underserved patient populations. The purpose of this study was to describe how adoption and utilization of electronic messaging occurred within a large primary care urban-based patient population., Methods: In this retrospective study, the frequency of electronic messages initiated by adult outpatient primary care patients was observed. Patients were classified as either non-portal adopters, non-message utilizers, low message utilizers, and high message utilizers. Logistic regression modeling was used to compare factors associated with message utilization rates to determine disparities in access., Results: Among a sample of 27,453 ethnically diverse adult patients from the Houston, Texas Metropolitan area, 33,497 unique messages were sent (1.22 messages/patient). Message burden was predominantly derived by a small number of high utilizers (individuals who sent 3 or more messages), who comprised 15.7 % of the study population (n = 4302) but accounted for 77 % of the message volume (n = 25,776). These high utilizers were typically older, White, English speaking, from middle to upper income zip codes, had higher number of comorbidities, and a higher number of clinical visits., Conclusions: Most inbox messages were generated by a small number of patients. While it was reassuring to see older and sicker individuals utilizing electronic messaging, patients from minority and/or lower income background utilized electronic messaging much less. This may propagate systematic bias and decrease the level of care for traditionally underserved patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

An aspect of a hospital's location, such as its degree of socioeconomic disadvantage, could potentially affect quality ratings of the hospital; yet, few studies have granularly explored this relationship in United States (US) metropolitan areas characterized by a wide breadth of socioeconomic disparities across neighborhoods. An understanding of the effect of neighborhood socioeconomic disadvantage on hospital quality of care is informative for targeting resources in poor neighborhoods. We assessed the association of neighborhood socioeconomic disadvantage with hospital quality of care across several areas of quality (including mortality, readmission, safety, patient experience, effectiveness of care, summary and overall star rating) in US metropolitan areas. Hospitals in the most disadvantaged neighborhoods, compared to hospitals in the least disadvantaged neighborhoods, had worse mortality scores, readmission scores, safety of care scores, patient experience of care scores, effectiveness of care scores, summary scores and overall star rating. Timeliness of care and efficient use of imaging scores were not strongly associated with neighborhood socioeconomic disadvantage; although, future studies are needed to validate this finding. Policymakers could target innovative strategies for improving neighborhood socioeconomic conditions in more disadvantaged areas, as this may improve hospital quality., Competing Interests: Declaration of competing interest No conflicts of interest relevant to the content of this manuscript were reported by the authors., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Teaching hospitals have a unique mission to not only deliver graduate medical education but to also provide both inpatient and ambulatory care and to conduct clinical medical research; therefore, they are under constant financial pressure, and it is important to explore what types of external environmental components affect their financial performance. This study examined if there is an association between the short-term and long-term financial performance of major teaching hospitals in the United States and the external environmental dimensions, as measured by the Resource Dependence Theory. Data for 226 major teaching hospitals spanning 46 states were analyzed. The dependent variable for short-term financial performance was days cash on hand, and dependent variable for long-term financial performance was return on assets, both an average of most recently available 4-year data (2014-2017). Utilizing linear regression model, results showed significance between outpatient revenue and days cash on hand as well as significant relationship between population of the metropolitan statistical area, unemployment rate of the metropolitan statistical area, and teaching hospital's return on assets. Additionally, system membership, type of ownership/control, and teaching intensity also showed significant association with return on assets. By comprehensively examining all major teaching hospitals in the U.S. and analyzing the association between their short-term and long-term financial performance and external environmental dimensions, based upon Resource Dependence Theory, we found that by offering diverse outpatient services and novel delivery options, administrators of teaching hospitals may be able to increase organizational liquidity.

Competing Interests: The author declares no conflicts of interest.

