1. Key Issues
2. Stakeholders
   1. insurers
   2. community
   3. govt.
      1. nurse-pt ratio required
      2. EMTALA
   4. Hosp employees
      1. staff
      2. clinicians (docs, nurses)
         1. docs
         2. nurses
      3. admin
3. Financial
   1. losing money
   2. federal pressure to reduce HC expenditures
   3. rising costs
   4. benchmarked
   5. drastic decrease in non-operating rev
      1. investment
         1. more than they should be?
   6. decreased reim
      1. Medi-Cal low reim
      2. medicare
      3. HMOs
      4. incr in uncollectable debt
      5. uninsured pt pop
4. SWOT
   1. Strength
      1. Pt satisfaction is high
      2. outpt services
         1. SNF with 90% occupancy
         2. Assisted living is at 100% with waiting list
      3. good cost control
      4. doctor-admitted pts have ins
      5. incr donations
   2. Weakness
      1. ED
         1. over capacity
         2. poor efficiency
         3. increased waiting times
         4. decreased quality
         5. uninsured/underinsured
      2. poor occupancy rate: 50%
      3. known as a low cost provider
      4. PPE
         1. small hosp: only 145 beds
         2. semi-private rooms
         3. lack of technology
      5. Staff
         1. physician concerns
            1. decreased salaries
            2. docs might not want to take call in the ED
            3. dx second-guessed by HMO directors
            4. refusals
            5. difficulty admitting insured pts
            6. refusal to treat Medi-Cal pts
            7. cost exceeds reim
         2. staffing shortages
            1. recently had to incr nurse pay 27% to recruit
   3. Opportunity
      1. excess capacity
   4. Threat
      1. EMTALA bad press
         1. forgot to take temp
         2. nursing pressure from understaffing?
         3. damage control needed
      2. competitors
         1. for profit
         2. integrated sys like Kaiser
         3. 100 miles east of San Fransisco
            1. high COL
            2. competition for pts
      3. pt pop
         1. 3rd largest uninsured pt pop
            1. EMTALA
         2. sicker pts
         3. older pts
5. Strategies
   1. partnerships
      1. IT with other hosps
         1. pro
         2. con
      2. purchasing power
         1. pro
         2. con
   2. Hospital-wide
      1. close hosp
      2. new hosp
      3. merger
         1. Pro
         2. Con
      4. sell hospital
         1. pro
         2. con
   3. ED
      1. close ED
         1. pro: incr paying pts
         2. con: decrease total pts
      2. outsource ED mgmt
   4. Within hosp
      1. change ops
      2. change pt mix
      3. change payor mix
         1. Federally funded clinic