Cognitive motivation theories contend that individuals have greater readiness for behavioral change during critical periods or life events, and a non-fatal overdose could represent such an event. The objective of this study was to examine if the use of a specialized mobile response team (assertive outreach) could help identify, engage, and retain people who have survived an overdose into a comprehensive treatment program. We developed an intervention, consisting of mobile outreach followed by medication and behavioral treatment, in Houston Texas between April and December 2018. Our primary outcome variables were the level of willingness to engage in treatment, and percent who retained in treatment after 30 and 90 day endpoints. We screened 103 individuals for eligibility, and 34 (33%) elected to engage in the treatment program, while two-thirds chose not to engage in treatment, primarily due to low readiness levels. The average age was 38.2 ± 12 years, 56% were male, 79% had no health insurance, and the majority (77%) reported being homeless or in temporary housing. There were 30 (88%) participants still active in the treatment program after 30 days, and 19 (56%) after 90 days. Given the high rates of relapse using conventional models, which wait for patients to present to treatment, our preliminary results suggest that assertive outreach could be a promising strategy to motivate people to enter and remain in long-term treatment., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective There has been moderate evidence of telehealth utilization in the field of emergency medicine, but less is known about telehealth in prehospital emergency medical services (EMS). The objective of this study is to explore the extent, focus, and utilization of telehealth for prehospital emergency care through the analysis of published research. Methods The authors conducted a systematic literature review by extracting data from multiple research databases (including MEDLINE/PubMed, CINAHL Complete, and Google Scholar) published since 2000. We used consistent key search terms to identify clinical interventions and feasibility studies involving telehealth and EMS, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results We identified 68 articles focused specifically on telehealth interventions in prehospital care. The majority (54%) of the studies involved stroke and acute cardiovascular care, while only 7% of these (4) focused on telehealth for primary care. The two most common delivery methods were real-time video-conferencing capabilities (38%) and store and forward (25%); and this variation was based upon the clinical focus. There has been a significant and positive trend towards greater telehealth utilization. European telehealth programs were most common (51% of the studies), while 38% were from the United States. Discussion and Conclusions Despite positive trends, telehealth utilization in prehospital emergency care is fairly limited given the sheer number of EMS agencies worldwide. The results of this study suggest there are significant opportunities for wider diffusion in prehospital care. Future work should examine barriers and incentives for telehealth adoption in EMS.

Scholarship is an important component of success for academic emergency physicians. Scholarship can take many forms, but all require careful planning. In this article, we provide expert consensus recommendations for improving junior faculty's scholarship in emergency medicine (EM). Specific focus is given to promoting your research career, obtaining additional training opportunities, networking in EM, and other strategies for strategically directing a long-term career in academic medicine., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Emergency physicians often must make critical, time-sensitive decisions with a paucity of information with the realization that additional unavailable health information may exist. Health information exchange enables clinician access to patient health information from multiple sources across the spectrum of care. This can provide a more complete longitudinal record, which more accurately reflects the way most patients obtain care: across multiple providers and provider organizations. This information article explores various aspects of health information exchange that are relevant to emergency medicine and offers guidance to emergency physicians and to organized medicine for the use and promotion of this emerging technology. This article makes 5 primary emergency medicine-focused recommendations, as well as 7 additional secondary generalized recommendations, to health information exchanges, policymakers, and professional groups, which are crafted to facilitate health information exchange's purpose and demonstrate its value., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: Differences in after-hours capability or performance of ST-elevation myocardial infarction (STEMI) centers has the potential to impact outcomes of patients presenting outside of regular hours., Methods: Using a prospective observational study, we analyzed all 1,247 non-transfer STEMI patients treated in 15 percutaneous coronary intervention (PCI) facilities in Dallas, Texas, during a 24-month period (2010-2012). Controlling for confounding factors through a variety of statistical techniques, we explored differences in door-to-balloon (D2B) and in-hospital mortality for those presenting on weekends vs. weekdays and business vs. after hours., Results: Patients who arrived at the hospital on weekends had larger D2B times compared to weekdays (75 vs. 65 minutes; KW=48.9; p<0.001). Patients who arrived after-hours had median D2B times >16 minutes longer than those who arrived during business hours and a higher likelihood of mortality (OR 2.23, CI [1.15-4.32], p<0.05)., Conclusion: Weekends and after-hour PCI coverage is still associated with adverse D2B outcomes and in-hospital mortality, even in major urban settings. Disparities remain in after-hour STEMI treatment.

Purpose: Community health clinics serving the poor and underserved are geographically expanding due to changes in U.S. health care policy. This paper describes the experience of a collaborative alliance of health care providers in a large metropolitan area who develop a conceptual and mathematical decision model to guide decisions on expanding its network of community health clinics., Design/methodology/approach: Community stakeholders participated in a collaborative process that defined constructs they deemed important in guiding decisions on the location of community health clinics. This collaboration also defined key variables within each construct. Scores for variables within each construct were then totaled and weighted into a community-specific optimal space planning equation. This analysis relied entirely on secondary data available from published sources., Findings: The model built from this collaboration revolved around the constructs of demand, sustainability, and competition. It used publicly available data defining variables within each construct to arrive at an optimal location that maximized demand and sustainability and minimized competition., Practical Implications: This is a model that safety net clinic planners and community stakeholders can use to analyze demographic and utilization data to optimize capacity expansion to serve uninsured and Medicaid populations., Originality/value: Communities can use this innovative model to develop a locally relevant clinic location-planning framework.

Background: The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI., Methods: Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression., Results: Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes., Conclusion: The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies., (Copyright © 2013 Mosby, Inc. All rights reserved.)

The objectives of this study were to provide an economic assessment as well as a calculated projection of the costs that typical U.S. tertiary-care hospitals would incur through policy reconfiguration and implementation to achieve the UNICEF/World Health Organization Baby-Friendly® Hospital designation and to examine the associated challenges and benefits of becoming a Baby-Friendly Hospital. We analyzed hospital resource utilization, focusing on formula use and staffing profiles at one U.S. urban tertiary-care teaching hospital, as well as conducted an online survey and telephone interviews with a selection of Baby-Friendly Hospitals to obtain their perspective on costs, challenges, and benefits. Findings indicate that added costs for a new Baby-Friendly Hospital will approximate $148 per birth, but these costs sharply decrease over time as breastfeeding rates increase in a Baby-Friendly environment.

A study used FTE employees per adjusted occupied bed (FTE/AOB) as a measure to ascertain the effect of EHR investments on labor productivity. The study focused on three primary questions: Do FTE/AOB decline as the number of EHR applications used in a hospital increases? Is impact on FTE/AOB greater with some EHR applications than with others? Do FTE/AOB decline overtime, as the hospital continues to use the EHR application?

Objectives: The objectives of this study were to provide an economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Children's Emergency Fund designation as a Infant-Friendly hospital. We hypothesized that baby-friendly hospitals will have higher costs than similar non-baby-friendly hospitals., Methods: Data from the 2007 American Hospital Association and the 2007 Centers for Medicare and Medicaid Cost Reports were used to compare labor and delivery costs in baby-friendly and non-baby-friendly hospitals. Operational costs per delivery were calculated using a matched-pairs analysis of a sample of baby-friendly and non-baby-friendly hospitals in the United States. Costs associated with labor-and-delivery diagnosis-related codes were analyzed for each baby-friendly hospital and compared with the mean and median costs incurred by non-baby-friendly hospitals., Results: Nursery plus labor-and-delivery costs for the baby-friendly sites were $2205 per delivery, compared with $2170 for the non-baby-friendly matched pair. Baby-friendly facilities have slightly higher costs than non-baby-friendly facilities, ranging from 1.6% to 5%, but these costs were not statistically significant (P > .05)., Conclusions: These results suggest that becoming baby-friendly is relatively cost-neutral for a typical acute care hospital. Although the overall expense of providing baby-friendly hospital nursery services is greater than nursery service costs of non-baby-friendly hospitals, the cost difference was not statistically significant. Additional research is needed to compare the economic impact of maternal and infant health benefits from breastfeeding versus the incremental expenses of becoming a baby-friendly hospital.

Objective: To assess academic emergency medicine (EM) chairs' perceptions of quality improvement (QI) training programs., Methods: A voluntary anonymous 20 item survey was distributed to a sample of academic chairs of EM through the Association of Academic Chairs of Emergency Medicine. Data was collected to assess the percentage of academic emergency physicians who had received QI training, the type of training they received, their perception of the impact of this training on behavior, practice and outcomes, and any perceived barriers to implementing QI programs in the emergency department., Results: The response rate to the survey was 69% (N = 59). 59.3% of respondents report that their hospital has a formal QI program for physicians. Chairs received training in a variety of QI programs. The type of QI program used by respondents was perceived as having no impact on goals achieved by QI (χ(2) = 12.382; p = 0.260), but there was a statistically significant (χ(2) = 14.383; p = 0.006) relationship between whether or not goals were achieved and academic EM chairs' perceptions about return on investment for QI training. Only 22% of chairs responded that they have already made changes as a result of the QI training. 78.8% of EM chairs responded that quality programs could have a significant positive impact on their practice and the healthcare industry. Chairs perceived that QI programs had the most potential value in the areas of understanding and reducing medical errors and improving patient flow and throughput. Other areas of potential value of QI include improving specific clinical indicators and standardizing physician care., Conclusion: Academic EM chairs perceived that QI programs were an effective way to drive needed improvements. The results suggest that there is a high level of interest in QI but a low level of adoption of training and implementation.

Healthcare organizations are being impacted by the current economic environment as severely as for-profit firms. As a result, hospital and system managers are being required to continuously assess and improve their operational efficiency, by focusing on productivity, costs and volumes. Benchmarking is one way to compare performance across hospitals, but many benchmarking methods are of limited value because they rely on ratio analysis which is fairly simplistic and does not allow for comparisons across organizations of different sizes, focus or risk profiles. One way to improve benchmarking efforts is an analytical technique called data envelopment analysis (DEA), which performs complex mathematical optimization of inputs (resources consumed) and outputs of healthcare production processes to facilitate comparison of one organization to others making adjustments for scale. This article outlines how healthcare organizations can use a new benchmarking technique to normalize, or standardize performance, using DEA tools.

Hospitals in dire financial straights must act decisively, but are they making the right decisions? The board has a different leadership role in a financial turnaround.

In turbulent times, the financial policies and decisions about cash and debt make or break hospitals' financial condition. Decisions about whether to continue saving cash or reduce debt burdens are probably the most vital policy decision for the hospital CFO. Unfortunately, my research shows that most administrators are relying on judgment, or best-guess heuristics to address these policy issues. This article explores one of the most common heuristics in health finance-ratios gauging debt and cash on hand. The subject is explored through the research and analysis of over 40 hospitals in a very competitive marketplace-the boroughs of New York City. Analyses of financial strength, through various statistical models, were conducted to explore the linkages between traditional heuristics and long-term economic results. Data were collected for 30 operational and financial indicators. Findings suggest that organizations require different cash-debt positions based on their overall financial health, and that a one-number heuristic does not fit all. Extremely financially constrained hospitals (those approaching bankruptcy conditions) should be building free cash flow and minimizing debt service, while financially secure hospitals need to minimize cash on hand while reducing debt. If all hospitals continue to try to meet an arbitrary days of cash heuristic, this simplification could cripple an organization. A much more effective metric requires each organization to model decisions more comprehensively.

Based on industry averages, healthcare providers spend from 1.5 percent to 3 percent of their revenues on information technology. That can equate to a million dollars a year for even the smallest hospitals and as much as $50 million or $60 million a year for large health systems. That significant amount of capital must be wisely managed because these investments are long-term assets that can help transform the enterprise and contribute to the organization's strategic goals. Unfortunately, in many hospitals these investments are often made without regard for the actual return on investment that the systems will generate. ROI, or economic value, is difficult to quantify in healthcare because of the complex multi-dimensional processes and perspectives that exist. Administrators and providers often question how a clinical system can be quantified and compared with an ERP, research technology or any other information system. When value can be defined in so many ways - such as improvements in clinical outcomes, improvements in system uptime or reliability, or enhancements in productivity and operational business processes-quantification of economic value becomes much more ambiguous and therefore easy to neglect. However, business value can be created by any combination of shifts in performance. Reductions in waiting lines, improvements in imaging capabilities, increased procedures per labor hour, extensions of system life and higher transaction processing all have potential value. However, ROI cannot be calculated or maximized if underlying key performance indicators are not defined and measured, both pre- and post-implementation. This article will build on solid governance strategies for IT that will help to ensure positive economics and improved productivity in healthcare. It also will discuss specific strategies and methods for extracting the most value out of IT in healthcare.

Despite the prestige and reputation of teaching hospitals, as a group they are in financial distress. If this trend continues, one would expect to see a higher incidence of mergers and acquisitions or divestitures of assets and services, and other strategies designed to combat failing businesses. Nearly one out of every six teaching hospitals sampled was predicted to be near immediate bankruptcy, and the overwhelming majority was not far behind. It will take a significant effort for these hospitals to continue to treat their operations as a clinical and research "business," but they must do just that if they are to survive the continually turbulent market.

The healthcare supply chain is a vast, disintegrated network of products and players, loosely held together by manual and people-intensive processes. Managing the flow of information, supplies, equipment, and services from manufacturers to distributors to providers of care is especially difficult in clinical supply chains, compared with more technology-intense industries like consumer goods or industrial manufacturing. As supplies move downstream towards hospitals and clinics, the quality and robustness of accompanying management and information systems used to manage these products deteriorates significantly. Technology that provides advanced planning, synchronization, and collaboration upstream at the large supply manufacturers and distributors rarely is used at even the world's larger and more sophisticated hospitals. This article outlines the current state of healthcare supply chain management technologies, addresses potential reasons for the lack of adoption of technologies and provides a roadmap for the evolution of technology for the future. This piece is based on both quantitative and qualitative research assessments of the healthcare supply chain conducted during the last two years.

Purpose: To describe the economics of teaching hospitals in an increasingly price-conscious managed care marketplace by determining the relationships between a teaching hospital's operations and cost per discharge., Method: A quantitative correlational regression analysis was undertaken of 1993 operational and financial data from the Health Care Financing Administration for a national sample of 100 major urban, non-federal teaching hospitals. The sample was systematically selected from membership in the Association of American Medical Colleges' Council of Teaching Hospitals., Results: The analysis indicated that the new economics of managed competition requires teaching hospitals to focus on reducing costs through five main areas: decreasing poorly utilized beds, increasing the numbers of discharges, renovating facilities to modernize and streamline patient flow, utilizing fewer employees and thus boosting productivity, and improving the internal financing of operations and investments through working-capital management., Conclusion: Achieving efficiency in operations in each of the five main areas will help teaching hospitals to survive the turbulence of market evolution toward managed care.